Abdominal haemorrhage--a preventable cause of death after field stabilization?

The causes of preventable death vary in different operational settings, and the topic has not previously been explored in a fully developed central European rescue system. The factors associated with potentially preventable death were studied in a retrospective study of 430 fatal traffic accident victims (1980-96) in Lörrach County, Germany. Mission protocols could be retrieved for detailed analysis in 239 of the cases. These were studied in order to identify factors associated with preventable death. At the scene of the accident, 38% of the patients died without cardiopulmonary resuscitation (CPR) and 18% after CPR. Four patients died after a certain delay without CPR before reaching hospital. A total of 43% of the victims were admitted to hospital, 5% had received prehospital CPR and the remaining 38% had not. In a subgroup representing the experience of a single emergency physician 60 fatalities were studied. Of these, 27 (45%) patients died within the hospital; almost half of these cases (13/27) had been conscious at some time after the accident and of these, seven (7/13) died from intra-abdominal bleeding within 4 h after admission. The same cause of death was found in 3 of the 14 comatose patients. Pleural drainage was carried out in four patients and unrecognized pneumothoraces or spinal injuries did not occur. Tracheal intubation was employed in 24/27. Medical antishock trousers (MAST) were not available. The data indicate that intra-abdominal haemorrhage is an underestimated cause of death in a comprehensive rescue system, possibly as a consequence of field stabilization. The use of MAST may be a relevant therapeutic option to prevent these fatalities. The method offers the possibility of intra-abdominal compression and haemostasis after tracheal intubation has been performed. Previous controlled studies on MAST may have been biased by faulty methodology (e.g. absence of tracheal intubation) and inappropriate indications (e.g. other causes of shock). The value of MAST in comprehensive rescue systems should therefore be reassessed. The difficulties in identifying factors leading to preventable death in a retrospective analysis, are discussed and it is recommended that a permanent prospective quality control be performed in all cases of fatal accidents in order to ensure the continued improvement of prehospital emergency medical systems.