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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 26  |  Issue : 1  |  Page : 45-52

Demographic characteristics and causes of death for persons brought in dead to emergency department of a Tertiary Health Facility in South-West Nigeria


Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Web Publication12-Mar-2019

Correspondence Address:
Oluseyi Adegoke
Department of Medicine, College of Medicine, University of Lagos, P. M. B. 12003 Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_170_18

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  Abstract 

Introduction: Identifying the demographic characteristics and causes of death in persons 'brought-in-dead' (BID) will inform possible strategies for the prevention of their occurrence. Objective: To characterise the demography as well as document the autopsy-determined underlying and immediate causes of death in BID cases presenting to the emergency department (ED) of a tertiary health facility. Methods: This is a 5-year retrospective descriptive study of 253 autopsied-BID cases. Data were obtained from ED 'death-register' and the hospital 'autopsy-register'. The underlying and immediate causes of death were classified and analysed across the age groups of 21–40, 41–60 and >60 years. Results: The age of the cases ranged from 22 to 101 years with a median of 56.0 (38-72) years. Almost half [110(43.5%)] of the cases were in the age-group >60 years. The male-to-female ratio was 1.04:1, and their ages were comparable. Non-communicable diseases accounted for 216 (85.4%) of the underlying causes of death. Three major specialities contributing to death were medicine 117 (46.2%), oncology 45 (17.0%) and surgery/trauma 42 (16.6%). Specialties of medicine and surgery/trauma were predominantly in age groups >60 years (60.0%) (P ≤ 0.0001) and 20–40 years (31.5%) (P = 0.0001), respectively. The chief underlying causes of death in the specialities of medicine, oncology and surgery/trauma were cardiovascular diseases (61 [52.1%]), breast cancer (11 [24.4%]) and road traffic accidents (31 [73.8%]), respectively. Overall immediate causes of death included heart failure (21.3%), unspecified circulatory collapse (17.0%), central nervous system pathologies (16.6%) and haemorrhagic shock (10.7%). Heart failure (33.6% [37/110]) and haemorrhagic shock (28.8% [21/73]) were the most common immediate causes of death in the >60 years' and 20–40 years' age groups, respectively. Conclusion: Non-communicable diseases are the leading causes of death in persons 'BID'. Deaths from medical conditions, especially heart failure, occurred mainly in the elderly. Deaths from trauma and haemorrhage occurred predominantly in the young.

Keywords: Brought in dead, causes of death, dead on arrival, emergency department


How to cite this article:
Adegoke O, Ajuluchukwu JN. Demographic characteristics and causes of death for persons brought in dead to emergency department of a Tertiary Health Facility in South-West Nigeria. Niger Postgrad Med J 2019;26:45-52

How to cite this URL:
Adegoke O, Ajuluchukwu JN. Demographic characteristics and causes of death for persons brought in dead to emergency department of a Tertiary Health Facility in South-West Nigeria. Niger Postgrad Med J [serial online] 2019 [cited 2019 Aug 22];26:45-52. Available from: http://www.npmj.org/text.asp?2019/26/1/45/253976


  Introduction Top


Persons 'brought in dead' (BID) often contribute to hospital emergency department (ED) mortality statistics.[1],[2],[3],[4] In Nigeria, this group accounted for 3.6%–19.9% of reported mortalities in ED and up to 86.1% of all sudden cardiac deaths in one centre.[1],[2],[3],[4],[5] Publications from Ghana and Pakistan reported a prevalence of 31%–70% of BID cases in ED mortalities.[6],[7] Whereas the pattern, characteristics and causes of ED-based mortalities have been widely investigated,[1],[3],[4],[8],[9] BID cases have been less well characterised. Some investigators either excluded BIDs from their analysis or analysed such data as part of ED deaths.[1],[2],[3],[4] The pattern of and the pathologies that characterise these BID cases may, however, differ from those whose deaths were managed in the ED. Some studies that characterised cases of persons BID were limited to specific specialities of medicine, surgery or obstetrics.[10],[11],[12] Concerning the determination of cause of death, several studies were based on clinical assessment only.[6],[7],[11],[12],[13] However, available evidence support the reliability of post-mortem reports for such observations.[14],[15]

Accurately identifying the characteristics and the causes of death in BID cases will inform possible future strategies for the prevention or reduction of their occurrence. It will also guide and enhance the ED preparedness to deal with such cases when they arrive alive.

