What should First Aiders and Medics prepare for?
Feel free to use any information in this article but please cite Real First Aid Ltd and a direct link back to this article. The original source and data set is not revealed publicly but is available on request.
It is common on First Aid courses to talk about fractures, bleeds and burns in equal measure and to talk about casualties in general.
While it is equally possible for anyone to sustain any type of injury, it is important to understand that:
- Some casualties are more susceptible to particular injuries.
- Not all casualties are equally affected by these injuries.
Statistical analysis of the causes of fatalities can reveal patterns which enable us to prepare for the most probable and / or serious events as well as any patterns which are exhibited amongst the casualties.
This article looks at data from a given year for all recorded fatalities from external causes (e.g. injury, poisoning, environmental factors) and not death from health or medical related causes.
Who is your casualty?
Simply examining the distribution of fatalities across age groups reveals three distinct clusters:
- Children under 15 have a comparatively low incidence of death through injury or external force.
- Adults between 15 and 64 represent a significant proportion of deaths through injury or external force.
- Death through injury or external force peaks around 80 to 94 years.
This unequal distribution is largely due to our physiology, lifestyle and relative numbers or population within a give age group:
- Children, especially infants, are at significantly less risk of fatal injury or external force as they are, in general, looked after by others who take responsibility and control for their behaviour and actions; protecting them from harm.
- Adults are exposed to significantly increased risk of fatal injury, primarily due to vehicle accidents, work related accidents and misadventure. For simplicity, the data here does not separate on gender but the original data source reveals that in this age group males make up the vast majority of these fatalities.
- Beyond a low incidence lull around 65 years, the incidence of fatalities increases with ages. Adults, still exposed to dangers in the home and on the streets, experience losses in their senses, coordination and balance, exposing them to more accidents. Again, while specifics on gender are not dealt with here, there is a marked increase in the number of female fatalities, which is assumed to reflect the increased population of older females who live longer than males. Osteoporosis appears to affect more females more than males, increasing the chance and severity of damage to bones in an accident.
If we concentrate on three broad categories; children ( 0-4 years ), adults (15-64 years) and elderly ( 65+ years) we can also see a marked difference in the external causes of death.
External Causes of Death
Click to enlarge:
Nearly half of deaths in children relate to injury with a significant proportion coming from other 'external forces'. This term covers a broad range of accidents of fatal incidents which will be explored later.
In adult cases, injury accounts for a greater proportion, followed by poisoning. In an elderly casualty, fatal incidents are majoritally caused by injury.
Injured Body Area
Whilst lifestyle and physiology accounts for variations in the causes of fatalities across age groups, it is the casualty's anatomy which accounts for variations in where casualty's sustain fatal injury:
- Nearly half of all fatal injuries of children will relate to a head injury; infants in particular have a disproportionately larger and heavier head in relation to their body than adults which is supported by a comparatively frail neck - accounting for over 10% of fatalities.
- The second most common cause of fatal injury in children is through 'multiple injury' reflecting their delicate structure - both bone and soft tissue - which is particularly susceptible to falls and impact.
- In adults, head injury still represents a significant proportion of fatal injury but 'multiple injuries' more so. This is again consistent with falls and direct impact, again, largely as a result of vehicular related incidents, work-related incidents and misadventure.
- Notice that despite our paranoia of spinal injuries only 3.5% of all adult casualties who died of a result of their injuries, died due to spinal injury. Spinal management is paramount to ensuring damage limitation to the casualty's nervous and circulatory system but the risk of death through spinal injury is slight. The risk of death through not maintaining an open airway despite spinal immobilisation is definite.
- With elderly casualties a new and significant cause emerges; injury to the hip or thigh. These injuries were responsible for 43 deaths in an adult population (between 15 and 64 years) for this data set but 2,981 deaths in casualties over 65 years. The greatest cause is from simple falls causing damage to a massive bone with rich blood supply. In a healthy adult a significant force is needed to do such damage but significantly less for an elderly casualty as their bones become weaker. The mechanism of injury is also consistent with a casualty with less balance and mobility.
