title: Necessity of including medico-legal autopsy data in epidemiological surveys of individuals with major trauma.
abstract: BACKGROUND
  It is rare that epidemiological surveys of patients with major trauma include both those admitted to the emergency department and those sent for medico-legal autopsy. The main aim of the present population-based study of major trauma was to examine the importance of medico-legal autopsy data.
  
  
  METHODS
  A new injury severity score (NISS)>15 or lethal outcome was used as criteria for major trauma and to identify patients at the emergency, anaesthesiology and forensic departments and/or being within the jurisdiction of the Malmö police authority and subjected to a medico-legal autopsy between 2011 and 2013. According to Swedish legislation all trauma related deaths should be reported to the police who refer these cases for medico-legal autopsy.
  
  
  RESULTS
  Among the 174 individuals included, 92 (53%) died and 81 (47%) underwent medico-legal autopsy. One hundred twenty-six patients were primarily admitted to hospital and 48 died before admission to hospital and were sent directly for medico-legal autopsy. Forty-four in-hospital deaths occurred, of whom 33 (75%) were sent to medico-legal autopsy. In those sent directly to the department of forensic medicine the proportion of accidents was lower (p<0.001), self-inflicted injuries higher (p<0.001) and gunshot wounds higher (p=0.002) in comparison with those sent to hospital. The most prevalent drugs detected by forensic toxicology screening in the 81 fatalities were ethanol (20%), sedatives (16%), anti-depressives (15%) and illicit narcotics (9%). Forty-four cases (54%) were positive for at least one drug, and twenty-eight cases (35%) were positive for two or more drugs. Factors associated with a lower rate of medico-legal autopsies among trauma-related deaths at hospital were high age (p<0.001), lower NISS (p<0.001), a longer duration between trauma and death (p<0.001), falls (p=0.030) and trauma-related infections (p<0.001).
  
  
  CONCLUSIONS
  This population based study covering clinical and forensic data shows that more than half of the individuals sustaining major trauma died. An additional 25% of the in-hospital fatalities should have undergone medico-legal autopsy according to legislation, but did not. The high proportion of positive toxicological findings among fatalities examined at medico-legal autopsy implies that toxicology screening should be routine in major trauma patients, in order to improve treatment and prevention.
authors.affiliation: Department of Surgery, Skåne University Hospital, Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Bagher
authors.affiliation: National Board of Forensic Medicine, Lund, Sweden; Unit for Forensic Medicine, Department of Clinical Sciences, Lund University, Sweden.
authors.forename: C J
authors.initials: CJ
authors.lastname: Wingren
authors.affiliation: National Board of Forensic Medicine, Lund, Sweden; Unit for Forensic Medicine, Department of Clinical Sciences, Lund University, Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Ottosson
authors.affiliation: Department of Emergency Medicine, Skåne University Hospital, Sweden.
authors.forename: L
authors.initials: L
authors.lastname: Andersson
authors.affiliation: Department of Surgery, Skåne University Hospital, Sweden.
authors.forename: S
authors.initials: S
authors.lastname: Wangefjord
authors.affiliation: Vascular Centre, Skåne University Hospital, Sweden. Electronic address: stefan.acosta@telia.com.
authors.forename: S
authors.initials: S
authors.lastname: Acosta
mesh_terms: D000046:Academic Medical Centers; D000059:Accidents / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D000293:Adolescent; D000328:Adult; D001344:Autopsy / Q000706:statistics & numerical data*; D002423:Cause of Death / Q000639:trends; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005554:Forensic Medicine / Q000331:legislation & jurisprudence; D006708:Homicide / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000453:epidemiology*; D011159:Population Surveillance; D015203:Reproducibility of Results; D013405:Suicide / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D013548:Sweden / Q000453:epidemiology
keywords: Forensic toxicology; Major trauma; Medico-legal autopsy; Mortality; New injury severity score; Prevention