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Trauma patients with the ‘triad of death’
  1. Biswadev Mitra1,2,
  2. Francesca Tullio1,
  3. Peter A Cameron1,2,
  4. Mark Fitzgerald3
  1. 1Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
  2. 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
  3. 3Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Biswadev Mitra, Emergency & Trauma Centre, The Alfred Hospital, Commercial Road., Melbourne, VIC 3004, Australia; b.mitra{at}


Introduction Injured patients presenting with hypothermia, acidosis and coagulopathy have been identified at high risk of death. This study aimed to describe the presentation, management and outcome of major trauma patients presenting with the ‘triad of death’ and identify ways to improve survival.

Methods A retrospective, explicit chart review was undertaken on patients presenting to a level I adult major trauma centre with the ‘triad of death’. These patients presented directly from the scene, were coagulopathic (international normalised ratio (INR) >1.5), hypothermic (temperature <35°C) and acidotic (pH <7.2) on arrival.

Results There were 90 patients over an 8-year period, with an overall mortality of 47.8%. No significant differences were observed among demographics and injury severity scores between survivors and non-survivors. Extremes of systolic blood pressure and heart rate, a high activated partial thromboplastin time activated partial thromboplastin time, low fibrinogen counts, pH, bicarbonate, base excess and haemoglobin were present among survivors. There were no survivors in our cohort with an initial INR greater than 3.2. Survivors received significantly lower volumes of packed red blood cells.

Conclusions There has been little change in mortality over time in this subgroup of major trauma patients. While the presence of the triad alone does not determine futility, there were no survivors over 8 years with extreme coagulopathy with concurrent hypothermia and acidosis.

  • Emergency department management
  • major trauma management
  • management
  • trauma
  • wounds

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Alfred Hospital Research and Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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