A postmortem study of demographics and severity of thoracoabdominal injuries among patients attending a teaching hospital in northeast India

ABSTRACT

Introduction:

The global estimate reflects 4.4 million injury-related deaths every year and the thoracoabdominal region is frequently injured since it is a wide area.

Methods:

An autopsy-based cross-sectional study was conducted using a convenient sampling technique for three years. A Chi-square test was conducted for categorical variables. A P value of less than 0.01 was considered statistically significant.

Results:

Out of 80 cadavers, the male:female ratio was 1:0.31. The commonest age group was 20–29 years. Victims of road traffic accidents were 54 (67.5%) followed by falls from height 10 (12.5%). External thoracic injuries were commoner than internal and vice versa in abdominal injuries. Liver injuries were major in number. Combined thoracic-abdominal and associated injuries were observed in 67 (83.75%) victims. The commonest cause of death was craniocerebral injury combined with hemorrhagic shock (36.25%). Eighteen (22.5%) victims died on the spot having an Injury Severity Score (ISS) of 73.37 followed by a survival time of 1–7 days in 17 (21.25%) cases. A significant correlation was found between ISS and survival period.

Conclusion:

All thoracic and abdominal injuries represent a possible increase in morbidity and mortality; hence, working toward their prevention and timely intervention is necessary.

Introduction

Accidents have always been a leading cause of blunt trauma throughout the world and blunt thoracoabdominal injuries are one of the major causes of unnatural deaths.[1] Thoracoabdominal injuries are caused due to road traffic accidents (RTA), falls from height, railway accidents, industrial accidents, agricultural accidents, domestic accidents, homicides, and suicides. In blunt traumas, the abdomen transmits the force of violence to more resistant organs inside the abdominal cavity, which get injured and are often unnoticed. They are also associated with injuries to other body parts like the head, spine, and limbs. Early detection of the injury and prompt treatment are necessary for saving lives.[2] The Injury Severity Score (ISS), formulated by Bekar et al.[3] from the Abbreviated Injury Scale (AIS), is an anatomical scoring system that gives an overall score for cases with multiple injuries. Thus, a postmortem study of ISS can point out what kind of injuries are incompatible with life as well as their severity. Primary care physicians are often the first contact for any RTA case and, hence, they need to conduct triaging and stabilize the cases by performing immediate life-saving procedures, and prior knowledge of the prevalent thoracoabdominal injuries following RTAs and ISS is a must.

Materials and Methods

Study design

This was a prospective cross-sectional study, which was conducted at the Department of Forensic Medicine and Toxicology of a teaching hospital in Northeastern India. The study period was for 3 years, starting from October 2020 till October 2023.

Sampling method

Convenient sampling was employed. All the cases of trauma admitted at the tertiary care hospital and upon death subjected to autopsy and were found to have thoracic or abdominal or combined thoracoabdominal injuries were included in this study. Cases with only head injuries or limb injuries or combined head and limb injuries without any involvement of injuries to the thoracic and abdominal region were excluded from this study.

Ethical considerations

Permission for this research was received from Institute’s Ethics Committee vide IEC/SFTMC/2020/06/026 dated 19 August, 2020. Written informed consent for participation in this research was obtained from the next of kin. Confidentiality was maintained throughout the research.

Data collection

A data collection proforma was used to gather detailed information regarding the deceased and circumstances leading to the death from all possible sources like police records, hospital treatment records from case sheets, investigating officers, legally authorized persons/relatives, and eyewitnesses. A thorough external and internal examination of the dead body was done at autopsy to look for every minute injury and detail resulting in the death of the person. The opinion regarding the cause of death was framed after the postmortem examination. ISS was calculated from the sum of the squares of the highest Abbreviated Injury scores (AIS) s of the three most severely injured body areas including the thoracoabdominal region, which gave us the range of severity of injury score which was incompatible with life. Further, it was compared with the survival period of the victim.[3] Injury to the pelvis was included in abdominal injury in our study; furthermore, the ‘associated injuries’ are head and neck injuries and limb injuries. As per requirements, these inferences were compared with other similar studies. The merits and the demerits with possible causes/reasons/solutions were deduced.

Data analysis

Data analysis was conducted using Statistical Package for the Social Sciences version 21.0.[4] Descriptive statistics, including frequencies and percentages, were used to express the data. Spearman’s correlation was employed to assess the relationships between variables, keeping a two-tailed significance level of 0.01.