This study, therefore, aimed to characterise the demography as well as document the autopsy-determined underlying and immediate causes of death in BID cases presenting to the adult ED of a tertiary health facility.


  Materials and Methods Top


This was a retrospective, descriptive study of persons 'BID' to the ED of Lagos University Teaching Hospital, Nigeria. The period of study was from 1 September 2011 to 31 August 2016. Ethical approval was obtained from the Health Research Ethics Committee of the institution before the commencement of the study (Ref: ADM/DSCT/HREC/APP/1905).

Inclusion criteria were 'BID' status, age ≥18 years, availability of demographic data, has undergone autopsy and availability of complete record of the underlying and immediate causes of death in the autopsy reports. Excluded from the study were deaths managed in the ED.

BID cases are first presented to the ED of the hospital where registration processes occur, death is confirmed and permission for transfer to the Department of Anatomic and Molecular Pathology (AMPD) of the hospital for autopsy is obtained from the next of kin. Autopsy procedures, supervised by the hospital consultant pathologists, are usually performed within 48 h of obtaining such consents. The underlying and immediate causes of death are then determined by the supervising consultant pathologist based on the autopsy findings, and these are recorded in the 'Autopsy Register'.

The demographic data (age and gender) of BID cases presented in the period of study were retrieved from the 'Death Register' maintained at the ED of the hospital. Data on the underlying and immediate causes of their death were retrieved from the 'Autopsy Register' maintained by the AMPD of the hospital. The retrieved underlying causes of death were then classified into clinical specialities, whereas the immediate causes of death were classified in accordance to the guidelines of the International Classification of Diseases (ICD)-10.[16]

Definition of terms

  1. 'BID' status in this study refers to persons whose deaths occurred before arrival at the ED of the hospital
  2. Underlying causes of death are the primary diseases or events that started the chain of events that led to death[16]
  3. Immediate causes of death are the final conditions or diseases that resulted in death, which could be consequences or complications of the underlying cause[16]
  4. The autopsy diagnosis of heart failure as immediate cause of death was based on morphology and pathology findings that included organ lesions secondary to venous congestion (either systemic or in the lungs) or systemic low output state, along with the presence of significant cardiac disease and absence of another cause for the death[17]
  5. 'Central nervous system pathologies' as immediate causes of death refer to the autopsy findings of intracerebral haemorrhage, brain tonsillar herniation, cerebral infarction, intracranial haemorrhage and/or cerebral oedema.[18]


Data handling and statistical analysis

The retrieved data were entered into Excel sheet for cleaning and imported into the IBM Statistical software Package for Social Sciences (SPSS) version 20.0 (IBM Corp., Armonk, NY, USA) for analysis. Continuous variables (age) were expressed as median with interquartile ranges because the data were skewed. Mann–Whitney test was used for measuring significance in continuous variables. Categorical variables were expressed as frequencies with percentages. Chi-square test was used to compare categorical variables to determine significant difference. Analysis of data was done across different age groups and gender. The level of statistical significance was set at P < 0.05. Fisher's exact P was used for comparisons with cell value <5 counts.


  Results Top


Of the 3297 deaths recorded by the ED during the study period, 378 (11.5%) persons were BID. However, data of 125 BID cases were excluded for the following reasons: age <18 years (5 cases), incomplete demographic data (22 cases) and non-availability or incomplete autopsy reports (98 cases). Hence, a total of 253 BID cases constituted the study population.

