PATTERN OF TRAUMATIC DEATHS IN PATIENTS ADMITTED TO SOAD KAFAFY HOSPITAL. MEDICOLEGAL STUDY

Background: The fifth most frequent cause of reported impairment is trauma, and is thought to be responsible for 10% of all deaths globally. For the first four decades of life, it continues to be the biggest threat to public health and the main reason for death and disability. Objectives: The current study aims to evaluate cases of death due to traumatic injuries admitted to Soad Kafafy Hospital regarding the manner of exposure, causes of injury, mechanism of injury, and time between admission and death. Methods: This study was a cross-sectional retrospective study conducted on cases of traumatic injury admitted to Soad kafafy hospital from the first of January till the last day of December 2019. Data was collected from the patient's records regarding demographic data, department of admission, and other data on medico-legal aspects such as exposure, causes of injury, mechanism of injury and time between admission and death. Results: thirty-five deaths due to traumatic causes were included within the study period. The majority of cases were males (71.4%) and the majority of them were within the first (< 10 years) and the fourth (30-40 years) age groups. The majority of cases were exposed to motor vehicle accidents and died due to head trauma. There was a significant correlation between the cause of injury, cause and manner of death, and period of survival. Conclusions and Recommendations: Motor vehicle accidents were the most common cause of injury-related deaths, the majority of causes fall under category A (CNS causes) and the highest percentage of deaths occurred after more than seven days. however, homicidal physical attacks, with Class A (CNS) injuries, and acute or early mortality were anticipated. Therefore, Prompt identification and early treatment are critical when a patient meets those criteria.


INTRODUCTION
The fifth most frequent cause of reported impairment is trauma and is thought to be responsible for 10% of all deaths globally.For the first four decades of life, it continues to be the biggest threat to public health and the main reason for death and disability (Fouad et al., 2019).
Trauma can have many different consequences, ranging from endangering life to seriously impairing mental and physical health and negatively affecting social and economic development (Mahran et al., 2016).
The World Health Organization (WHO) states that 2.37% of all yearly fatality cases are attributable to injuries sustained on the road.14.46 deaths occur for every 100,000 people (Alhaizaey et al., 2015).
The standard trimodal distribution of trauma deaths was described by (Baker et al., 1980), in their 1977 study on trauma deaths over one year in the San Francisco area.Rapid exsanguination and nonsurvivable central nervous system (CNS) injuries were the main causes of the first peak's instantaneous deaths.The early hospital deaths, which were primarily brought on by brain damage and exsanguination, were included in the second peak.Seventy-five percent of the late deaths were ascribed to multiple organ failure (MOF), constituting the third peak (Evans et al., 2010).
The most frequent traumatic injuries are bone fractures and traumatic head injuries, which account for a large percentage of injury cases requiring forensic analysis.Injuries to the head are thought to be among the leading causes of homicidal deaths globally (Ali et al., 2022).
Given that they occur in between 3% and 8% of all patients who experience trauma, pelvic ring fractures are regarded as rare fractures.Similar to several skeletal fractures, traumatic pelvic fractures have been linked to several medico-legal ramifications, including the need to pursue compensation, the possibility of long-term disability, and malpractice claims (Mohamed & Elzahed, 2019).
The aim of the current study is to assess cases of death due to traumatic injuries admitted to Soad Kafafy Hospital regarding the manner of exposure, causes of injury, mechanism of injury, and time between admission and death.

SUBJECTS AND METHODS
This study was a cross-sectional retrospective study conducted on cases of traumatic injury admitted to Soad Kafafy Hospital from the first of January till the last day of December 2019.Data were collected from the patient's records regarding demographic data, department of admission, and other data on medico-legal aspects such as the manner of exposure, causes of injury, mechanism of injury and time between admission and death.(e) other-other fatal injuries, such as airway injuries, or subsequent complications, such as myocardial infarction, pulmonary embolism, etc.; and (f) uncertain.

d-Time between admission and death
Following admission, deaths were categorized as acute (before 48 hours), early (between 3 to 7 days after injury), and late (after 7 days) (Sauaia et al., 1995).

