Eur J Trauma Emerg Surg (2012) 38:19–24 DOI 10.1007/s00068-011-0114-5
ORIGINAL ARTICLE
Multiple blunt trauma after suicidal attempt: an analysis of 4,754 multiple severely injured patients T. Topp • T. Mu¨ller • I. Kiriazidis • R. Lefering • S. Ruchholtz • Trauma Registry of the German Trauma Society • C. A. Ku¨hne
Received: 26 April 2011 / Accepted: 26 April 2011 / Published online: 12 May 2011 Ó Springer-Verlag 2011
Abstract Purpose The suicidal attempt is a significant cause for multiple severe injuries in Germany. The aim of the present study was to obtain information regarding injury patterns, clinical treatment, and outcome. Methods We analyzed the data of 4,754 patients of the Trauma Registry of the German Trauma Society (1993–2007) with an Injury Severity Score (ISS) C9 after a suicidal jump from a height (SUICIDE) and after an accidental fall from a height (ACCIDENT). Results Comparing the data of 3,682 patients with accidental fall versus those with intentional fall/jump (n = 1,072), we found that male patients were predominant in the ACCIDENT group (84.9 vs. 52.2%). The SUICIDE group had more severe injuries (ISS: 31.8 vs. 26.4). The ACCIDENT group suffered more severe head injuries (51.1 vs. 36.6%). Mortality (21.4 vs. 14.2%), length of stay in hospital (29.5 vs. 26.5 days), and costs (€34,833 vs. €24,701) were higher in the SUICIDE group. Conclusions Falls from a height are a common cause of injury among severely injured patients. The resulting trauma composes a particular form of blunt trauma with severe and multiple injuries, which depends on the fact of whether the free fall from a height was caused by an
T. Topp (&) T. Mu¨ller I. Kiriazidis S. Ruchholtz C. A. Ku¨hne Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033 Marburg, Germany e-mail: [email protected] R. Lefering Faculty of Medicine, Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
accident or as a result of a suicidal attempt. Taking the injury severity into consideration, there is no difference in the prognosis of the patients. Keywords Suicide Multiple blunt trauma Mortality Injury pattern Epidemiology Outcome
Introduction In Germany, severe blunt trauma is the most common cause of death in patients younger than 40 years of age. A total of 32,000–36,000 patients are treated in trauma centers every year following multiple severe trauma [1, 2]. The socioeconomic relevance of multiple injured patients for the health system is fundamental. Recently published studies showed calculated costs of €24,004 per patient [3]. Although most of these patients were injured in car or workplace accidents, blunt trauma after a suicidal attempt is one of the most important mechanisms of injury among the group of multiple injured patients in modern industrial nations. Until today, no reliable data exist concerning the incidence of multiple blunt trauma after suicidal attempts. The official mortality statistics show the importance of suicides in our society. In Germany, 9,402 suicides were reported in 2007, more than the number of deaths as a consequence of traffic accidents (n = 4,949). A total of 1,514 of these cases showed multiple blunt trauma [4]. According to a World Health Organization (WHO) Multicenter Study on parasuicide from 1989 to 1995, suicide is attempted by 77 of 100,000 men and 127 of 100,000 women per year in Germany. Jumps from a height occur in approximately 9% of all suicides and in approximately 6% of all suicidal attempts. In Europe, an occurrence of 28 suicides per 100,000 inhabitants per year was found [5].
123
20
Materials and methods The Trauma Registry of the German Trauma Society (TR-DGU) was established in 1993 by the society’s Working Group on Polytrauma to prospectively collect multicentric data from patients with severe trauma. Currently, hospitals in Germany, Austria, Switzerland, Slovenia, and the Netherlands participate in the TR-DGU. Parameters for prehospital and trauma-room treatments, and subsequent treatment in the intensive care unit (ICU), are continuously recorded on a web-based data server. Each patient admitted to one of the participating trauma hospitals because of severe trauma or being treated in the ICU is recorded in the registry. Data anonymity is guaranteed for participating patients, as well as for hospitals. The registry records epidemiological, physiological, laboratory, diagnostic, operative, interventional, and intensive care medical data, as well as injury severity scores and outcome data [9]. Inclusion criteria for this study were patients with an Injury Severity Score (ISS) C9, a blunt trauma after a jump/fall from a height, and a documented attempt of suicide or accident. During the period 1993–2007, 30,603 datasets were analyzed. Objects of the analysis were gender, age, Glasgow Coma Scale (GCS) score, mortality, shock, alcohol and drug abuse, mechanism of injury, length of stay in the ICU, number of admitted packed red blood cells (PRBC), preclinical substitution of volume, multiorgan failure (MOF), sepsis, and costs. The prognosis of the patients were derived using the Revised Injury Severity Classification (RISC) score, and the Standardized Mortality Ratio (SMR; ratio of recorded to expected mortality) was calculated. This score was developed with data from 2,009 patients in the Trauma Registry (1993–2000) and has been validated for 3,475 patients (2001–2003). RISC-score-adjusted outcome comparisons have been routinely reported every year by the Trauma Registry since 2003 [10]. The five categories of the GOS (1, dead; 2, vegetative state, unable to interact with environment; 3, severe disability, able to follow commands/ unable to live independently; 4, moderate disability, to live independently, unable to return to work or school; 5, good
123
recovery, able to return to work or school) were used as additional parameters to compare the clinical outcome of the patients. Injury patterns were described for the following four body regions: ‘‘head and neck’’, ‘‘thorax’’, ‘‘abdomen’’, and the ‘‘extremities’’. Each of these regions was classified as severely injured if an Abbreviated Injury Scale (AIS) severity grade was C3. To estimate the costs for in-hospital treatment, an algorithm established by Pape et al. [11] with data of the TR-DGU in 2003 was used. The costs were calculated from material and personnel expenses at different times of the clinical care: rescue phase, emergency room, operating room, ICU, and general ward. Data are presented as mean with standard deviation (SD) and were analyzed with the Chi-square test for categorical variables and the t-test for continuous variables. Confidence intervals of 95% are reported. SPSS 18 for Windows statistical software was used (IBM Corporation, Somers, NY, USA).