Characteristics of the study population

Data of the 253 BID cases analysed comprised of 129 males and 124 females, with a male: female ratio of 1.04:1. Their age ranged from 22 to 101 years with a median of 56.0 (38–72) years. The median age of the males and females was comparable (57.0 (41.0-70.0) vs. 55.0 [36.0–76.0] years, P = 0.870). We had no record of persons BID aged 18–21 years in the study period. Hence, the study population was categorised into the following age groups: 21–40 years, 41–60 years and >60 years. In the age groups of 21–40 years, 41–60 years and >60 years, there were 73 (28.9%), 70 (27.7%) and 110 (43.5%) cases, respectively.

Underlying causes of death

Non-communicable diseases accounted for 216 (85.4%) of the underlying causes of death. Infectious diseases accounted for 33 (13%).

As shown in [Table 1], the underlying causes of death were mainly from the clinical speciality of medicine (117 [46.2%]). Male gender predominance was noted in the surgery specialty (21.7% [28/129] vs. 11.3% [14/124], P = 0.026). [Table 2] shows age group distribution of the underlying causes of death across clinical specialities. It shows that medicine speciality-related deaths occurred more in persons above 40 years, with the highest (60.0% [66/110]) being in cases older than 60 years, P < 0.0001. Surgery-related underlying causes of death were mainly in the 21–40 years' age group, P = 0.0001.
Table 1: Gender distribution of the underlying causes of death across clinical specialities

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Table 2: Age distribution of the underlying causes of death across clinical specialities

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[Table 3] summarises the conditions in each speciality. It shows that cardiovascular diseases constituted more than half (52.1%) of the conditions in the medical speciality. Breast cancer was the most common (24.4%) oncology. Road traffic accident (RTA) made up 73.8% of the surgery-related deaths. In addition, of the RTA victims, 12 (38.7%) had suffered head injury. No case of malarial infection was seen.
Table 3: Frequency of the underlying causes of death in each speciality

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Immediate causes of death

[Table 4] summarises the distribution of the immediate causes of death. It shows that heart failure was the most common immediate cause of death (21.3%) in this study. There was no significant gender difference in the proportion of cases that died of heart failure. More males than females were noted to have died from central nervous system pathologies, 21.7% (28/129) versus 11.3% (14/124), P = 0.0260.
Table 4: Gender distribution of immediate causes of death

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As shown in [Table 5], heart failure occurred mainly in cases who were older than 60 years (33.6% [37/110]). Haemorrhagic shock occurred most commonly in the 21–40 years' age group (28.8% [21/73]).
Table 5: Age group distribution of immediate causes of death

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In addition, haemorrhagic shock was the immediate cause of death in 11 (91.7%) of the obstetric deaths.

[Table 6] shows distribution of the specific pathologies of the central nervous system that caused death. Tonsillar herniation was the single most common (11 [26.3%]) specific pathology of the central nervous system that caused death.
Table 6: Specific central nervous system pathologies that caused death

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However, when all the stroke subtypes (cerebral infarction, intracerebral haemorrhage and subarachnoid haemorrhage) were combined, stroke constituted the most common pathology (19/42 [45.2%]) of central nervous system. Of this, 11/19 (57.9%) were haemorrhagic stroke (intracerebral haemorrhage and subarachnoid haemorrhage).


  Discussion Top


Persons BID constituted 11.5% of the ED mortality statistics in this study, which falls within the range of 4.2% and 18.0% that have been reported in two urban tertiary health facilities in Nigeria.[2],[3] The median age of 56 years is in keeping with the average life expectancy of 53.8 years in Nigerians.[19] It is, however, higher than the mean age of 44 years reported in an earlier BID study in Nigeria.[10] The inclusion in that study, of paediatric age group, may be responsible for the reported lower mean age. The peak age group of >60 years in our BID cases is lower than the ≥70 years reported among BID cases in Ghana.[6] This difference may be related to the higher average life expectancy of 67 years in Ghanaians.[20] It is, however, higher than the peak age group of 31–45 years reported from Nepal.[13] It also contrasts with the peak age range of 20–50 years reported for deaths managed in ED s in Nigeria.[1],[3] The older age of the BID cases may suggest later presentation of this age group for emergency care.[6] Other reasons may include chronicity of the underlying illness and lack of recognition by patient and relatives regarding critical deterioration.[6],[21]