Results

In a cohort comprising 80 study participants, demographic and incident-related characteristics were meticulously analyzed. Notably, the most commonly affected age group was 20–29 years (25%) as depicted in Figure 1, constituting two-third of the cases (mean age 38.49), with males prevailing over females at a ratio of 1:0.31. The temporal distribution revealed a preponderance of accidents during weekends, constituting 31 cases (38.75%), while 29 incidents (36.25%) occurred in the morning, with 17 cases (21.25%) transpiring at night. Urban areas accounted for 44 victims (55%), contrasting with their rural counterparts. Unfortunate outcomes were observed, with 45 victims (56.25%) succumbing to injuries within hospital premises and 19 individuals (23.75%) meeting their demise on-site. Regarding survival times post-thoraco-abdominal trauma, 18 victims (22.5%) perished instantly, 17 individuals (21.25%) survived between 1 and 7 days, and 16 cases (20%) experienced mortality within the initial hour. The distribution of cases by the type of accident is depicted in Figure 2. The manner of injury analysis revealed that 71 victims (88.75%) succumbed to accidental injuries, while 5 individuals (6.25%) and 4 (5%) met their end due to suicidal and homicidal injuries, respectively. Thoracic trauma predominated, with 57 cases (71.25%) displaying external thoracic injuries, encompassing contusions (54.38%), abrasions (38.59%), complete transactions (3.5%), and other injury types. External abdominal injuries were identified in 34 victims (43.05%), with contusions (44.11%) and abrasions (23.52%) being the most prevalent. Rib fractures constituted 61.25% of thoracic injuries, followed by lung injuries (23.75%) and heart injuries (8.75%). Liver injuries (21.25%) were the most common abdominal visceral injuries, followed by splenic injuries (17.5%), kidney injuries, and mesenteric injuries (11.25% each). The study underscored the prevalence of combined thoracoabdominal and associated injuries in 67 individuals (83.75%), while the thorax and associated injuries were identified in 7 cases (8.75%). Moreover, head and neck injuries were the most frequent associated injuries (88.75%), followed by lower limb injuries (76.25%) and upper limb injuries (57.5%). The primary causes of death were identified, with craniocerebral injury combined with hemorrhagic shock accounting for 36.25% of fatalities, and hemorrhagic shock alone contributing to 33.75% of cases. In assessing the correlation between survival periods and ISS, victims who succumbed on the spot exhibited a mean ISS of 73.37, while those who died in less than 1 h had a mean score of 45.5. The mean ISS for victims succumbing to concomitant thoracoabdominal injuries is detailed in Table 1. The relationship between the severity of injury based on the ISS and survival time of 78 victims were evaluated by Spearman Correlation Coefficient and the value was (−0.818) and the P value was 0.01, which signifies as the ISS increases, the survival time decreases drastically and there was a statistically significant correlation between ISS and the survival period the victims [Table 2 and Figure 3]. In the rest of the two cases, only thoracic or abdominal injury was present, so AIS was calculated and the value was 5 (fatal injury) for each case and the survival time was 1–2 h.

Figure 1.

Pie chart showing the distribution of study participants according to Age group

Figure 2.

Bar diagram showing the percentage of cases based on type of accident

Table 1.

Tabulation of injury severity score (ISS) with survival period

Survival Time	Injury Severity Score (Mean Value±Standard Deviation)
On spot death	73.37±16.37
<1 h	45.5±9.21
1–2 h	44.25±10.56
>2–6 h	43.5±11.24
>6–12 h	41.5±6.56
>12–24 h	32.11±5.97
>1–7 days	31.7±6.71
>1–2 weeks	24.5±6.03
Total (0–2 weeks)	45.88±19.32

Table 2.

Correlation between ISS with survival time

	Survival time	ISS
Correlation Coefficient	1.000	−0.818**
Survival time Sig. (2-tailed)		0.000
Spearman’s
n	78	78
Correlation Coefficient	−0.818**	1.000
ISS Sig. (2-tailed)	0.000
n	78	78

**Correlation is significant at the 0.01 level (2-tailed)

Figure 3.

