Distribution of causes of death and associated organ injuries in road traffic accident-related fatalities: a postmortem study in Addis Ababa, Ethiopia
Mortality from trauma is typically trimodal: the first peak occurs in the prehospital phase, due to head injuries and major blood vessel injuries; the second peak occurs shortly after hospital admission, due to trauma-related complications; and the third peak occurs in the days following trauma, often due to a systemic inflammatory response and multiorgan failure . Road traffic accidents (RTAs) are a leading cause of death worldwide with higher rates of RTA-related fatalities in low- and middle-income countries compared to high-income countries. In low- and middle-income countries, 92 percent of deaths occur from RTAs, with Africa accounting for 19 percent of global RTA fatalities. Victims from low-income countries have a three times higher risk of death compared to those from high-income countries . RTAs pose a significant public health issue and developmental challenge causing substantial social, health, and economic burdens since more than half of the fatalities affect the working population (ages between 18–59 years). In 2019, RTA became the leading cause of death among individuals aged 5 to 29 years old, surpassing fatalities from HIV/AIDS, diarrheal diseases, tuberculosis, and malaria. It ranks as the 12th cause of death across all age groups . In Ethiopia, RTAs are the leading cause of accidental death, particularly among pedestrians, highlighting the urgent need for effective legal and preventive measures . This study aims to identify the immediate causes of death and associated organ injuries in RTA-related fatalities. By understanding these factors, clinical interventions and policy changes can be made to improve road safety and trauma care in Ethiopia.   The study was conducted at the Department of Forensic Medicine of Saint Paul’s Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia, from January 1 to March 31, 2018, using a descriptive retrospective cross-sectional study design. All autopsies conducted for RTA-related deaths in the study period were used as the study population. From the study population, a sample size of 207 was determined using a single population proportion formula, with 198 meeting the inclusion criteria. Five bodies underwent external examinations only due to families declining full body dissection, and data for four victims were deemed unsatisfactory. Sampling was performed randomly without replacement. The study included bodies that underwent complete autopsy examinations, excluding non-RTA victims and those with external examinations only. Every accessible organ is examined during the autopsy procedure, and at least one forensic pathologist or forensic medicine specialist is involved in each case. Data were collected using a structured checklist, with modifications made during data collection. Data collection commenced after obtaining permission from the forensic medicine department. Sociodemographic characteristics of the victims, circumstances of the RTA, and autopsy findings (such as sex, age, place of injury, organ damage, etc.) were extracted from victims' files containing police requests for forensic examination, hospital request letters, and autopsy result reports. Data completeness and consistency were verified, and data analysis was conducted using the Statistical Package for Social Sciences (SPSS) software. Statistical analysis The data from the checklists ware entered and analyzed using SPSS. Tables, graphs, and charts were used to report the results. Operational definitions A transport accident is any accident that involves a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another . Underlying causes of death are a cascade of events or circumstances that initiate or lead to the immediate causes of death . The immediate causes of death are injuries or complications that directly precede death. In other words, the consequences of underlying causes of death . Ethical considerations Ethical approval was obtained from the institutional review board, and confidentiality was maintained. We followed the declaration of Helsinki strictly in the research process.   The data from the checklists ware entered and analyzed using SPSS. Tables, graphs, and charts were used to report the results.   A transport accident is any accident that involves a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another . Underlying causes of death are a cascade of events or circumstances that initiate or lead to the immediate causes of death . The immediate causes of death are injuries or complications that directly precede death. In other words, the consequences of underlying causes of death .   Ethical approval was obtained from the institutional review board, and confidentiality was maintained. We followed the declaration of Helsinki strictly in the research process.   Demographics and general findings Of the 207 samples, 198 met our inclusion criteria. Nine of the samples did not meet the criteria, with five victims having only external examinations, and the data recorded for the other four victims being unsatisfactory. Among the 198 victims, 70.7% were male and 29.3% were female, with ages ranging from 3 months to 80 years (mean age 34.65 years, SD = 18.07). The most common age group affected was 21–30 years (28.8%), followed by 31–40 years, which accounted for 20.7% of the cases. Together, they represented 49.5% of the RTA-related deaths. Figure . The setting of death Most of the fatalities (49%) occurred in the prehospital setting. The other 37.9% occurred in the hospital, and 5.6% died at home. In the remaining 7.5% of fatalities, the settings were not recorded. The major causes of death in the prehospital setting are blunt head injury, multiple injuries, traumatic shock, craniocerebral injury, hemorrhage, and blunt injury to the head and chest Figure . Type of Victim 140 (71%) of the victims were pedestrians. The remaining 32 cases (16%) were passengers, 8 cases (4%) were drivers, 5 cases (3%) were motorists, 4 cases (2%) were bystanders, 1 case (1%) was a conductor, and 8 cases (4%) were unknown victims Figure . Place of injury Most accidents occurred in urban areas (115 cases, 58.1%), followed by rural areas with 64 cases (32.3%). In the remaining 19 cases (9.6%), the place of the accident was not recorded. Immediate causes of death The leading causes were craniocerebral injury (36.9%), polytraumas (14.6%), and hemorrhage (11.1%) Table . Associated organ injuries A total of 75.3% had head injuries, 58.6% had musculoskeletal injuries, 51% had thoracic injuries, and 34.8% had abdominal injuries Table .   