Emergency. 2018; 6 (1): e48 BR I E F RE P O RT Characteristics of Mortalities related to Pulmonary Em- bolism following Multiple Trauma; a Brief Report Fares Najari1∗, Babak Mostafazadeh1, Asadollah Akbari2, Ideh Baradaran kayai2, Dorsa Najari3 1. Forensic Medicine Department, Shohadaye Tajrish Hospital, Medical Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Legal Medicine Organization, Tehran, Iran. 3. Medical Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: March 2018; Accepted: May 2018; Published online: 7 August 2018 Abstract: Introduction: Pulmonary embolism (PE) is introduced as the third major cause of death after trauma in those who survive more than 24 hours. This study aimed to describe the characteristics of mortalities due to trauma related PE in cases referred to the forensic medicine department. Methods: The present cross sectional study was conducted on medical profiles of cadavers that were registered as trauma related mortality in the dissec- tion department of the Forensic Medicine Organization, Tehran, Iran, during 2011 to 2016. Results: The cause of death for 92 of the 10800 (0.85%) evaluated cadavers was diagnosed as trauma related PE. The mean age of these patients was 58.37 ± 19.39 years (66.3% male). Only 14 (15.2%) hospitalized patients had received anti- coagulant agents. The most frequent trauma related PE mortality cases were male (p = 0.003) and aged > 55 years (p = 0.005), with trauma to death time of < 3 weeks (p = 0.004), lower limb injury (p = 0.003), car crash trauma mechanism (p = 0.003), and no anticoagulant prescribed (p = 0.001). Conclusion: According to the re- sults of the present study, the prevalence of trauma related PE mortality was 0.85%. It seems that, having a clear anticoagulation therapy protocol in trauma centers could be helpful in decreasing the prevalence of traumatic thromboembolism and its’ related mortality. Keywords: Venous Thromboembolism; multiple trauma; Pulmonary Embolism; mortality; forensic medicine © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Najari F, Mostafazadeh B, Akbari A, Baradaran kaya I, Najari D. Characteristics of Mortalities related to Pulmonary Em- bolism following Multiple Trauma; a Brief Report. 2018; 6(1): e48. 1. Introduction Trauma patients are predisposed to venous thromboem- bolism (VTE) and pulmonary embolism (PE). Increase in the activity of blood coagulation factors, local vascular injuries in the damaged tissues, and hospitalization are some of the predisposing factors of thrombosis in these patients. So, some traumas may not be fatal in nature but may cause death due to PE (1). PE is introduced as the third major cause of death after trauma in patients who survive more than 24 hours after injury (2). The reported incidence of VTE after trauma anges from 7% to 58% depending on the demographics of the patients, the nature of the injuries, the method of detection (i.e. surveillance imaging versus clinical ∗Corresponding Author: Fares Najari; Forensic Medicine Department, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran. Tel: 00989123195140 Email: najari.hospital@sbmu.ac.ir. detection), and the type of VTE prophylaxis (if any) used in the study population (1-5). VTE is asymptomatic, and more than 70% of PE cases go undetected until a postmortem examination is performed after sudden death. Sudden death is often the first sign of PE (6). Since the mortality rate of post-traumatic PE approaches 50% in some series, most trauma centers have developed protocols for VTE prophy- laxis, although there are no large studies to document the efficacy of any method of prophylaxis in this heterogeneous population. In a study by Mostafazadeh et al. on 200 cadav- ers suspected of having PE, its prevalence was estimated as 13.5% (7). This study aimed to describe the characteristics of trauma related VTE mortality cases referred to the forensic medicine department. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com F. Najari et al. 2 2. Methods 2.1. Study design and setting The present cross sectional study was conducted on med- ical profiles of cadavers who were registered as trauma re- lated mortality in the dissection department of the Forensic Medicine Organization, Tehran, Iran, from 2011 to 2016. The study was approved by the ethics committee of Shahid Be- heshti University of Medical Sciences; all data were treated as confidential. 2.2. Participants Cases whose cause of death was diagnosed as trauma related PE at least 48 hours post trauma were enrolled. PE was con- firmed based on autopsy and pathology findings or by com- puted tomography (CT) angiography conducted in the hos- pital. Trauma related PE was define as PE that had started at least forty eight hours after the trauma up to 90 days after the trauma in a healthy patient without any underlying risk factor for thromboembolism. 2.3. Data gathering Data were gathered from medical profiles and autopsy re- ports by a trained forensic medicine resident. Using a researcher-made data collection form demographic data (age, sex), trauma to death time, site of injury, trauma mech- anism, and anticoagulant therapy were gathered for all of trauma related PE mortality cases. 2.4. Statistical analysis Data were descriptively analyzed using SPSS version 18 soft- ware. Qualitative data are reported as frequencies and per- centages, and quantitative data as mean ± standard devia- tion. Chi square test was used for analysis and P < 0.05 was considered as the level of significance. 3. Results: 10,800 cadavers of patients who had died from trauma were evaluated. The cause of death was diagnosed as trauma re- lated PE for 92 (0.85%) cadavers. The mean age of these pa- tients was 58.37 ± 19.39 (23-89) years (66.3% male). Table 1 shows the baseline characteristics of studied cadav- ers. PE was confirmed based on autopsy findings in 82 (89.1%) cases and via CT angiography in 10 (10.9%) cases. 