| Abstract | Cilj istraživanja Istraživanjem je testirana hipoteza o postojanju pravilnosti u težini i rasporedu ozljeda kod smrtno stradalih sudionika u prometu prema njihovu svojstvu sudjelovanja u prometu (pješaci, biciklisti, motociklisti, vozači, suvozači i ostali putnici u vozilu) i u odnosu na trenutnu smrt i smrt unutar 30 dana od ozljeđivanja. Ciljevi istraživanja bili su utvrditi razliku u opsegu ozljeda smrtno stradalih sudionika u prometu između mlađih i starijih dobnih skupina, osoba poginulih na licu mjesta prometne nesreće i umrlih tijekom bolničkog liječenja; potom utvrditi trend u smrtnom stradavanju u promatranom vremenskom razdoblju, ukupno i prema spolu te po svojstvu sudjelovanja u prometu; te ispitati postoji li pravilnost u raspodjeli smrtnog stradavanja u prometu u odnosu na dob dana i dan u tjednu, vremenske uvjete, stupanj obrazovanja te stanja alkoholiziranosti u vrijeme stradavanja. Nacrt studije Presječna studija iz povijesnih podataka obuhvatila je smrtno stradale sudionike prometnih nesreća (pješake, bicikliste, motocikliste, vozače, suvozače i putnike) koji su bili obducirani na Kliničkom zavodu za patologiju i sudsku medicinu KBC Osijek tijekom vremenskog razdoblja 1998. – 2018. godine. Izvor povijesnih podataka bio je arhiv Kliničkog zavoda za patologiju i sudsku medicinu KBC Osijek (obdukcijski zapisnici) i elektronička arhiva prometne policije Osječko-baranjske županije, Ministarstva unutarnjih poslova Republike Hrvatske. Ispitanici i metode U istraživanje je bilo uključeno 678 smrtno stradalih, obduciranih sudionika prometnih nesreća uključujući umrle unutar 30 dana od prometne nesreće. Ozljede evidentirane u obdukcijskom zapisniku klasificirane su prema težini pomoću skraćene ljestvice (engl. The Abbreviated Injury Scale, AIS), zadnjeg revidiranog izdanja iz 2015. godine. MAIS 3+ (AIS 3 do AIS 6) skupina najteže ozlijeđenih osoba proučavana je zasebno od AIS 2 ozljeda i uspoređivana po svojstvu sudjelovanja u prometu, vremenu smrti od ozljeđivanja i dobi, a s obzirom na njezinu važnost u doprinosu nastanka smrtnog ishoda. Za svakog ispitanika utvrđena je maksimalna težina ozljede (MAIS) i kumulativni učinak višestrukih ozljeda izračunavanjem vrijednosti ISS-a (engl. Injury Severity Score) i NISS-a (engl. New Injury Severity Score). Za sve analizirane varijable napravljena je deskriptivna statistika. Kontinuirane varijable prikazane su kao aritmetička sredina i standardna devijacija, a kategorijske frekvencijom i relativnom frekvencijom (postotak). Usporedbe između kategorijskih varijabli rađene su χ2 (Chi2) testom, odnosno Fisherovim egzaktnim testom. Jednostrukom linearnom regresijom utvrđeni su trendovi broja smrtno stradalih sudionika u prometu po promatranim godinama za ukupan broj i posebno prema spolu. Jednofaktorskom analizom varijance (ANOVA) testirane su razlike između ISS-a prema svojstvu sudjelovanja u prometu, dobnim skupinama i vremenu smrti. Tukeyevim post hoc testom utvrđene su stvarne razlike između analiziranih skupina. Ako nije bio zadovoljen uvjet homogenosti varijance, primijenjen je Kruskal-Wallisov test. U svrhu analize međudjelovanja pojedinih skupina, dvofaktorskom analizom varijance s interakcijom testirane su razlike u ISS-u prema svojstvu sudjelovanja u prometu i vremenu smrti, svojstvu sudjelovanja u prometu i dobnih skupina, dobnih skupina sudionika i vremena smrti, svojstvu sudjelovanja u prometu i spola te spola i vremena smrti. Pearsonovim koeficijentom korelacije utvrđene su povezanosti između ISS-a i NISS-a u skupinama prema svojstvu sudjelovanja u prometu. Za sve statističke analize odabrana je razina značajnosti od 5 %. Rezultati U promatranom 21-godišnjem razdoblju na području Osječko-baranjske županije u cestovnom prometu smrtno je stradalo i obducirano 728 sudionika, od čega je analizirano 678 sudionika prometa i šifrirano 4949 ozljeda pomoću AIS-a. Zabilježen je značajan negativan ukupni trend smrtnog stradavanja u prometu (P < 0,001) u razdoblju 1998. – 2018. godine, pri čemu se broj smrtno stradalih u prosjeku smanjivao svake godine za 1,426. Za muškarce je negativan trend smrtnog stradavanja u prometu bio statistički značajan (P < 0,001), dok za žene nije (P < 0,10). Značajan negativan trend smrtnog stradavanja zabilježen je kod pješaka (P < 0,005), biciklista (P < 0,006), vozača (P < 0,04) i suvozača (P < 0,009), dok za motocikliste i putnike negativan trend nije bio statistički značajan. Značajni broj sudionika smrtno je stradao na mjestu događaja (P < 0,001), i to u naselju na suhom kolniku. Većinom su to bili muškarci u dobi 45 – 64 godina sa srednjom stručnom spremom. Smrtno stradali sudionici u prometu su u najvećem broju bili ozlijeđeni