Of the 207 samples, 198 met our inclusion criteria. Nine of the samples did not meet the criteria, with five victims having only external examinations, and the data recorded for the other four victims being unsatisfactory. Among the 198 victims, 70.7% were male and 29.3% were female, with ages ranging from 3 months to 80 years (mean age 34.65 years, SD = 18.07). The most common age group affected was 21–30 years (28.8%), followed by 31–40 years, which accounted for 20.7% of the cases. Together, they represented 49.5% of the RTA-related deaths. Figure .   Most of the fatalities (49%) occurred in the prehospital setting. The other 37.9% occurred in the hospital, and 5.6% died at home. In the remaining 7.5% of fatalities, the settings were not recorded. The major causes of death in the prehospital setting are blunt head injury, multiple injuries, traumatic shock, craniocerebral injury, hemorrhage, and blunt injury to the head and chest Figure .   140 (71%) of the victims were pedestrians. The remaining 32 cases (16%) were passengers, 8 cases (4%) were drivers, 5 cases (3%) were motorists, 4 cases (2%) were bystanders, 1 case (1%) was a conductor, and 8 cases (4%) were unknown victims Figure .   Most accidents occurred in urban areas (115 cases, 58.1%), followed by rural areas with 64 cases (32.3%). In the remaining 19 cases (9.6%), the place of the accident was not recorded.   The leading causes were craniocerebral injury (36.9%), polytraumas (14.6%), and hemorrhage (11.1%) Table .   A total of 75.3% had head injuries, 58.6% had musculoskeletal injuries, 51% had thoracic injuries, and 34.8% had abdominal injuries Table .   Among the 198 victims, 70.7% were male, and 29.3% were female. The ages of the victims ranged from 3 months to 80 years, with a mean age of 34.65 years (SD = 18.07). The leading causes of death were craniocerebral injury, blunt head injury, multiple injuries, hemorrhage, blunt injury to the head and chest, and traumatic shock in descending order. The majority of the victims were pedestrians and passengers. Males were more frequently involved in RTA-related deaths than females, consistent with previous studies, likely due to the social structure of the community where males are more active outdoors. In our study, the most commonly affected age group was between 21–40 years old, aligning with findings from various studies . However, Jiwane A. et al. found that the age group most affected is 41–50 , and Fremingston Marak et al. reported that the age group between 51–60 years is commonly affected . This variation may be due to the difference in demographics and their day-to-day activities in different populations. The majority of victims died of craniocerebral injury, as shown in many studies . In our study, polytraumas and hemorrhage were the second and third most common causes of death, respectively. In contrast, in the study of Kalougivaki JJVP and Goundar RPS, the second and third most common causes of death were thoracic and abdominal injuries, respectively . On the other hand, Chourasia S et al. found hemorrhage is the second most common cause of death . Egejuru RO et al. found that hemorrhage was the leading cause of death . Our study found that the most common setting of death is at the prehospital level, which is compatible with a study performed in Fiji . However, Chourasia S et al. reported that the majority of deaths occurred within 12–24 h of hospital admission . In our study, pedestrians were the most affected road users, in agreement with other studies. However, Kalougivaki JJVP and Goundar RPS reported that passengers took first place, followed by pedestrians . The disproportionate pedestrian involvement may be explained by inappropriate road crossings and lack of attention while crossing. In our study, the majority of the accidents occurred in urban areas, in agreement with the findings of Abegaz T and Gebremedhin . This high rate of accidents in urban areas can be explained by disproportionately high numbers of vehicles in cities and towns of Ethiopia, high activities and population movements in these areas, and disproportionate traffic congestion. Another reason could be, rural victims may not be admitted for autopsy due to cultural barriers and it needs further investigation. In addition to soft tissue injuries, head trauma was the most common type of injury in RTAs, followed by musculoskeletal, thoracic, and abdominal injuries, as shown in other studies . Head trauma was the most common type of trauma in RTAs in two other studies, with different degrees of involvement of other body regions . The leading immediate causes of death in head trauma patients were craniocerebral injury, multiple injuries, blunt head and chest trauma, and traumatic shock in descending order of frequency, which is in agreement with another study .   RTA-related fatalities among males and young adults, with craniocerebral injuries being the most common cause of death. The majority of fatalities occurred in prehospital settings, underscoring the importance of first aid training in schools, for volunteers, and at selected institutions. Collaborative efforts with governmental and non-governmental organizations are necessary to establish an emergency response system in hotspot areas. Continuous professional development training on basic life support and ultrasound imaging applications for trauma should be provided at hospitals, colleges, and universities to reduce fatalities. Localized interventions and further research are needed to address specific differences in findings. Collaborative efforts among stakeholders are crucial to reduce RTA fatalities. Limitations of the study Because of resource constraints, the study period is short, which affects its generalizability. There were no imaging examinations to augment the autopsy results, and poor data recordings also prevented the research from addressing what types of hospital care were given to victims who died in the hospital setting.   Because of resource constraints, the study period is short, which affects its generalizability. There were no imaging examinations to augment the autopsy results, and poor data recordings also prevented the research from addressing what types of hospital care were given to victims who died in the hospital setting.   