Trauma Surgery

The Time of my Life

Our life is made by the death of others.

Leonardo da Vinci

Hello everyone!

The post we release today is a little bit different from the ones we published before…

Today we are going to talk about why and when trauma patients die, how things have changed during the last 50 years, and how they have not…

Epidemiology of Trauma

We have already said (read Why we speak up) that trauma is the leading cause of death (COD) in the population between 1 and 39 years old in the United States (US), and it is believed it will progressively rise to that position even in older age groups. Similarly, in Italy, trauma is the first COD in the population aged 15-24 years old. Likewise, in the population between 25 and 44 years old, it is the principal COD in males and the second in females. Regardless of age, in the US, trauma is the third COD in the male population, and the sixth among females.

However, the US and European statistics are far from representing the real impact of this problem globally. It needs to be considered that more than 90% of worldwide trauma-related deaths occur in low- and middle-income countries.

For example, in South Africa (not a real third-world country) the burden of trauma on the National Health System is unimaginable. In a recent bulletin of the World Health Organization, it was reported that in the year 2000, South Africa had twice and 8-times higher road traffic- and homicide-related mortalities compared to the global average, respectively. Moreover, trauma-related mortality accounted for about 12% of the overall national death rate. There are multiple reasons based on this main issue, such as poverty, abuse of alcohol, socioeconomic disparities, xenophobia, lack of adult supervision, aggressive driving, etc…

Addressing the Neglected Problem of Modern Society

It was 1966 when the National Academy of Sciences published the paper “Accidental death and disability: the neglected burden of modern society”. This document recognized for the first time trauma as one of the leading causes of death in the US.

What worries most about trauma deaths is the young age of the victims. This means losing a consistent part of the population able to produce income, thus creating a major socioeconomic issue. In fact, in papers published between the Seventies and the Eighties, it was reported that 59-65% of the trauma deaths involved patients younger than 50-year-old, and 22-27% were between 20 and 30 years.

Moreover, to promptly address this problem, the authors laid the groundwork for the construction of the emergency medical services system and the national trauma system. In the last few years, the trauma systems have improved in the US and other developed countries, the same cannot be said for most the low- and middle-income countries though.

Research on trauma was one of the first steps to be taken to improve the survival of injured patients. After all, if you want to defeat an enemy, you need to know him first.

In 1983, Donald Trunkey published in Scientific American a paper that would have become one of the cornerstones in trauma literature. He showed how trauma had a trimodal distribution when the death rate is reported as a function of time after injury.

Image by Trunkey et al.

The trimodal distribution of trauma deaths is composed of three peaks:

  • The first peak was represented by “immediate deaths”, secondary to injuries to the brain, brain stem, or spinal cord, or massive and intractable hemorrhage;
  • The second peak, the “early deaths”, included patients who died during the first few hours, mainly because of hemorrhage;
  • The third and last peak, the “late deaths”, grouped victims who died after several days or weeks, mainly because of sepsis and/or multi-organ failure.

Trunkey presumed that most patients belonging to the first peak would have died anyway. However, the same could not be said about patients belonging to the second and third peaks. To avoid the “early deaths”, he underlined the importance of reducing as much as possible the interval between injuries and definitive treatments. This could be achieved with rapid transportation, adequate ambulance personnel, and trauma centers with 24/7 in-house coverage by trained health practitioners (i.e. surgeons, anesthesiologists, nursing staff, etc…). The dependence of survival on time to surgery was confirmed by Clarke et al.. In their paper, they demonstrated that the probability of death had a relationship to both the grade of hypotension and the time spent in the Emergency Department. Additionally, they showed how the death rate increased by about 1% every 3 minutes spent outside the operating room.

For what concerns the “late deaths”, Trunkey claimed they were dependent on the quality of medical care and the extent of medical knowledge.

Understanding the Pathophysiology of Trauma

As stated previously, “early deaths” can be avoided with an improvement of the trauma system. However, even if these bleeding patients are treated as fast as possible, stopping the ongoing blood loss, they are still exposed to all the consequences related to the hemorrhage. These consequences are responsible, at least in part, for the “late deaths”.

As already stated in one of our previous posts, severely injured trauma patients are used to developing three conditions: acidosis (pH <7.35), hypothermia (core temperature <35°C), and coagulopathy (INR >1.5). These events, together known as the “vicious cycle”, if not promptly corrected, may precipitate patients’ conditions, leading eventually to death.

Furthermore, the efforts made during the resuscitation of trauma patients may worsen the effects of this cycle.

For all these reasons, the management of trauma patients must focus on preventing and treating this “Vicious cycle”, and all the actions must start immediately, from the prehospital phase.