subotom (P = 0,054), što nije statistički značajno u odnosu na ostale dane u tjednu. Prema vremenu stradavanja, smrtno stradali sudionici su značajno češće bili ozlijeđeni u vremenu od 12:00 – 17:59 sati nego u ostala doba dana. Značajna većina smrtno stradalih bili su vozači osobnih automobila (OA) (P < 0,001) koji su ujedno značajnije od ostalih sudionika bili pod utjecajem alkohola (P < 0,001). Ranjivija skupina sudionika pješaci, biciklisti i motociklisti činili su gotovo polovicu (49,9 %) smrtno stradalih obduciranih sudionika u prometu. Usporedbom učestalosti distribucije ozljeda AIS 2 između šest promatranih skupina sudionika u prometu utvrđeno je da su pješaci imali značajno češće prijelome donjih ekstremiteta (P < 0,001) i zdjelice (P < 0,04), dok su suvozači u OA imali značajno češće ozljede abdomena (P = 0,01) i lica (P = 0,03). Usporedbom učestalosti distribucije najmanje jedne teške MAIS 3+ ozljede između šest promatranih skupina sudionika u prometu utvrđeno je da su ozljedu glave značajno češće imali biciklisti (P < 0,001), dok su vozači osobnih automobila značajno češće imali ozljedu abdomena (P < 0,001), a suvozači u osobnom automobilu tešku ozljedu prsnog koša (P < 0,001). Za skupinu motociklista značajno su češće bile ozbiljne MAIS 3 + ozljede gornjih (P = 0,002) i donjih (P = 0,03) ekstremiteta. Značajna većina sudionika u prometu smrtno je stradala na mjestu prometne nesreće (P< 0,001), potom 2. – 30. dana (27 %), dok je unutar 1. dana od ozljeđivanja umrlo 25,2 % sudionika. Promatrajući pozitivitet na najmanje jednu AIS 3 do AIS 6 ozljedu (MAIS 3+), sudionici umrli na mjestu događaja (n = 324) imali su statistički značajno češće MAIS 3+ prsnog koša, abdomena, vratne kralježnice, prsne kralježnice, otvorene prijelome gornjih ekstremiteta, ozbiljne prijelome donjih ekstremiteta, nestabilne prijelome zdjelice, vanjske ozljede na koži tijela i ozljede lica. Sudionici umrli na mjestu ozljeđivanja imali su značajno češće maksimalne ozljede (AIS 6) glave, vratne kralježnice, prsnog koša i abdomena (P < 0,001). Sudionici prometa umrli 2. – 30. dana (n = 183) imali su značajno češće ozbiljne (AIS 3), teške (AIS 4) i kritične (AIS 5) ozljede glave. Značajna većina sudionika u prometu (78,5 %) imala je maksimalnu ozljedu u jednoj ISS regiji, od čega 313 sudionika u području ISS regije glave i vrata, 173 prsnog koša, 27 abdomena i 19 u regiji ekstremiteta. Maksimalnu ozljedu u istodobno dvije ISS regije je imalo 17,1 % smrtno stradalih u prometu. Sudionici u prometu umrli na mjestu ozljeđivanja imali su najveću prosječnu vrijednost ISS-a od 61,66, dok su sudionici umrli 2. – 30. dana imali najmanji prosječni ISS od 35,74. Sudionici prometa umrli unutar 1. dana od ozljeđivanja imali su prosječni ISS od 48,16. Na mjestu prometnog događaja najveći broj smrtno stradalih bio je dobi 25 – 44 godine (33,0 %), dok su sudionici dobne skupine 45 – 64 godine najčešće umirali unutar 30 dana hospitalizacije. Prema rezultatima ANOVE postoji značajna razlika u ISS vrijednosti za šest skupina sudionika u prometu te između dobnih skupina smrtno stradalih sudionika. Utvrđeno je da se sudionici dobi mlađe od 25 godina značajno razlikuju prema ISS-u od sudionika dobne skupine 75 i više godina. Interakcija vrste sudionika u prometu i vremena smrti nije statistički značajna, što upućuje na to da se ISS ponaša približno jednako za svih 6 skupina sudionika po vremenu smrti. Utvrđena je statistički značajna korelacija između dva pokazatelja kumulacije ozljeda (ISS i NISS) za svih 6 skupina smrtno stradalih sudionika u prometu (P < 0,001). Zaključak Analiza trenda smrtnog stradavanja u prometu u Osječko-baranjskoj županiji za razdoblje od 1998. – 2018. pokazala je značajan negativni ukupan trend smrtnog stradavanja svih sudionika u prometu. Istraživanjem se utvrdila pravilnost u težini i rasporedu ozljeda prema vrsti smrtno stradalih sudionika u prometu, kao i po vremenu smrti od ozljeđivanja, kao i statistički značajna razlika u kumulaciji ozljeda između promatranih dobnih skupina smrtno stradalih sudionika u prometu. Ovo je istraživanje pokazalo da se AIS klasifikacija može koristiti i za klasificiranje ozljeda smrtno stradalih u prometnim nesrećama. Na isti način mogla bi se ova klasifikacija primijeniti i na druge oblike nasilnog oštećenja zdravlja sa smrtnim ishodom. Ovako dobiveni podaci o smrtnom ozljeđivanju, uz klinički dobivene i klasificirane ozljede preživjelih, trebali bi biti dio Nacionalnog registra za traumu, koji ima većina zemalja EU-a. |