The overall sex ratio of the BID cases was 1.04:1, and this is consistent with the sex ratio reported for Nigerians.[19] This is, however, lower than the ratios of 1.2:1, 1.37:1 and 1.4:1 reported among BIDs in earlier studies from Nepal, Nigeria and Ghana, respectively.[6],[10],[13] The non-inclusion of obstetric BID cases in the studies from Nepal and Ghana may have contributed to the higher male ratio in those studies. The male-to-female ratio in our cases is also lower than the ratio of 1.5:1 and 2.1:1 reported for ED deaths in two tertiary health facilities in urban Nigeria.[1],[3]

The leading underlying causes of death were medical conditions, especially cardiovascular and central nervous system diseases. The major contribution of the clinical speciality of medicine to the underlying causes of death is similar to that reported for deaths in the ED.[2],[3],[22],[23] Our finding of cardiovascular diseases as the most common medical cause of death is consistent with reports from previous BID and ED death studies.[1],[3],[10],[24] This is similar to what was obtained in the Western world and is in keeping with the reported increasingly high contribution of cardiovascular diseases to mortality burden in developing countries.[25],[26] It, however, differs from the finding of chronic obstructive pulmonary disease as the most common medical cause of death among BID cases as reported from Nepal.[13] This difference may be due to the higher prevalence of tobacco smoking in Nepal (19.6% in females and 56.5% in males) compared to Nigeria (1.1% in females and 10% in males), as tobacco smoking has been strongly associated with an increased risk for chronic obstructive pulmonary disease.[27],[28],[29] The predominance of medical conditions among persons who were older than 60 years in our study compares with its higher prevalence with increasing age in developed countries.[25] It, however, contrasts with its predominance in the 31–40 years' age group in a previous BID study.[10] This disparity may be explained by the exclusion of hypertension-related deaths in that study which have been documented to be more common in older age groups in Nigeria and other parts of the world.[6],[25],[30]

The predominance of RTAs in surgery-related deaths is in keeping with the pattern reported for BID and ED mortalities in Nigeria.[1],[3],[11] This, as well as the predominance of the male gender and the 21–40 years' age group in surgery-related deaths, is also similar to patterns reported from South Africa, Asian countries and Europe.[31],[32],[33],[34],[35] Explanations that have been offered for these observations include a more active nature, higher tendency to disobey traffic rules and greater tendency to alcohol/substance abuse in males of this age group.[36],[37] In the study from Ghana, however, RTA contributed minimally to BID cases.[6] The higher rate of RTA in our study compared to that from Ghana may be due to the tertiary status of our institution which is likely to attract more severe cases unlike the secondary status of the health facility in the study from Ghana. Approximately 40% of the RTA victims had suffered head injury, consistent with reports from Nigeria, South Africa, Korea and Italy, that head injuries contribute a larger percentage to death in RTAs.[11],[31],[33],[35],[38],[39] Provision of dedicated equipped ambulances with trained emergency medical team has been shown to reduce the frequency of these deaths.[40] These pre-hospital care for RTA victims is, however, largely less well established in some developing countries.[41],[42]