Results From 1993–2007, 30,603 severe trauma patients with an Injury Severity Score (ISS) C9 were documented. The group of patients with a free fall from a height consisted of 3,682 accidentally injured patients (77.5%, ACCIDENT) and 1,070 patients with a suicidal attempt (22.5%, SUICIDE). Males comprised 84.9% of the patients in the ACCIDENT group and 52.2% of the patients in the SUICIDE group (Fig. 1, p \ 0.001). The mean age of the patients in the ACCIDENT group was 44.6 years, compared to a mean age of 39.6 years in the SUICIDE group (p [ 0.05). Patients after a suicidal attempt were more severely injured than patients after an accidental fall from a height. Patients in the SUICIDE group had a mean ISS of 31.8,
percentage
Most clinical studies on this topic were based on monoinstitutional databases with relatively small numbers of patients [6–8]. The presented study examined the epidemiological and clinical findings of patients admitted to hospital after an attempted suicide. Findings were compared to those patients who had severe injuries caused by an accident, based on a large database of more than 30,000 patients from the Trauma Registry of the German Trauma Society (TR-DGU).
T. Topp et al.
90,00% 80,00% 70,00% 60,00% 50,00%
ACCIDENT SUICIDE
40,00% 30,00% 20,00% 10,00% 0,00% Female
Male
Fig. 1 Distribution of the sexes in the ACCIDENT and SUICIDE groups
Multiple blunt trauma after suicidal attempt
21
Table 1 Number of applied packed red blood cells (PRBC) and ventilation-free days, duration of stay in the intensive care unit (ICU), and duration of hospitalization Packed red blood cells
Ventilation-free days
Days in ICU
Days in hospital
ACCIDENT
1.4 (±4.6)
20.6 (±11.7)
11.0 (±15.2)
28.4 (±33.3)
SUICIDE
4.0 (±7.0)
16.8 (±12.3)
14.9 (±17.7)
34.7 (±34.9)
p-value non-suicide versus suicide for all parameters: p \ 0.0001 100,00% 90,00% ACCIDENT
80,00%
SUICIDE
70,00%
percentage
Fig. 2 Percentage of patients who needed operative treatment, percentage of unconscious patients with a Glasgow Coma Scale (GCS) \8, percentage of patients with multiorgan failure (MOF) and shock situations, and percentage of in-hospital mortality
60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00%
operations
whereas patients in the ACCIDENT group had a mean ISS of 26.4 (p \ 0.001). Table 1 shows the different amounts of required PRBC and differences between ventilation-free days, days in the ICU, and the duration of hospitalization. The need for operations (88.2 vs. 79.2%, p \ 0.001) and the number of unconscious patients (35.2 vs. 25.3%, p \ 0.001) was also higher in the SUICIDE group. In addition to this, MOF and shocks occurred at a higher percentage in this group (MOF: 32.7 vs. 20.0%, p \ 0.001; shock 27.6 vs. 10.8%, p \ 0.001). Patients with a suicidal attempt also had a higher ‘‘in-hospital mortality’’ than patients without a suicidal attempt (21.4 vs. 14.2%, p \ 0.001) (Fig. 2). The different injury patterns among these two groups are given in Fig. 3. Head injuries with an AIS C3 occurred more often within the ACCIDENT group than within the SUICIDE group (51.1 vs. 36.6%, p \ 0.001). Severe injuries with an AIS C3 of the thorax (61.8 vs. 53.2%, p \ 0.001), the abdomen (40.0 vs. 20.4%, p \ 0.001), and the extremities (62.5 vs. 33.1%, p \ 0.001) were found more often in the SUICIDE group (Fig. 3). Severe pelvic injuries were also found more often in patients after a suicidal attempt (29.0 vs. 11.5%, p \ 0.001). Spinal trauma with a resulting paraplegia was found in both groups with a similar percentage of about 5% (5.2% ACCIDENT vs. 5.5% SUICIDE, p [ 0.05). The prognosis for both groups (SUICIDE: 21.7%, ACCIDENT: 15.9%, p \ 0.001) correlated with the real mortality rate (SUICIDE: 20.6%; ACCIDENT: 14.1%, p \ 0.001). This yields an SMR of 0.95 and 0.89, respectively. The GOS differs in both groups: 71.1% of the
GCS < 8
MOF
shock
mortality
Fig. 3 Injury patterns in the ACCIDENT and SUICIDE groups showing differences among head injuries, abdominal injuries, and injuries of the extremities with an AIS C3
patients in the ACCIDENT group and 57.9% of the patients in the SUICIDE group had a GOS [3 (p B 0,001; ACCIDENT vs. SUICIDE: GOS 1: 13.9 vs. 22.2%; GOS 2: 2.5 vs. 2.4%; GOS 3: 12.6 vs. 17.6%; GOS 4: 25.2 vs. 30.7%; GOS 5: 45.9 vs. 27.2%). The time of admittance to hospital differed between these two groups. More patients in the SUICIDE group (32.9%) were admitted at night (8:00 p.m. to 5:59 a.m.) than patients in the ACCIDENT-group (22.5%) (p \ 0.001). In addition, incorporating daily and monthly patterns, higher rates of
