Tri-modal Distribution of Trauma Deaths in a Resource-Limited Setting: Perception Versus Reality

Advances in trauma care in high-income countries have significantly reduced late deaths following trauma, challenging the classical trimodal pattern of trauma-associated mortality. While studies from low and middle-income countries have demonstrated that the trimodal pattern is still occurring in many regions, there is a lack of data from sub-Saharan Africa evaluating the temporal epidemiology of trauma deaths.

We conducted a retrospective analysis of the trauma registry at Kamuzu Central Hospital in Lilongwe, Malawi, including all injured patients presenting to the emergency department (ED) from 2009 to 2021. Patients were compared based on timing of death relative to time of injury. We then used a modified Poisson regression model to identify adjusted predictors for early mortality compared to late mortality.

Crude mortality of patients presenting to the ED in the study period was 2.4% (n = 4,096/165,324). Most patients experienced a pre-hospital death (n = 2,330, 56.9%), followed by death in the ED (n = 619, 15.1%). Early death (pre-hospital or ED) was associated with transportation by police (RR1.52, 95% CI 1.38, 1.68) or private vehicle (RR1.20, 95% CI 1.07, 1.31), vehicle-related trauma (RR1.10, 95% CI 1.05, 1.14), and penetrating injury (RR1.11, 95% CI 1.04, 1.19). Ambulance transportation was associated with a 40% decrease in the risk of early death.

At a busy tertiary trauma center in Malawi, most trauma-associated deaths occur within 48 h of injury, with most in the pre-hospital setting. To improve clinical outcomes for trauma patients in this environment, substantial investment in pre-hospital care is required through first-responder training and EMS infrastructure.