| Abstract (english) | Aim of the research The study tested the hypothesis of regularity in the severity and distribution of injuries in road fatalities according to the type of road user (pedestrians, cyclists, motorcyclists, drivers, front-seat passengers, and other passengers in the vehicle) and in relation to immediate death and death within 30 days of injury. The aims of the study were to determine the difference in the extent of injuries in road fatalities between younger and older age groups, those killed at the scene of a traffic accident and those who died during hospital treatment; to determine the trend in traffic fatalities in the observed time period, in total, by sex, and by the road user type; and to assess if there is regularity in the distribution of road fatalities with respect to age and day of the week, weather condition, level of education, and blood alcohol concentration at the time of injury. Study Design A cross-sectional study from historical data included road traffic fatalities of all types of road users (pedestrians, cyclists, motorcyclists, drivers, front-seat passengers, and passengers) who were injured in the area of Osijek-Baranja County and autopsied at the University Institute of Pathology and Forensic Medicine, University Hospital Center Osijek, between 1998 and 2018. The source of historical data was the archive of the University Institute of Pathology and Forensic Medicine, University Hospital Center Osijek (autopsy records), and the electronic archive of the Ministry of the Interior, traffic police of Osijek-Baranja County. Subjects and Methods The study included 678 road traffic fatalities including all victims who died of injuries within 30 days of the traffic accident. The injuries recorded in the autopsy reports were classified according to severity using the Abbreviated Injury Scale (AIS), the last revised 2015 edition. The group of subjects with maximum severity of injury (MAIS) of 3+ (AIS 3 to AIS 6) was analyzed separately from AIS 2 subjects and compared by the type of road use, time of death from injury and age, and its importance in contributing to the onset of death. The cumulative effect of multiple injuries was then determined for each subject by calculating the ISS (Injury Severity Score) and NISS (New Injury Severity Score). Descriptive statistics were made for all analyzed variables. For continuous variables arithmetic mean and standard deviation were used, and for the categorical frequency and relative frequency (percentage). Comparisons between categorical variables were performed using chi-square test, or Fisher's exact test. Single linear regression determined the trends in the number of fatalities in traffic by observed years for the total number and especially by sex. One-way analysis of variance (ANOVA) tested the differences between ISS in terms of traffic participation, age groups, and time of death. Tukey's post hoc test determined the real differences between the analyzed groups. If the condition of homogeneity of variance was not met, the Kruskal-Wallis test was used. For the purpose of analysis of interaction between individual groups, two-factor analysis of variance with interaction tested differences between ISS by traffic participation and time of death, traffic participation and age groups of participants, age groups of participants and time of death, traffic participation and sex and sex and time of death. Pearson's correlation coefficient established the connections between ISS and NISS by groups with respect to the type of road use. A significance level of 5 % was selected for all statistical analyses. Results In the 21-year study period, a total of 728 road users were lethally injured and autopsied. Among them, 678 were analyzed according the type of road use. A total of 4949 injuries were sustained and coded according the AIS classification. There was a significantly negative overall trend of fatalities in road traffic (P < 0.001) in the period 1998-2018, with the number of fatalities decreasing on average by 1,426 each year. For men, there was a significant negative trend of fatalities in traffic (P < 0.001), while for women it was not (P < 0.10). A significantly negative trend of fatalities was recorded among pedestrians (P < 0.005), cyclists (P < 0.006), drivers (P < 0.04) and front-seat passengers (P < 0.009), while for motorcyclists and passengers the negative trend was not statistically significant. A significant number of participants died at the scene (P < 0.001) in a populated area, on a dry road. The significant majority were men aged 45 – 64 with secondary-level education. Lethally injured traffic participants were mostly injured on Saturdays, which is not statistically significant compared to other days of the week. According to the time of the time of the accident, the lethally injured traffic participants