123
22
T. Topp et al.
The fact that we found a larger percentage of men in the ACCIDENT group than in the SUICIDE group can be explained by the fact that sports and working activities with a high risk of being severely injured are carried out more often by men. This yields to a very large group of severely injured male patients without a suicidal attempt [14]. The ISS for both groups was higher in our present study than Teh et al. [8] found in 2003 with a mean ISS of 26.1 after a suicidal attempt versus an ISS of 18.1 after an accidental trauma. Studies on suicidal jumps showed that the height of the jumps varied from 1 to 27 floors. Comparing free falls out of buildings, about 60% of suicidal attempts and 85% of accidental falls were from the 4th floor or less [15, 16]. Richter et al. [7] found that the average height of a fall for suicidal jumpers was 7.8 m compared to an average height of 6.8 m for accidental falls. More severe injuries in the SUICIDE group may be explained by a greater height of the free fall than in the ACCIDENT group. The higher ISS values in the SUICIDE group also correlated with a longer hospitalization and length of stay in the ICU for patients in this group. According to these findings, patients with a suicidal attempt also had higher rates of emergency operations, MOF, and shock situations. Patients who suffered severe head injuries often do not reach the hospital alive. Patients who survive primary severe head injuries have a better
patients admitted to hospital on Sundays and between November and March were found in the SUICIDE group. In absolute numbers, the majority of patients counted in both groups were taken to hospital in July. Furthermore, most SUICIDE patients were admitted to hospital on Mondays and most ACCIDENT patients on Saturdays (Figs. 4 and 5). Costs which are caused by the treatment of patients after a suicidal attempt (€34,833 ± €27,591) were significantly higher than costs of accidentally injured patients (€24,701 ± €23,364) (p \ 0.001). In 2007, 185 suicidal attempts were reported to the German Trauma Registry from 101 participating hospitals. Extrapolating this number of patients to the 748 hospitals in Germany which are treating multiple injured patients [2], the calculated number of patients admitted after a jump from a height was about 1,370. This leads to the conclusion that the calculated costs for severely injured patients after a suicidal jump are about €47,721,210 ± €37,799,670 per year in Germany.
Discussion Many authors describe the ‘‘jump from a height’’ as a common method for attempting trauma suicide. The rates how often this method is used differ in publications between 7 and 26% [6, 12, 13].
14,00%
Percentage
Fig. 4 Differences in the monthly admittance to hospital in the ACCIDENT and SUICIDE groups
12,00%
ACCIDENT
10,00%
SUICIDE
8,00% 6,00% 4,00% 2,00% 0,00% Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Fig. 5 Differences in the daily admittance to hospital in the ACCIDENT and SUICIDE groups
ACCIDENT
Percentage
SUICIDE 18,00% 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% Sun
Mon
Tue
Wed
Day
123
Thu
Fri
Sat
Multiple blunt trauma after suicidal attempt
prognosis than patients with severe thoracic or abdominal injuries, who have a higher risk of developing MOF and shock situations [17]. Comparing the injury patterns of patients in both groups, we found that patients without a suicidal background had more severe injuries of the head and neck region. However, patients who jumped from a height had significantly more severe injuries of the thorax, the abdomen, and the extremities. This shows that patients with a suicidal intent hit the ground in a different way than patients who fall accidentally. These findings are in contrast to Richter et al. [7], who did not find significant differences in the distribution of injuries between ‘‘jumpers’’ and ‘‘fallers’’. However, they do correlate with the findings of Teh et al. [8] and Katz et al. [18], who found a higher fracture rate of the calcaneus in ‘‘jumpers’’ and a similar injury pattern regarding thoracic and abdominal trauma, and injuries of the extremities [7]. Ruchholtz et al. [19] also found more head and neck injuries in trauma patients after an accidental fall (54 vs. 26%) and more severe injuries of the legs (69 vs. 23%) and the pelvis (69 vs. 19%) after a suicidal jump. With special attention to the head injuries, it is important to note that we only counted patients who reached the hospital alive. Several studies have shown that those patients who land ‘‘head first’’ tend not to reach the hospital alive [16, 20, 21]. Besides the position at landing, other important factors which highly influence the spectrum of injuries are the height of the fall, the nature of the impacted surface, and the victim’s age and weight [21]. Patients after a jump from a height with a suicidal intent were more often severely injured and had a higher ‘‘in-hospital mortality’’ than patients who accidentally fell. The calculated mortality, determined with the RISC score for both groups, correlated with the real mortality, which is reflected in an SMR of 0.95 and 0.89. Follow up data were not analyzed in this study, but Ruchholtz et al. [20] described long-term results after parasuicidal multiple blunt trauma that show the chance of good recovery of these patients being approximately 20% lower than in multiple injured patients without a parasuicidal background. This correlates with the different GOS values in our patient sample. Patients in the SUICIDE group had a significantly worse outcome than patients in the ACCIDENT group. This might be due to the fact that patients with a suicidal attempt more often suffer from severe injuries of the extremities, which compromise the daily level of activity and handicaps the return to work. Looking at the specific time, day, and month periods of patients’ admittance to hospital, we found a higher percentage of patients in the SUICIDE group being admitted
23
to hospital at night between 8:00 p.m. and 5:59 a.m., on Sundays, and between November and March compared to the ACCIDENT group. These findings correlate with the lower working activities at night, on Sundays, and in the winter months. Highest absolute values were found in both groups during the daytime and in the month of July. Most deaths in 2006 in Germany after a suicidal attempt occurred in the months of May and July, with rates [9.5% [4]. Other authors found peaks of suicidal jumps from a height in the fall [7, 18]. Due to the more intense treatment of polytrauma patients after a jump from a height with a suicidal attempt, costs were significantly higher in the SUICIDE group, being €34,833 ± €27,591 versus €24,701 ± €23,364 in the ACCIDENT group. This led to total estimated costs of €47,721,210 ± €37,799,670 per year in Germany for patients after a suicidal jump from a height. Other authors found calculated costs in the past of between €21,866 and €31,166 per patient for multiple severely injured trauma patients [4, 22, 23]. These numbers show the enormous socioeconomic relevance of the treatment of these patients.