Advanced Trauma Life Support & Stop the Bleed

One of the major turning points in the prehospital, as well as in-hospital, trauma care, was the development of the Advanced Trauma Life Support program. The purpose behind the creation of this system was to give all the physicians involved in the initial management of trauma patients a tool to standardize this process.

Similarly, after recent terrorist attacks and shootings in the US, the American College of Surgeons has introduced a new course (i.e. Stop the Bleed). This is mainly for non-medical personnel and it is focused on teaching how to stop the bleeding while waiting for an ambulance. The final goal of this course is to decrease the preventable trauma deaths secondary to hemorrhages, involving civilians in the initial management of these bleeding patients.

Damage Control Resuscitation & Surgery

In the last few years, thanks to the more and more accurate knowledge on trauma pathophysiology, some measures were progressively introduced in trauma management, to prevent or treat all the factors supporting the “Vicious cycle”. All these actions create the so-called Damage Control Resuscitation.

Moreover, trauma patients, even if young and healthy, might be very fragile. Therefore, for the same reasons why it is important to choose carefully which medical treatment to give to these patients, it is fundamental to decide which is the best surgical procedure to perform. Surgery is per se an important source of stress for the human body. Longer and/or more complex the procedure, the more stressful is the surgery, and this is far truer in severely injured patients.

To avoid any unnecessary exposure to more demanding situations for already critical patients, the so-called Damage Control Surgery was introduced as a possible alternative to conventional definitive surgery.

What Stands at the End of the Lane

All the improvements made during the last few decades lead to a radical change in the management of trauma patients, where those principles are applied.

By Siddiqi et al.

This improvement in the management of trauma patients was reflected in a change in the mortality trend. In fact, since the beginning of the XXI Century, it has been recorded a shift from the classic trimodal pattern of death toward a bimodal (and sometimes unimodal) distribution. This important variation depended upon the flattening of the third peak curve, reflecting significant advances in trauma and ICU care, and the widespread adoption of damage control principles.

This new trend towards a single peak of early deaths was confirmed by Bardes et al., who demonstrated that this pattern was not influenced either by the main body region injured or by the mechanism of trauma. The same was recorded in Europe and Australia.

The Monster in the Closet

However, although the medical scientific community is cheering these astonishing results, they are by definition the consequence of investments, in terms of trained prehospital personnel, dedicated hospital units, advanced technologies, application of precise protocols, ICU beds’ availability, etc… Therefore, it is clear that only developed countries have the resources to reach these improvements. However, the vast majority of worldwide trauma deaths take place in middle- and low-income nations. Consequently, the trauma mortality in these countries has mainly maintained the classic trimodal distribution.

Other substantial differences between trauma deaths in low-income countries and in the Western world can be found in the demographics. It is well known in the literature that most trauma patients are young men, but it is interesting to note that in the study by Callcut et al. (USA), their cohort was composed of 74.5% of men, with a median age of 55 years old, and that similar results can be found in similar studies. On the contrary, the papers by Moodley et al. (South Africa) and Masella et al. (Brazil) showed younger patients and a higher proportion of men. These differences may be explained by the proportion of patients suffering penetrating injuries, who are generally young men, meaning a higher incidence of violence.

Why & When Trauma Patients Die

Most trauma patients decease because of central nervous system (CNS) injuries or exsanguination. However, the proportion between the two of them is variable, because it depends on the mechanism of the index trauma. For example, Lansink et al. reported CNS injuries as their leading COD by far compared to exsanguination (59.9% vs. 12.9%). This important gap between the two causes of death lies in the 88.2% of deaths caused by traffic accidents and falls from height. Similarly, Oyeniyi et al. showed how their patients died mainly because of severe TBI (61%). Even in their cohort, blunt injuries were the main mechanism of trauma (80%).

The percentage of patients dying during the first 24-48 hours seems to have a wide variability between studies. McGwin et al. showed a significant, although small, increase in early trauma deaths after the establishment of a Regional Trauma System, a change more evident in blunt patients compared to penetrating ones. They justified their findings as consistent with the availability and proper organization of trauma care resources. In other words, this means an improvement in the prehospital services, leading to an increased number of critical patients arriving alive at the hospital. On the contrary, Cothren et al. registered a shift toward late trauma deaths between 1992 and 2002, with an overall decrease in the early trauma deaths (<24 h) from 65% to 54%. They explained that this may be due to the prevention campaign they carried on during the years, resulting in reduced penetrating injuries, which appeared to be the main cause of the early deaths.

In conclusion, rapid prehospital services, adherence to strict protocols, high experience in life-saving procedures, such as ERT, DCS, and REBOA, rapid access to the emergency OR, etc… are all effective means to decrease the early deaths. However, sometimes, despite the good medical knowledge and the corroborated trauma system, the resources at disposal are not enough to improve the outcomes.