Statistical analysis of the data
Data were fed to the computer using IBM SPSS software package version 24.0.Shapiro-Wilk test was used to test of normality of data, the data Time between admission and death was nonparametric data, and the Kolmogorov-Smirnov and Shapiro-Wilk had p value <0.05.
For normally distributed data, the mean and standard deviation were used to characterize quantitative data.
For normally distributed data, comparisons between two independent populations were done using the Whitney -test, while for comparisons between more than two groups we used the Kruskal-Wallis test The chi-square test was used to compare between categorized data.
The results of significance tests are expressed as a two-tailed probability.The results were considered significant at the 5% level.

RESULTS
In the current study, thirty-five deaths due to traumatic causes were included within the study period.The majority of cases were males (71.4%) from greater Cairo with mean age 24 years and the majority of them were within the first (<10 years) and the fourth (30-40 years) age groups (table 1).Regarding the department of admission, 83 % of cases were admitted to the neurosurgery department and 17 % were admitted to the orthopedic department (table 1).
From the medico-legal aspect, when studying the cause of injury, motor vehicle accidents were the most common cause followed by physical assaults, so accidental incidents were the most prevalent at 71 %.Regarding the causes of death, the majority of the causes are included in category A (CNS causes) as skull fractures, brain edema, and extra, subdural, and subarachnoid hemorrhages.Also, other categories were organ failure (category D) as renal failure and ARDS and others (category E) as pulmonary embolism and shock.Regarding time between admission and death, 42.9 % of cases died late after more than 7 days, while 31 % died between 3 to 5 days and 25 % of cases died within two days of admission (table 2).
When discussing the relationship between demographic data and the time between admission and death, we can find a significant correlation regarding sex and residence where the majority of female cases died late (> 7 days) (table 3).Furthermore, there was a significant correlation between injury cause and period of survival where patients exposed to severe physical assault died earlier than those of motor vehicle accidents, also period of survival showed a significant correlation with cause and manner of death where direct CNS trauma and homicidal cases showed significant lower survival period after admission than others (table 4).
Table ( 5), shows the Multiple logistic regression analysis of different risk factors affecting the time between admission and death.This model was done using the significant variables which affect early mortality, from this significant item it was found that the most predictor factors for acute and early mortality were mechanisms of injury (assault), direct relation between trauma and death, class A (CNS) injuries, and homicidal death.If these factors were found in one patient, the mortality was acute or early.