Conclusion Trauma patients with an attempted suicide are an important group of patients with a fundamental clinical and socioeconomic relevance. Knowing the different injury patterns of these patients caused by different mechanisms of trauma is significant for the emergency treatment and further clinical management. Although patients in the SUICIDE group were younger than patients in the ACCIDENT group, more severe thoracic and abdominal injuries led to a higher mortality rate in the SUICIDE group and the need for special attention during clinical management. The accumulated costs during the treatment of trauma patients who tried to commit suicide were significantly higher than the costs caused by other trauma patients. Although the overall mortality rate was higher in the group of patients after an attempted suicide, the more intense treatment of these patients during their hospitalization led to a clinical outcome which correlated to their calculated risk using the Revised Injury Severity Classification (RISC) score. Hence, the psychological situation of these patients does not seem to influence their clinical outcome during their hospitalization. As a result, the higher mortality rate is explained by the different mechanisms of injury leading to more severe and life-threatening injuries in the thoracic and abdominal regions. Conflict of interest
All authors declare no conflicts of interest.
123
24
T. Topp et al.
References 1. Ku¨hne CA, Ruchholtz S, Buschmann C, Sturm J, Lackner CK, Wentzensen A, Bouillon B, Waydhas C, Weber C; AG Polytrauma DGU. Trauma centers in Germany. Status report. Unfallchirurg. 2006;109:357–66. 2. Liener UC, Rapp U, Lampl L, Helm M, Richter G, Gaus M, Wildner M, Kinzl L, Gebhard F. Incidence of severe injuries. Results of a population-based analysis. Unfallchirurg. 2004; 107:483–90. 3. Juhra C, Franz D, Roeder N, Vordemvenne T, Raschke MJ. Classification of severely injured patients in the G-DRG System 2008. Unfallchirurg. 2009;112:525–32. 4. Statistisches Bundesamt Deutschland (2007). 5. Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, Crepet P, Haring C, Hawton K, Lo¨nnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe I, Salander-Renberg E, Temesva´ry B, Wasserman D, Fricke S, Weinacker B, SampaioFaria JG. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand. 1996;93:327–38. 6. Hadjizacharia P, Brown CV, Teixeira PG, Chan LS, Yang K, Salim A, Inaba K, Rhee P, Demetriades D. Traumatic suicide attempts at a level I trauma center. J Emerg Med. 2010;39:411–8 7. Richter D, Hahn MP, Ostermann PA, Ekkernkamp A, Muhr G. Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional high falls. Injury. 1996;27:655–9. 8. Teh J, Firth M, Sharma A, Wilson A, Reznek R, Chan O. Jumpers and fallers: a comparison of the distribution of skeletal injury. Clin Radiol. 2003;58:482–6. 9. Ruchholtz S. The Trauma Registry of the German Society of Trauma Surgery as a basis for interclinical quality management. A multicenter study of the German Society of Trauma Surgery. Unfallchirurg. 2000;103:30–7. 10. Lefering R. Development and validation of the Revised Injury Severity Classification score for severely injured patients. Eur J Trauma Emerg Surg. 2009;35:437–47. 11. Pape HC, Grotz M, Schwermann T, Ruchholtz S, Lefering R, Rieger M, Tro¨ger M, Graf von der Schulenburg JM, Krettek C; AG Polytrauma der DGU. The development of a model to calculate the
123
12.
13.
14.
15. 16.
17.
18.
19.
20.
21. 22.
23.
cost of care for the severely injured—an initiative of the Trauma Register of the DGU. Unfallchirurg. 2003;106:348–57. Bo¨stman OM. Suicidal attempts by jumping from heights. A three-year prospective study of patients admitted to an urban university accident department. Scand J Soc Med. 1987; 15:119–203. Etzersdorfer E, Voracek M, Kapusta N, Sonneck G. Epidemiology of suicide in Austria 1990–2000: general decrease, but increased suicide risk for old men. Wien Klin Wochenschr. 2005;117:31–5. Dzupa V, Chmelova´ J, Pavelka T, Obruba P, Wendsche P, Simko P. Multicentric study of patients with pelvic injury: basic analysis of the study group. Acta Chir Orthop Traumatol Cech. 2009;76:404–9. Isbister ES, Roberts JA. Autokabalesis: a study of intentional vertical deceleration injuries. Injury. 1992;23:119–22. Mathis RD, Levine SH, Phifer S. An analysis of accidental free falls from a height: the ‘spring break’ syndrome. J Trauma. 1993;34:123–6. Aufmkolk M, Majetschak M, Voggenreiter G, Obertacke U, Schmit-Neuerburg KP. Follow-up and prognosis of severe accidental trauma in the aged. Unfallchirurg. 1997;100:477–82. Katz K, Gonen N, Goldberg I, Mizrahi J, Radwan M, Yosipovitch Z. Injuries in attempted suicide by jumping from a height. Injury. 1988;19:371–4. Ruchholtz S, Nast-Kolb D, Waydhas C, Schweiberer L. The injury pattern in polytrauma. Value of information regarding accident process in clinical acute management. Unfallchirurg. 1996;99:633–41. Ruchholtz S, Pajonk FG, Waydhas C, Lewan U, Nast-Kolb D, Schweiberer L. Long-term results and quality of life after parasuicidal multiple blunt trauma. Crit Care Med. 1999;27:522–30. Warner KG, Demling RH. The pathophysiology of free-fall injury. Ann Emerg Med. 1986;15:1088–93. Schmelz A, Ziegler D, Beck A, Kinzl L, Gebhard F. Costs for acute, stationary treatment of polytrauma patients. Unfallchirurg. 2002;105:1043–8. Schwermann T, Grotz M, Blanke M, Ruchholtz S, Lefering R, V d Schulenburg JM, Krettek C, Pape HC. Evaluation of costs incurred for patients with multiple trauma particularly from the perspective of the hospital. Unfallchirurg. 2004;107:563–74.