Type of Injury
- Of all recorded deaths through injury or other external force for this year, only three classifications were required to record cause of death in children; Internal Organs including the brain ( 66.7%), Fracture (22.2%) and Open Wound (11.1%). This data provides evidence to children's vulnerability to falls and impacts, yet resistance to bone injury: whilst children have small, soft bones, their pliability resists fracture to a greater degree compared to more rigid bones of a similar size in adults.
- Worryingly, an injured child - who may not be able to tell you what is wrong with them - is likely to have serious internal injuries which will need to be identified as quickly as possible.
- Adults display a more uniform distribution of approximately 30% of all fatal injuries relating to either Internal Organs, Fracture or Open Wound.
- Elderly fatalities attribute 75% of all fatal injuries causes to fractures, mirroring the evidence from Body Area that an elderly casualty is at significant risk to slips, trips and fall.
- A seriously injured child has an almost 50% chance that it is related to injury (with one third of fatalities relating to other external forces).
- Over half of fatal injuries in children are head injuries and the root cause of death in two thirds of fatalities is damage to the internal organs (including the brain).
- Never underestimate the potential underlying injuries which may be caused from falls of even low height or minor impacts.
- Given the pliability of young bones, just because there is not a obvious fracture does not mean a significant force has been applied.
- If the child cannot talk, how are you going to find underlying problems, signs or symptoms? This is what you will need to do.
- Over half of adult fatalities are due to injury with a significant proportion relating to multiple body areas and one third relating to head injuries alone.
- The complex nature of multiple body injuries (rather than a single, obvious injury) is also mirrored in the equal distribution of injury types; internal; organ, open wound and fracture.
- Adults lead more complex lives and engage in more complex tasks than children. Where a rather benign incident, such as falling off a swing, can be potentially fatal in a child, an adult casualty is likely to have sustained multiple and varied injuries.
- Is the injury you have found, the most serious? You have found a serious injury, are there any more to be found?
- Complex casualties require rapid assessment and continued monitoring.
- Elderly casualties present a for more predictable pattern of fatal injury, as with children; Whilst there is a possibility they may have sustained any kind of injury, the greatest incidence of fatalities comes from fractures, typically from the hip or pelvis and most commonly through falls.
- As with all falls, remember to check for head injuries ( the obvious external injuries as well as other clues) as one quarter of all fatal injuries affect the head and are caused by damage to the internal organs.
- Whilst there is a clear trend here, the danger is failing to look beyond the obvious.
Other External Causes
So far we have only looked at fatal injuries. The list of 'other external factors' which have been refered is varied but also rather predicable:
click to enlarge
- From the year examined, the only external factors responsible for fatalities in children were asphyxiation and drowning.
- In the adult group asphyxiation has been seen to be the leading external cause of death other than injury. This include suffocation, strangulation, choking and aspirating fluids (i.e. choking on ones vomit - a real risk with unconscious casualties left on their back) and also failings to protect the airway of unconscious casualties.
- Other factors account for relatively rare occurrences. Interesting, it is in the adult group that we first see fatal cases of anaphylactic reaction.
- In the elderly group, asphyxiation, drowning and hypothermia are again the three most common external factors but we also see an increase of fatalities as a result of traumatic wound infection (as opposed to other infections).
- Elderly casualties do not tolerate morbidity at all and can deteriorate rapidly, being more sensitive to physiological change from infection,illness or burns, for example. The anatomy of children is may be as fragile as that of an elderly person but they tolerate illness and infection, compensating for a much longer period before finally, rapidly, deteriorating.
Recognising that, based on age alone, patterns of injury differ enables us to prepare psychologically for what we might find when we are called to a casualty.
Understanding that because of differences in anatomy and physiology between age groups we are aware that some accidents will reveal simple, obvious injuries with some casualties but more serious, hidden injuries in others. This prompts us to take a more rigorous assessment of the casualty to avoid missing potentially serious injuries.