We hope you didn’t get bored along the way…

Besides protocols, flowcharts, guidelines, and fancy techniques, knowing how these work on a large scale is useful to understand why we need to follow these “rules” and what we should aim to reach…

See you next time, dudes!


  1. Siegel RL, et al. Cancer statistics, 2019. Ca Cancer J Clin 2019; 69:7-34.
  2. Rhee P, et al. Increasing trauma deaths in the United States. Ann Surg 2014;260:13-21.
  3. WHO. The injury chartbook: a graphical overview of the global burden of injuries. Geneva; 2002.
  4. Matzopoulos R, et al. Injury-related mortality in South Africa: a postmortem investigations. Bull World Health Organ 2015;93:303-13.
  5. Norman R, et al. The high burden of injuries in South Africa. Bull World Health Organ 2007;85:695-702.
  6. Committee on Trauma and Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. Accidental death and disability: the neglected disease of modern society. 1966. p. 1-38.
  7. Trunkey DD, et al. Analysis of 425 consecutive trauma fatalities: an autopsy study. J Am Coll Emerg Physician 1974;3:368-71.
  8. Baker CC, et al. Epidemiology of trauma deaths. Am J Surg 1980;140:144-50.
  9. Sakran JV, et al. Care of the injured worldwide: trauma still the neglected disease of modern society. Scand J Trauma Resusc Emerg Med 2012;20:64.
  10. Masella CA, et al. Temporal distribution of trauma deaths: quality of trauma care in a developing country. J Trauma 2008;65:653-8.
  11. Trunkey DD. Trauma. Sci Am 1983;249: 28-35.
  12. Pfeifer R, et al. Patterns of mortality and causes of death in polytrauma patients – Has anything changed? Injury 2009;40:907-11.
  13. Clarke JR, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 2002;52:420-5.
  14. Gunst M, et al. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc (Bayl Univ Med Cent) 2010;23:349-54.
  15. McGwin G, et al. Reassessment of the tri-modal mortality distribution in the presence of a regional trauma system. J Trauma 2009;66:526-30.
  16. Kleber C, et al. Overall distribution of trauma-related deaths in Berlin 2010: advancement or stagnation of German trauma management? World J Surg 2012;36:2125-30.
  17. Bardes JM, et al. The contemporary timing of trauma deaths. J Trauma Acute Care Surg 2018;84:893-9.
  18. Oyeniyi BT, et al. Trends in 1029 trauma deaths at a level 1 trauma center. Injury 2018;48:5-12. 
  19. de Knegt C, et al. Applicability of the trimodal distribution of trauma deaths in a Level I trauma centre in the Netherlands with a population of mainly blunt trauma. Injury 2008;39:993-1000.
  20. Lansink KWW, et al. Cause of death and time of death distribution of trauma patients in a Level I trauma centre in the Netherlands. Eur J Trauma Emerg Surg 2013;39:375-83.
  21. Callcut RA, et al. The why & how our trauma patients die: a prospective multicenter Western Trauma Association study. J Trauma Acute Care Surg 2019;86:864-70.
  22. Rogers FB, et al. Trauma deaths in a mature urban vs rural trauma system. Arch Surg 1997;132:376-82.
  23. Abbasi H, et al. Time distribution of injury-related in-hospital mortality in a trauma referral center in South of Iran (2010-2015). Medicine (Baltimore) 2017;96:e6871.
  24. Gofrit N, et al. The trimodal death distribution of trauma victims: military experience from the Lebanon War. Mil Med 1997;162:24-6.
  25. Johnson LJ, et al. Trimodal death and the injuries of survivors in Krabi Province, Thailand, post-tsunami. ANZ J Surg 2006;76:288-9.
  26. Moodley N, et al. An audit of trauma-related mortality in a provincial capital in South Africa. S Afr J Surg 2014;52:101-4. 
  27. Acosta A, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg 1998;186:528-33.
  28. Cothren CC, et al. Epidemiology of urban trauma deaths: a comprehensive reassessment 10 years later. World J Surg 2007;31:1507-11.
  29. Valdez C, et al. Timing of death after traumatic injury – a contemporary assessment of the temporal distribution of death. J Surg Res 2016;200:604-9.
  30. Søreide K, et al. Epidemiology and contemporary patterns of trauma deaths: changing place, similar place, older face. World J Surg 2007;31:2092-103.
  31. Arslan ED, et al. Assessment of traumatic deaths in a level one trauma center in Ankara, Turkey. Eur J Trauma Emerg Surg 2015;41:319-23.

How to Cite This Post

Bellio G, Plani F, Marrano E. The Time of my Life. Surgical Pizza. Published on May 1, 2022. Accessed on June 9, 2024. Available at [].

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