ORIGINAL ARTICLE
Multiple blunt trauma after suicidal attempt: an analysis of 4,754 multiple severely injured patients T. Topp • T. Mu¨ller • I. Kiriazidis • R. Lefering • S. Ruchholtz • Trauma Registry of the German Trauma Society • C. A. Ku¨hne
Received: 26 April 2011 / Accepted: 26 April 2011 / Published online: 12 May 2011 Ó Springer-Verlag 2011
Abstract Purpose The suicidal attempt is a significant cause for multiple severe injuries in Germany. The aim of the present study was to obtain information regarding injury patterns, clinical treatment, and outcome. Methods We analyzed the data of 4,754 patients of the Trauma Registry of the German Trauma Society (1993–2007) with an Injury Severity Score (ISS) C9 after a suicidal jump from a height (SUICIDE) and after an accidental fall from a height (ACCIDENT). Results Comparing the data of 3,682 patients with accidental fall versus those with intentional fall/jump (n = 1,072), we found that male patients were predominant in the ACCIDENT group (84.9 vs. 52.2%). The SUICIDE group had more severe injuries (ISS: 31.8 vs. 26.4). The ACCIDENT group suffered more severe head injuries (51.1 vs. 36.6%). Mortality (21.4 vs. 14.2%), length of stay in hospital (29.5 vs. 26.5 days), and costs (€34,833 vs. €24,701) were higher in the SUICIDE group. Conclusions Falls from a height are a common cause of injury among severely injured patients. The resulting trauma composes a particular form of blunt trauma with severe and multiple injuries, which depends on the fact of whether the free fall from a height was caused by an
T. Topp (&) T. Mu¨ller I. Kiriazidis S. Ruchholtz C. A. Ku¨hne Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033 Marburg, Germany e-mail: [email protected] R. Lefering Faculty of Medicine, Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
accident or as a result of a suicidal attempt. Taking the injury severity into consideration, there is no difference in the prognosis of the patients. Keywords Suicide Multiple blunt trauma Mortality Injury pattern Epidemiology Outcome
Introduction In Germany, severe blunt trauma is the most common cause of death in patients younger than 40 years of age. A total of 32,000–36,000 patients are treated in trauma centers every year following multiple severe trauma [1, 2]. The socioeconomic relevance of multiple injured patients for the health system is fundamental. Recently published studies showed calculated costs of €24,004 per patient [3]. Although most of these patients were injured in car or workplace accidents, blunt trauma after a suicidal attempt is one of the most important mechanisms of injury among the group of multiple injured patients in modern industrial nations. Until today, no reliable data exist concerning the incidence of multiple blunt trauma after suicidal attempts. The official mortality statistics show the importance of suicides in our society. In Germany, 9,402 suicides were reported in 2007, more than the number of deaths as a consequence of traffic accidents (n = 4,949). A total of 1,514 of these cases showed multiple blunt trauma [4]. According to a World Health Organization (WHO) Multicenter Study on parasuicide from 1989 to 1995, suicide is attempted by 77 of 100,000 men and 127 of 100,000 women per year in Germany. Jumps from a height occur in approximately 9% of all suicides and in approximately 6% of all suicidal attempts. In Europe, an occurrence of 28 suicides per 100,000 inhabitants per year was found [5].
123
20
Materials and methods The Trauma Registry of the German Trauma Society (TR-DGU) was established in 1993 by the society’s Working Group on Polytrauma to prospectively collect multicentric data from patients with severe trauma. Currently, hospitals in Germany, Austria, Switzerland, Slovenia, and the Netherlands participate in the TR-DGU. Parameters for prehospital and trauma-room treatments, and subsequent treatment in the intensive care unit (ICU), are continuously recorded on a web-based data server. Each patient admitted to one of the participating trauma hospitals because of severe trauma or being treated in the ICU is recorded in the registry. Data anonymity is guaranteed for participating patients, as well as for hospitals. The registry records epidemiological, physiological, laboratory, diagnostic, operative, interventional, and intensive care medical data, as well as injury severity scores and outcome data [9]. Inclusion criteria for this study were patients with an Injury Severity Score (ISS) C9, a blunt trauma after a jump/fall from a height, and a documented attempt of suicide or accident. During the period 1993–2007, 30,603 datasets were analyzed. Objects of the analysis were gender, age, Glasgow Coma Scale (GCS) score, mortality, shock, alcohol and drug abuse, mechanism of injury, length of stay in the ICU, number of admitted packed red blood cells (PRBC), preclinical substitution of volume, multiorgan failure (MOF), sepsis, and costs. The prognosis of the patients were derived using the Revised Injury Severity Classification (RISC) score, and the Standardized Mortality Ratio (SMR; ratio of recorded to expected mortality) was calculated. This score was developed with data from 2,009 patients in the Trauma Registry (1993–2000) and has been validated for 3,475 patients (2001–2003). RISC-score-adjusted outcome comparisons have been routinely reported every year by the Trauma Registry since 2003 [10]. The five categories of the GOS (1, dead; 2, vegetative state, unable to interact with environment; 3, severe disability, able to follow commands/ unable to live independently; 4, moderate disability, to live independently, unable to return to work or school; 5, good
123
recovery, able to return to work or school) were used as additional parameters to compare the clinical outcome of the patients. Injury patterns were described for the following four body regions: ‘‘head and neck’’, ‘‘thorax’’, ‘‘abdomen’’, and the ‘‘extremities’’. Each of these regions was classified as severely injured if an Abbreviated Injury Scale (AIS) severity grade was C3. To estimate the costs for in-hospital treatment, an algorithm established by Pape et al. [11] with data of the TR-DGU in 2003 was used. The costs were calculated from material and personnel expenses at different times of the clinical care: rescue phase, emergency room, operating room, ICU, and general ward. Data are presented as mean with standard deviation (SD) and were analyzed with the Chi-square test for categorical variables and the t-test for continuous variables. Confidence intervals of 95% are reported. SPSS 18 for Windows statistical software was used (IBM Corporation, Somers, NY, USA).