60 (65.2%) cases had died during hospitalization, and 32 (34.8%) after discharge from hospital and in outpatients set- ting. None of the discharged patients were prescribed anti- coagulant and only 14 (15.2%) hospitalized patients had re- ceived anticoagulant agents. The most frequent trauma re- lated PE mortality cases were male (p = 0.003) and aged > 55 Table 1: Relationship between baseline characteristics of patients and trauma related thromboembolism mortality Variables Number (%) P Sex Male 61 (66.3) 0.003 Female 31 (33.7) Age (year) 23 - 35 6 (6.5) 35 - 55 23 (25) 0.004 > 55 63 (68.5) Trauma mechanism Car crash 64 (69.6) Falling 18 (19.6) 0.003 Assault 5 (5.4) Unknown 5 (5.4) Body site of injury Lower limb 45(48.9) Head 36 (39.1) 0.003 Spinal cord 10 (10.9) Upper limb 1 (1.1) Trauma to death time (day) 2 – 7 13 (14.1) 7 – 14 25 (27.2) 0.004 14 – 21 17 (18.5) > 21 37 (40.2) Anticoagulant therapy Yes 14 (15.2) 0.001 No 78 (84.8) years (p = 0.005), with trauma to death time of < 3 weeks (p = 0.004), lower limb injury (p = 0.003), car crash trauma mecha- nism (p = 0.003), and no anticoagulant prescribed (p = 0.001). 4. Discussion According to the results of the present study, the prevalence of trauma related PE mortality was 0.85%. In a study by Ho et al. in 2009 in Perth, West Australia, the prevalence of thromboembolism in similar cases was reported as 1.6% (8). In another study by Echeverria et al., in Sao Jose Hospital in Rio Pareto, Brazil, from July 2004 to June 2005, the total prevalence of thromboembolism was 2.75% (9). To explain the difference among the reported rates, former studies just focused on inpatients that died from thromboembolism af- ter trauma, whereas the present study also included patients who died in their homes and were assessed in the dissection department of the forensic organization. The mean age of the patients in the present study was 58.4 years, and most of the cases were aged >50 years. In line with our results, in the study by Mostafazadeh et al. most of the investigated cases were also aged >50 years (7). Some other studies also re- ported age of >40 years as a risk factor of thromboembolism (2, 4). In addition, a study by Alikhan et al. on cadavers that had undergone biopsy between 1991 and 2000 in King’s Col- lege Hospital, London, UK, showed that the mean age of the This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e48 patients who died from PE was 72 years and that 80% of them were aged >60 years (10). The aforementioned results indi- cated that as age increases, the mortality from thromboem- bolism after trauma also increases. In a study by Ho et al. that was published in the British Jour- nal of Anaesthesia, a significant association was reported be- tween fatal embolism and old age, accompanying disease, and high body mass index, although no significant associ- ation was observed with the place of trauma (8). However, a significant association was observed between lower limb and head injuries, with death from embolism after trauma in the present study. In a study conducted by Lu in China from 2003 to 2004 on traumatized patients with lower limb fractures, the prevalence of VTE was reported to be 12.4% and femoral shaft fracture was the most common fracture among the studied cases (11). It is noteworthy that patients with head trauma were also at high risk of thromboembolism (12). According to the results of the present study, the max- imum time interval between the incidence of trauma and death was less than 3 weeks; however, in a study by Yarak et al. in Istanbul, Turkey, from January 2010 to December 2014, the prevalence of death from PTE was 74% within the sec- ond week post trauma (13). Echeveria et al., in a study from 2004 to 2005, also reported car crash followed by falling from height as the main causes of death among cases who were referred to the forensic medicine organization; the findings were in agreement with those of the present study (9). Since approximately 35% of fatal embolism cases occur in outpa- tients immobilized because of splinting or casting, the ap- plication of a pharmaceutical/non-pharmaceutical method at the time of discharge is recommended to prevent throm- boembolism in such patients. Hence, mechanical or medi- cal prophylaxis, such as Clexane, is recommended to prevent thromboembolism in outpatients. 5. Conclusion According to the results of the present study, the prevalence of trauma related PE mortality was 0.85%. It seems that, hav- ing a clear anticoagulation therapy protocol in trauma cen- ters could be helpful in decreasing the prevalence of trau- matic thromboembolism and its related mortality. 6. Appendix 6.1. Acknowledgements The authors are grateful to the manager and staff of the au- topsy Hall of Tehran Medicine organization. 6.2. Author contribution All authors met the four criteria for authorship contribution based on the recommendations of the international commit- tee of medical journal editors. 6.3. Funding This study did not receive any specific grant from public funding agencies or commercial, or not-for-profit sectors. 6.4. Conflict of interest None. References 1. McLaughlin DF, Wade CE, Champion HR, Salinas J, Holcomb JB. Thromboembolic complications following trauma. Transfusion. 2009;49(s5):256S-63S. 2. Knudson MM, Ikossi DG. Venous thromboembolism af- ter trauma. Curr Opin Crit Care. 2004;10(6):539-48. 3. Golin V, Sprovieri SRS, Bedrikow R, Salles MJC. Pul- monary thromboembolism: retrospective study of necropsies performed over 24 years in a university hospi- tal in Brazil. Sao Paulo Medical Journal. 2002;120(4):105- 8. 4. Anderson FA, Spencer FA. 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Critical Care and Re- suscitation. 2012;14(1):10. 13. Yakar A, Yakar F, Ziyade N, Yildiz M, Uzun I. Fatal pul- monary thromboembolism. European review for medi- cal and pharmacological sciences. 2016;20(7):1323-6. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Methods Results: Discussion Conclusion Appendix References