DISCUSSION
Trauma is considered one of the most common causes of death worldwide.The current study was conducted on dead cases due to traumatic causes in Soad Kafafy Hospital.As regards the age of cases, most cases (85.7 %) were below 40 years, whereas the lowest number were more than 40 years (14.3 %) of all cases, this was in line with research from India (Sivakumar et al., 2018) and studies from England, Belgium and South Africa, that revealed that young individuals in active age groups had the highest risk of traumatic injuries (Jasper, 2014).The study's findings may be the consequence of young adults as young adults often engage in riskier activities compared to other age groups, such as extreme sports, reckless driving, or participating in dangerous stunts, which increases their chances of experiencing traumatic injuries (El-Farouny, 2021).
Males were around three times more likely than females in our study to die from traumatic injuries; other studies conducted in Iran, Bangladesh, and Taiwan also revealed comparable results (Akber et al., 2016;Hsu et al., 2018;Roshanaei et al., 2022), these studies all revealed a majority of men.It is expected that men are more prone to trauma due to the nature of their occupational standing in comparison to women.(Beigzadeh et al., 2015;Kanwar et al., 2019) Men are more likely to be in stressful situations, which increases their vulnerability to becoming involved in violent acts, and they are also more likely to work outside, which makes them more likely to be involved in traffic accidents, attacks, and injuries.This reflects the gender's susceptibility to trauma and the detrimental effects it has on their life productivity (Habib, 2019).
The study center's proximity to a major highway is likely the source of this high rate.RTAs can be caused by dangerous vehicles and roads, inadequate safety measures, or human mistakes; of these, human error is the most frequent cause.A few examples of human error include driving while intoxicated, speeding and passing illegally, using a phone while operating a vehicle, and poor driving skills (Bahadorimonfared et al., 2013;Soori et al., 2011).
Regarding the causes of death, the majority of the causes are included in category A (CNS causes) as skull fractures, brain edema, extra, subdural and subarachnoid hemorrhages (62.9 %).According to other publications, CNS injuries account for the majority of deaths, with rates ranging from 21% to 71%.(Carrasco et al., 2012;Kauvar et al., 2006;Pfeifer et al., 2009).This may be owing to a Lack of Protective Mechanisms; unlike other parts of the body, the CNS has limited natural protective mechanisms.For instance, the brain lacks thick layers of muscle or fat to absorb impact, and the spinal cord is surrounded by bony vertebrae, which can be damaged in traumatic events.
Regarding time between admission and death, 42.9 % of cases died late after more than 7 days, while 31 % died between 3 to 5 days and 25 % of cases died within two days of admission.
This was in accordance with the first case series in 1972, permanent brain injury, such as brain, brain stem, or spinal cord lacerations, was the cause of death for 45% of the patients in the immediate death category (Carrasco et al., 2012).
The reason why most trauma deaths occur after the first two days could be attributed to fewer severe injuries, improved prehospital care, and quicker transportation to trauma centers.
In addition, our study revealed that direct CNS trauma and homicidal cases showed significantly lower survival periods after admission than others while late deaths were mostly due to organ failure.According to research by Baker and colleagues (Baker et al., 1980), the majority of head injury deaths occurred within the first two days following the accident.Cowley stated that irreparable head injuries were the most common causes of death in his studied group.(Cowley, 1976) .Meislin et al. also demonstrated that more than 80% of early deaths were caused by brain damage and circulatory collapse or bleeding (Meislin et al., 1997).According to Trunkey's research, infections or multiple organ failure accounted for 80% of hospitalized patients' late deaths (Trunkey, 1983).Similarly, Baker discovered that sepsis and multiple organ failure accounted for 78% of deaths that occurred after 7 days (Baker et al., 1980).According to Sauaia et al, organ failure accounted for (61%) of patient deaths that occurred more than one week after the initial injury (Sauaia et al., 1995).Likewise, among those who died between two and three weeks following their accident, 48% suffered from neurological damage, 35% from hemorrhage or circulatory collapse, and 16% from multiple organ failure.According to this research, multiple organ failure becomes increasingly common with time, even in patients who survive the first twenty-four hours, bleeding and head traumas continue to be major causes of death.(Sobrino & Shafi, 2013).
In contrast to our study, Sauaia et al., 1995 concluded that trauma deaths that occurred within 48 hours of the injury were most frequently caused by exsanguination (51%) as a result of damage to the heart, liver, or major blood vessels.
Our results showed that class A (CNS) injuries, homicidal death, and injuries caused by physical assaults were predictive factors.when the patient is fulfilling this criterion, the mortality is expected to be acute or early, therefore prompt diagnosis and treatment are essential.Further researches are needed to confirm our results and prove them with more strong pieces of evidence.

CONCLUSION AND RECOMMENDATIONS
In conclusion, motor vehicle accidents were the most common cause of injury-related deaths, and the highest percentage of deaths occurred after more than seven days.The most common causes of injuries related deaths fall under category A (CNS causes), which include brain edema, intracranial hemorrhages, and skull fractures.Traumatic deaths also tended to occur Egypt J. Forensic Sci.Appli.Toxicol.
Vol 23 (4), Dec 2023 of injury: (Road traffic accident, fall, physical assault, …etc).c-Mechanism of death: was classified into six categories(Sauaia et al., 1995): (a) CNS (central nervous system) --Fatal injuries related to the high cervical spine, brain, and brain stem; (b) exsanguination-mostly caused by uncontrollable hemorrhage; (c) The combination of categories (a) and (b).(d) organ failure-Multiple organ failure or Acute respiratory distress syndrome;

Table ( 1
): demographic data and admission department of the studied cases.

Table ( 2
): Distribution of the studied group regarding the death conditions.

Table ( 3
): Relation between time between admission and death regarding basic demographic data.
Dependent Variable: time between admission and death.
at a higher percentage in Males and people under 40 years of age.Predictive indicators of mortality were Class A (CNS) injuries, homicidal attacks, and injuries from physical assaults.Prompt identification and treatment are critical because when a patient meets those criteria, acute or early mortality is anticipated.We recommend conducting additional research over a longer period and utilizing established medical scores to assess the severity of injuries.Additionally, the establishment of trauma centers that are easily accessible to children and adolescents who are experiencing trauma, as these populations deserve more attention and study.