Results From 1993–2007, 30,603 severe trauma patients with an Injury Severity Score (ISS) C9 were documented. The group of patients with a free fall from a height consisted of 3,682 accidentally injured patients (77.5%, ACCIDENT) and 1,070 patients with a suicidal attempt (22.5%, SUICIDE). Males comprised 84.9% of the patients in the ACCIDENT group and 52.2% of the patients in the SUICIDE group (Fig. 1, p \ 0.001). The mean age of the patients in the ACCIDENT group was 44.6 years, compared to a mean age of 39.6 years in the SUICIDE group (p [ 0.05). Patients after a suicidal attempt were more severely injured than patients after an accidental fall from a height. Patients in the SUICIDE group had a mean ISS of 31.8,
percentage
Most clinical studies on this topic were based on monoinstitutional databases with relatively small numbers of patients [6–8]. The presented study examined the epidemiological and clinical findings of patients admitted to hospital after an attempted suicide. Findings were compared to those patients who had severe injuries caused by an accident, based on a large database of more than 30,000 patients from the Trauma Registry of the German Trauma Society (TR-DGU).
T. Topp et al.
90,00% 80,00% 70,00% 60,00% 50,00%
ACCIDENT SUICIDE
40,00% 30,00% 20,00% 10,00% 0,00% Female
Male
Fig. 1 Distribution of the sexes in the ACCIDENT and SUICIDE groups
Multiple blunt trauma after suicidal attempt
21
Table 1 Number of applied packed red blood cells (PRBC) and ventilation-free days, duration of stay in the intensive care unit (ICU), and duration of hospitalization Packed red blood cells
Ventilation-free days
Days in ICU
Days in hospital
ACCIDENT
1.4 (±4.6)
20.6 (±11.7)
11.0 (±15.2)
28.4 (±33.3)
SUICIDE
4.0 (±7.0)
16.8 (±12.3)
14.9 (±17.7)
34.7 (±34.9)
p-value non-suicide versus suicide for all parameters: p \ 0.0001 100,00% 90,00% ACCIDENT
80,00%
SUICIDE
70,00%
percentage
Fig. 2 Percentage of patients who needed operative treatment, percentage of unconscious patients with a Glasgow Coma Scale (GCS) \8, percentage of patients with multiorgan failure (MOF) and shock situations, and percentage of in-hospital mortality
60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00%
operations
whereas patients in the ACCIDENT group had a mean ISS of 26.4 (p \ 0.001). Table 1 shows the different amounts of required PRBC and differences between ventilation-free days, days in the ICU, and the duration of hospitalization. The need for operations (88.2 vs. 79.2%, p \ 0.001) and the number of unconscious patients (35.2 vs. 25.3%, p \ 0.001) was also higher in the SUICIDE group. In addition to this, MOF and shocks occurred at a higher percentage in this group (MOF: 32.7 vs. 20.0%, p \ 0.001; shock 27.6 vs. 10.8%, p \ 0.001). Patients with a suicidal attempt also had a higher ‘‘in-hospital mortality’’ than patients without a suicidal attempt (21.4 vs. 14.2%, p \ 0.001) (Fig. 2). The different injury patterns among these two groups are given in Fig. 3. Head injuries with an AIS C3 occurred more often within the ACCIDENT group than within the SUICIDE group (51.1 vs. 36.6%, p \ 0.001). Severe injuries with an AIS C3 of the thorax (61.8 vs. 53.2%, p \ 0.001), the abdomen (40.0 vs. 20.4%, p \ 0.001), and the extremities (62.5 vs. 33.1%, p \ 0.001) were found more often in the SUICIDE group (Fig. 3). Severe pelvic injuries were also found more often in patients after a suicidal attempt (29.0 vs. 11.5%, p \ 0.001). Spinal trauma with a resulting paraplegia was found in both groups with a similar percentage of about 5% (5.2% ACCIDENT vs. 5.5% SUICIDE, p [ 0.05). The prognosis for both groups (SUICIDE: 21.7%, ACCIDENT: 15.9%, p \ 0.001) correlated with the real mortality rate (SUICIDE: 20.6%; ACCIDENT: 14.1%, p \ 0.001). This yields an SMR of 0.95 and 0.89, respectively. The GOS differs in both groups: 71.1% of the
GCS < 8
MOF
shock
mortality
Fig. 3 Injury patterns in the ACCIDENT and SUICIDE groups showing differences among head injuries, abdominal injuries, and injuries of the extremities with an AIS C3
patients in the ACCIDENT group and 57.9% of the patients in the SUICIDE group had a GOS [3 (p B 0,001; ACCIDENT vs. SUICIDE: GOS 1: 13.9 vs. 22.2%; GOS 2: 2.5 vs. 2.4%; GOS 3: 12.6 vs. 17.6%; GOS 4: 25.2 vs. 30.7%; GOS 5: 45.9 vs. 27.2%). The time of admittance to hospital differed between these two groups. More patients in the SUICIDE group (32.9%) were admitted at night (8:00 p.m. to 5:59 a.m.) than patients in the ACCIDENT-group (22.5%) (p \ 0.001). In addition, incorporating daily and monthly patterns, higher rates of