were significantly more often injured between 12:00 and 17:59 than other times of the day. A significant majority of road traffic fatalities were car drivers (P < 0.001) who were also more significantly under the influence of alcohol than other study subjects (P < 0.001). The most vulnerable group of road users (pedestrians, cyclists, and motorcyclists) accounted for almost half (49.9 %) of fatally injured and autopsied traffic accident victims. Comparing the frequency of distribution of AIS 2 injuries among the six observed traffic participants, it was found that pedestrians had statistically significant fractures of the lower extremities (P < 0.001) and pelvis (P < 0.04), while co-drivers in cars had statistically significant abdominal injuries (P = 0.01) and facial injuries (P = 0.03). Comparing the frequency of distribution of at least one severe MAIS 3+ injury between the six observed groups of road users, it was found that cyclists had a significantly more frequent head injury (P < 0.001), while car drivers had a significantly more frequent abdominal injury (P < 0.001). Co-drivers had severe chest injury (P < 0.001). Serious MAIS 3 + injuries of the upper (P = 0.002) and lower (P = 0.03) extremities were statistically more significant for motorcyclists. Almost half of the analyzed road traffic accident victims died at the scene of the accident (P < 0.001), 27 % died between the 2nd - 30th day from the accident, while 25.2% of the study subjects died from injuries within the 1st day. With respect to the presence of at least one AIS 3 to AIS 6 injury (MAIS 3+), participants who died at the scene (n = 324) had statistically significantly more frequent MAIS 3+ of the chest, abdomen, cervical spine, thoracic spine, open fractures of the upper extremities, severe lower extremity fractures, unstable pelvic fractures, external injuries to the skin of the body, and facial injuries. Road traffic users who died at the site of injury had significantly maximal injuries (AIS 6) of the head, cervical spine, chest, and abdomen (P < 0.001). Road traffic users who died on days 2 – 30 after the accident (n = 183) had statistically significantly more frequent severe (AIS 3), severe (AIS 4), and critical (AIS 5) head injuries. A significant majority of road traffic users (78.5 %) had maximum injury in one ISS region, of whom 313 participants in the head and neck region, 173 in the chest region, 27 in the abdomen, and 19 in the limb region; 17.1% of traffic fatalities had the maximum injury in two ISS regions at the same time. Road traffic users who died at the site where they sustained injuries had the highest average ISS value of 61.66, whereas those who died on days 2 – 30 after the accident had the lowest average ISS of 35.74. Road traffic users who died within 1 day of injury had an average ISS of 48.16. The largest number of victims who died at the scene of the accident were aged 25-44 years (33.0 %). The road traffic victims in the age group 45 – 64 years most often died within 30 days of hospitalization. According to the results of ANOVA, there was a significant difference in ISS values among the 6 groups of road users. There was a significant difference in ISS values between the observed age groups of road traffic fatalities, with the road users under the age of 25 having significantly different ISS values than those aged over 75. The interaction of the type of traffic participants and the time of death is not statistically significant, which indicates that the ISS behaves approximately uniformly for all 6 groups of participants at the time of death. A statistically significant correlation was found between the two indicators of injury accumulation (ISS and NISS) for all 6 groups of fatal traffic participants (P < 0.001). Conclusion Trend analysis for the road traffic fatalities in Osijek-Baranja County between 1998 and 2018 showed a significantly negative trend of fatalities for all road users (total trend), with the number of fatalities decreasing on average by 1,426 each year. The study found the regularity in severity and distribution of injuries according to the type of road traffic user, and between the time period from the injury and the onset of death and the type of road user. This research study showed that the AIS classification can also be used to classify injuries of fatalities in traffic accidents. In the same way, this classification could be applied to other forms of violent damage to health with fatal outcome. The fatal injury data obtained in this way, in addition to the clinically obtained and classified injuries of the survivors, should be part of the National Trauma Registry, which most EU countries have. |
