J Trauma Acute Care Surg. 2019 May;86(5):864-870

# The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study.

Callcut R, Kornblith L, Conroy A, Robles A, Meizoso J, Namias N, Meyer D, Haymaker A, Truitt M, Agrawal V, Haan J, Lightwine K, Porter J, San Roman J, Biffl W, Hayashi M, Sise M, Badiee J, Recinos G, Inaba K, Schroeppel T, Callaghan E, Dunn J, Godin S, McIntyre R Jr, Peltz E, OʼNeill P, Diven C, Scifres A, Switzer E, West M, Storrs S, Cullinane D, Cordova J, Moore E, Moore H, Privette A, Eriksson E, Cohen M; Western Trauma Association Multicenter Study Group.

BACKGROUND: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.

METHODS: Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.

RESULTS: One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.

CONCLUSION: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.

LEVEL OF EVIDENCE: Epidemiologic, level II.