123
22
T. Topp et al.
The fact that we found a larger percentage of men in the ACCIDENT group than in the SUICIDE group can be explained by the fact that sports and working activities with a high risk of being severely injured are carried out more often by men. This yields to a very large group of severely injured male patients without a suicidal attempt [14]. The ISS for both groups was higher in our present study than Teh et al. [8] found in 2003 with a mean ISS of 26.1 after a suicidal attempt versus an ISS of 18.1 after an accidental trauma. Studies on suicidal jumps showed that the height of the jumps varied from 1 to 27 floors. Comparing free falls out of buildings, about 60% of suicidal attempts and 85% of accidental falls were from the 4th floor or less [15, 16]. Richter et al. [7] found that the average height of a fall for suicidal jumpers was 7.8 m compared to an average height of 6.8 m for accidental falls. More severe injuries in the SUICIDE group may be explained by a greater height of the free fall than in the ACCIDENT group. The higher ISS values in the SUICIDE group also correlated with a longer hospitalization and length of stay in the ICU for patients in this group. According to these findings, patients with a suicidal attempt also had higher rates of emergency operations, MOF, and shock situations. Patients who suffered severe head injuries often do not reach the hospital alive. Patients who survive primary severe head injuries have a better
patients admitted to hospital on Sundays and between November and March were found in the SUICIDE group. In absolute numbers, the majority of patients counted in both groups were taken to hospital in July. Furthermore, most SUICIDE patients were admitted to hospital on Mondays and most ACCIDENT patients on Saturdays (Figs. 4 and 5). Costs which are caused by the treatment of patients after a suicidal attempt (€34,833 ± €27,591) were significantly higher than costs of accidentally injured patients (€24,701 ± €23,364) (p \ 0.001). In 2007, 185 suicidal attempts were reported to the German Trauma Registry from 101 participating hospitals. Extrapolating this number of patients to the 748 hospitals in Germany which are treating multiple injured patients [2], the calculated number of patients admitted after a jump from a height was about 1,370. This leads to the conclusion that the calculated costs for severely injured patients after a suicidal jump are about €47,721,210 ± €37,799,670 per year in Germany.
Discussion Many authors describe the ‘‘jump from a height’’ as a common method for attempting trauma suicide. The rates how often this method is used differ in publications between 7 and 26% [6, 12, 13].
14,00%
Percentage
Fig. 4 Differences in the monthly admittance to hospital in the ACCIDENT and SUICIDE groups
12,00%
ACCIDENT
10,00%
SUICIDE
8,00% 6,00% 4,00% 2,00% 0,00% Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Fig. 5 Differences in the daily admittance to hospital in the ACCIDENT and SUICIDE groups
ACCIDENT
Percentage
SUICIDE 18,00% 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% Sun
Mon
Tue
Wed
Day
123
Thu
Fri
Sat
Multiple blunt trauma after suicidal attempt
prognosis than patients with severe thoracic or abdominal injuries, who have a higher risk of developing MOF and shock situations [17]. Comparing the injury patterns of patients in both groups, we found that patients without a suicidal background had more severe injuries of the head and neck region. However, patients who jumped from a height had significantly more severe injuries of the thorax, the abdomen, and the extremities. This shows that patients with a suicidal intent hit the ground in a different way than patients who fall accidentally. These findings are in contrast to Richter et al. [7], who did not find significant differences in the distribution of injuries between ‘‘jumpers’’ and ‘‘fallers’’. However, they do correlate with the findings of Teh et al. [8] and Katz et al. [18], who found a higher fracture rate of the calcaneus in ‘‘jumpers’’ and a similar injury pattern regarding thoracic and abdominal trauma, and injuries of the extremities [7]. Ruchholtz et al. [19] also found more head and neck injuries in trauma patients after an accidental fall (54 vs. 26%) and more severe injuries of the legs (69 vs. 23%) and the pelvis (69 vs. 19%) after a suicidal jump. With special attention to the head injuries, it is important to note that we only counted patients who reached the hospital alive. Several studies have shown that those patients who land ‘‘head first’’ tend not to reach the hospital alive [16, 20, 21]. Besides the position at landing, other important factors which highly influence the spectrum of injuries are the height of the fall, the nature of the impacted surface, and the victim’s age and weight [21]. Patients after a jump from a height with a suicidal intent were more often severely injured and had a higher ‘‘in-hospital mortality’’ than patients who accidentally fell. The calculated mortality, determined with the RISC score for both groups, correlated with the real mortality, which is reflected in an SMR of 0.95 and 0.89. Follow up data were not analyzed in this study, but Ruchholtz et al. [20] described long-term results after parasuicidal multiple blunt trauma that show the chance of good recovery of these patients being approximately 20% lower than in multiple injured patients without a parasuicidal background. This correlates with the different GOS values in our patient sample. Patients in the SUICIDE group had a significantly worse outcome than patients in the ACCIDENT group. This might be due to the fact that patients with a suicidal attempt more often suffer from severe injuries of the extremities, which compromise the daily level of activity and handicaps the return to work. Looking at the specific time, day, and month periods of patients’ admittance to hospital, we found a higher percentage of patients in the SUICIDE group being admitted
23
to hospital at night between 8:00 p.m. and 5:59 a.m., on Sundays, and between November and March compared to the ACCIDENT group. These findings correlate with the lower working activities at night, on Sundays, and in the winter months. Highest absolute values were found in both groups during the daytime and in the month of July. Most deaths in 2006 in Germany after a suicidal attempt occurred in the months of May and July, with rates [9.5% [4]. Other authors found peaks of suicidal jumps from a height in the fall [7, 18]. Due to the more intense treatment of polytrauma patients after a jump from a height with a suicidal attempt, costs were significantly higher in the SUICIDE group, being €34,833 ± €27,591 versus €24,701 ± €23,364 in the ACCIDENT group. This led to total estimated costs of €47,721,210 ± €37,799,670 per year in Germany for patients after a suicidal jump from a height. Other authors found calculated costs in the past of between €21,866 and €31,166 per patient for multiple severely injured trauma patients [4, 22, 23]. These numbers show the enormous socioeconomic relevance of the treatment of these patients.
