Content area
Full Text
Population-based studies have reported significant reductions in mortality among major trauma patients in the past decade. 1-3 Advances in medical and surgical care, trauma centres and the development of trauma systems have been associated with this improvement in mortality among hospitalised patients. 4-7 A significant reduction in overall 'preventable deaths' in the past decade has been attributed to a greater number and proportion of trauma patients being managed primarily at major trauma centres, where preventable death rates have been observed to be consistently lower than at other hospitals. 3 8 Advances in trauma care have focused on early management and 'damage control' to limit immediate life-threatening sequelae of injury.
The trauma 'triad of death' describes the combination of hypothermia, acidosis and coagulopathy. 9 These three can develop quickly in the exsanguinating trauma patient and, once established, form a vicious circle that may be impossible to overcome. 10 Staged laparotomy has been described as one procedure that has improved the outcome from certain death to possible survival in this group of patients. 11
The profile of patients presenting to the emergency department (ED) with all three of hypothermia, acidosis and coagulopathy remains unknown. This study aimed to review the presentation, management and outcome of patients presenting with the trauma 'triad of death'. This was undertaken to outline any change in outcome of such patients over time and examine potential strategies for improvement.
Methods
Setting
The state of Victoria, Australia, has one paediatric and two adult major trauma services (MTS) located within metropolitan Melbourne. Ambulance Victoria triages adult major trauma patients directly to an adult MTS when the travel time is less than 30 min. There are no current provisions for the administration of blood products during transit. The Alfred Hospital, Melbourne, Victoria, is the largest adult MTS in Australasia. There are more than 1930 trauma team activations per year. In 2008, 1007 patients had an injury severity score (ISS) of greater than 15 (unpublished data, The Alfred Trauma Registry).
Inclusion criteria
All major trauma (ISS >15) patients who presented to the Alfred Emergency and Trauma Centre between January 2003 and August 2010 and had the 'triad of death' on presentation were included in this study. Patients transferred from other centres were excluded ( figure 1 ).