Graph showing Spearman’s correlation between Survival time (X-axis) and ISS (Y-axis)

Discussion

The current research focuses on thoracoabdominal trauma, which includes demographic and incident-related variables. It is significant in emergency, primary, and trauma care because it systematically uses the ISS to predict patient outcomes based on mortality or hospital stay duration. The ISS is a widely used scoring system in trauma literature that assigns a score (1–6) to each injury in six body regions and calculates the overall severity by summing the squared values of the three most severely affected body parts.[3] However, the ISS system is criticized for potentially underestimating injury severity because it can only calculate one lesion per body region. The study aligns with existing literature, such as works done by Th M and Nabachandra H, Al-Salem AH and Qaisaruddin S, Singh M et al., and Reddy NB et al., particularly in the patterns of internal thoracic, liver, spleen, and kidney injuries.[5,6,7,8] The prevalence of craniocerebral injury combined with hemorrhagic shock as the primary cause of death corresponds with previous findings.[5] The study shows a negative correlation between survival periods and ISS among victims, indicating that as ISS increases, survival period significantly decreases (Spearman Correlation Coefficient: −.818, P value: 0.01). The study suggests integrating the ISS system into hospital guidelines for trauma patients to facilitate comprehensive assessment. It also highlights the medico-legal relevance of ISS in determining the nature and preventability of injuries. Timely diagnosis and surgical intervention in thoracoabdominal injuries, especially those without visible external injuries, are crucial for reducing morbidity and mortality rates. The discussion extends beyond the study’s findings to address the broader implications of thoracic and abdominal injury assessment, severity grading, and the role of radiological investigations in polytrauma cases. It stresses the importance of early intervention and life-saving measures to decrease mortality and morbidity rates. The subsequent addition to the discussion underscores the crucial role of primary care physicians in the initial evaluation and management of thoracoabdominal injuries. It outlines key steps, including initial evaluation and triage, stabilization, pain management, diagnostic workup, consultation and referral, monitoring and follow-up, counselling and education, and care coordination. The significance of primary care physicians in ensuring prompt and effective care is emphasized while recognizing that severe cases may require the expertise of surgeons, trauma specialists, and other healthcare providers with specific training in trauma care. Primary care physicians have pivotal roles encompassing initial evaluation and triage, where they assess injury severity and determine the need for emergency care, ranking patients based on vital signs. They also engage in stabilization, performing life-saving measures for unstable or critical patients, addressing issues like maintaining airways and controlling bleeding. Pain management involves utilizing pharmaceutical and nonpharmacological methods for thoracoabdominal injuries. Primary care physicians contribute to the diagnostic workup by ordering or assisting with tests such as CT scans, ultrasounds, or X-rays to identify fractures or internal damage. Consultation and referral involve collaborating with specialists, like radiologists or trauma surgeons, based on injury extent, facilitating prompt patient referral for additional care. Monitoring and follow-up ensure ongoing patient progress, counseling, and education involve informing patients about conditions and providing emotional support during healing. Care coordination involves working with other medical professionals to ensure comprehensive treatment. As the thorax and abdomen contain complex structures and effects of biomechanics of injuries are often unnoticed or undiagnosed because of lack of early clinical features. Unless and until radiological investigations and proper clinical evaluations are done in due time, one cannot stop the catastrophe. Here is the role of robust and pro-active policies that should be framed at different healthcare levels fundamentally focusing on primary care. Routine and mandatory evaluations of all suspected/trivial thoracic and abdominal injuries using necessary investigations should be the ‘Good Practice’ among the ‘First Contact Physicians’. While primary care physicians are crucial in the initial treatment of thoracoabdominal injuries, severe cases often necessitate the expertise of surgeons, trauma specialists, and healthcare providers with specific trauma care training, highlighting the importance of prompt and effective care in diagnosis and treatment.

Limitation

This study involved only fatal cases of thoracoabdominal injury, which were subjected to medicolegal autopsy for formulating the ISS. Co-morbid conditions were not taken into consideration in this study, as this study focused on survival periods based on trauma scoring. However, the presence of co-morbidities and their impact on trauma outcomes may need further evaluation for validating the trauma scoring if any.

Conclusion

The chest and abdomen contain vital organs and complex structures that can easily be damaged even with minor trauma. Primary care physicians are usually the first medical professionals to attend many of these injury cases in India. Therefore, there should be an effort to increase awareness among primary care physicians, radiologists, and other specialists about using severity scoring systems in emergency rooms and trauma centers. Doing so can help reduce mortality and morbidity.

Data availability statement

The data collected and analyzed during the study are available from the corresponding author upon request.

Financial support and sponsorship

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.