Conclusion Trauma patients with an attempted suicide are an important group of patients with a fundamental clinical and socioeconomic relevance. Knowing the different injury patterns of these patients caused by different mechanisms of trauma is significant for the emergency treatment and further clinical management. Although patients in the SUICIDE group were younger than patients in the ACCIDENT group, more severe thoracic and abdominal injuries led to a higher mortality rate in the SUICIDE group and the need for special attention during clinical management. The accumulated costs during the treatment of trauma patients who tried to commit suicide were significantly higher than the costs caused by other trauma patients. Although the overall mortality rate was higher in the group of patients after an attempted suicide, the more intense treatment of these patients during their hospitalization led to a clinical outcome which correlated to their calculated risk using the Revised Injury Severity Classification (RISC) score. Hence, the psychological situation of these patients does not seem to influence their clinical outcome during their hospitalization. As a result, the higher mortality rate is explained by the different mechanisms of injury leading to more severe and life-threatening injuries in the thoracic and abdominal regions. Conflict of interest
All authors declare no conflicts of interest.
123
24
T. Topp et al.
References 1. Ku¨hne CA, Ruchholtz S, Buschmann C, Sturm J, Lackner CK, Wentzensen A, Bouillon B, Waydhas C, Weber C; AG Polytrauma DGU. Trauma centers in Germany. Status report. Unfallchirurg. 2006;109:357–66. 2. Liener UC, Rapp U, Lampl L, Helm M, Richter G, Gaus M, Wildner M, Kinzl L, Gebhard F. Incidence of severe injuries. Results of a population-based analysis. Unfallchirurg. 2004; 107:483–90. 3. Juhra C, Franz D, Roeder N, Vordemvenne T, Raschke MJ. Classification of severely injured patients in the G-DRG System 2008. Unfallchirurg. 2009;112:525–32. 4. Statistisches Bundesamt Deutschland (2007). 5. Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, Crepet P, Haring C, Hawton K, Lo¨nnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe I, Salander-Renberg E, Temesva´ry B, Wasserman D, Fricke S, Weinacker B, SampaioFaria JG. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand. 1996;93:327–38. 6. Hadjizacharia P, Brown CV, Teixeira PG, Chan LS, Yang K, Salim A, Inaba K, Rhee P, Demetriades D. Traumatic suicide attempts at a level I trauma center. J Emerg Med. 2010;39:411–8 7. Richter D, Hahn MP, Ostermann PA, Ekkernkamp A, Muhr G. Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional high falls. Injury. 1996;27:655–9. 8. Teh J, Firth M, Sharma A, Wilson A, Reznek R, Chan O. Jumpers and fallers: a comparison of the distribution of skeletal injury. Clin Radiol. 2003;58:482–6. 9. Ruchholtz S. The Trauma Registry of the German Society of Trauma Surgery as a basis for interclinical quality management. A multicenter study of the German Society of Trauma Surgery. Unfallchirurg. 2000;103:30–7. 10. Lefering R. Development and validation of the Revised Injury Severity Classification score for severely injured patients. Eur J Trauma Emerg Surg. 2009;35:437–47. 11. Pape HC, Grotz M, Schwermann T, Ruchholtz S, Lefering R, Rieger M, Tro¨ger M, Graf von der Schulenburg JM, Krettek C; AG Polytrauma der DGU. The development of a model to calculate the
123
12.
13.
14.
15. 16.
17.
18.
19.
20.
21. 22.
23.
cost of care for the severely injured—an initiative of the Trauma Register of the DGU. Unfallchirurg. 2003;106:348–57. Bo¨stman OM. Suicidal attempts by jumping from heights. A three-year prospective study of patients admitted to an urban university accident department. Scand J Soc Med. 1987; 15:119–203. Etzersdorfer E, Voracek M, Kapusta N, Sonneck G. Epidemiology of suicide in Austria 1990–2000: general decrease, but increased suicide risk for old men. Wien Klin Wochenschr. 2005;117:31–5. Dzupa V, Chmelova´ J, Pavelka T, Obruba P, Wendsche P, Simko P. Multicentric study of patients with pelvic injury: basic analysis of the study group. Acta Chir Orthop Traumatol Cech. 2009;76:404–9. Isbister ES, Roberts JA. Autokabalesis: a study of intentional vertical deceleration injuries. Injury. 1992;23:119–22. Mathis RD, Levine SH, Phifer S. An analysis of accidental free falls from a height: the ‘spring break’ syndrome. J Trauma. 1993;34:123–6. Aufmkolk M, Majetschak M, Voggenreiter G, Obertacke U, Schmit-Neuerburg KP. Follow-up and prognosis of severe accidental trauma in the aged. Unfallchirurg. 1997;100:477–82. Katz K, Gonen N, Goldberg I, Mizrahi J, Radwan M, Yosipovitch Z. Injuries in attempted suicide by jumping from a height. Injury. 1988;19:371–4. Ruchholtz S, Nast-Kolb D, Waydhas C, Schweiberer L. The injury pattern in polytrauma. Value of information regarding accident process in clinical acute management. Unfallchirurg. 1996;99:633–41. Ruchholtz S, Pajonk FG, Waydhas C, Lewan U, Nast-Kolb D, Schweiberer L. Long-term results and quality of life after parasuicidal multiple blunt trauma. Crit Care Med. 1999;27:522–30. Warner KG, Demling RH. The pathophysiology of free-fall injury. Ann Emerg Med. 1986;15:1088–93. Schmelz A, Ziegler D, Beck A, Kinzl L, Gebhard F. Costs for acute, stationary treatment of polytrauma patients. Unfallchirurg. 2002;105:1043–8. Schwermann T, Grotz M, Blanke M, Ruchholtz S, Lefering R, V d Schulenburg JM, Krettek C, Pape HC. Evaluation of costs incurred for patients with multiple trauma particularly from the perspective of the hospital. Unfallchirurg. 2004;107:563–74.