The occurrence of oncology as the second largest speciality contributing the underlying causes of death tends towards the pattern described in Korea and the United States where cancers were the largest and second largest causes of death, respectively.[25],[43] An increasing trend in the incidence of cancers in many sub-Saharan African countries has also been observed and is believed to be due, in part, to adoption of Western lifestyle.[44] The 17.8% contribution of oncology to the underlying causes of death in our study is higher than the 4.2% reported among deaths that occurred in the ED.[1] It is, however, closer to the prevalence of 10.9% reported among BIDs in a previous study.[10] The higher occurrence among BID cases may be related to the debilitating and terminal nature of such conditions which may prompt the patients to seek alternative non-orthodox care.[45] In a study from Ontario, terminally ill cancer patients visited the ED at the end of life only when their usual care fails as such visits are often disrupting and exhausting.[46] Our observation that most of the cancer types seen were those amenable to screening and/or treatment also suggests possible low level of awareness leading to late presentation.[47] A similar trend was observed in Zimbabwe and Tanzania, where 80%–91% of patients with otherwise treatable cancers presented late.[48],[49] The types and pattern of cancers seen in this study are similar to those previously reported.[10],[50] Breast cancer was the most common cause of cancer-related deaths similar to other reports from Nigeria and Ghana.[50],[51] This, however, differs from reports from Korea and Europe where breast cancer was a less common cause of cancer-related deaths.[43],[52] This is in keeping with the lower breast cancer 5-year survival rate of 12% reported in Africans compared with the rate of 90% recorded in some developed countries, despite higher incidence rates of breast cancer reported in developed countries.[53] Poor attitude towards breast cancer screening leading to low awareness is a possible explanation that has been given for this discrepancy,[47],[53] whereas lung cancer was seen in only 8.9% of cancer-related deaths in our study, which is the leading cause of cancer-related deaths in Europe and Korea.[43],[52] It is also the most common cancer that caused death among the BIDs in Nepal.[13] The relatively lower prevalence of lung cancer as the cause of death in our study may be due to the lower prevalence of smoking in Nigerians which is strongly linked to lung cancer.[28],[54]

The 13% contribution of infectious diseases to the underlying causes of death, though lower than the 85.4% contributed by non-communicable diseases, suggests that the health burden posed by infectious diseases is not yet over.[55] The infectious diseases that caused death in our cases are similar to those that have been reported for deaths in the ED and among BIDs in Nigeria, other African countries and Pakistan.[6],[7],[8],[10],[56] However, while we found septicaemia to be the most common infection similar to the pattern reported in Pakistan;[7] AIDS/HIV-related infections were the most common in Ghana, Kenya and among deaths in ED in Nigeria.[6],[8],[56] The more common occurrence of septicaemia among our cases may be related to the ease of access to over-the-counter antibiotics in Nigeria which, in turn, increases the probability of self-medication and procurement of fake, wrong or expired drugs. AIDS/HIV-related infections were the second most common in keeping with the increasing HIV-related mortality in spite of a declining HIV infection incidence rate reported in Nigeria, due to low antiretroviral therapy coverage compared to other countries.[57] Interestingly, no malaria-related deaths were seen in our study or in a previous BID study.[10] This may be explained by the relative immunity to malaria in adults living in Nigeria as well as the relative ease of access to over-the-counter antimalarial drugs.

The causes of obstetric deaths in our study are similar to those reported among BID cases in Nigeria and in other parts of the world.[10],[12],[58],[59] The predominance of post-partum haemorrhage as the underlying cause of death in this group has called for re-training of birth attendants to promptly identify at-risk patients for early referral.[12],[58] Similarly, the predominance of haemorrhagic shock as the immediate cause of death in this group also calls for improved access to blood transfusion facilities within the community.[12]

Our finding of heart failure as the leading immediate cause of death contrasts with stroke reported for deaths managed in EDs in Nigeria.[2],[8],[18],[22] The often chronic nature of heart failure as opposed to the more dramatic and sudden nature of stroke may make presentation to the ED less prompt in persons suffering from heart failure. In addition, majority of those who died of heart failure were older than 60 years in contrast with the average age of 40–53 years reported among the stroke cases in the EDs.[2],[8],[18],[22] The older age of our cases may have contributed to this difference as higher prevalence of mortality from heart failure in older individuals is well documented.[17],[60] Furthermore, the symptoms of heart failure in the elderly are often atypical, absent or mistaken for old age.[60] The resultant low awareness by patients and caregivers leads to late health-seeking behaviour and may explain why these cases were BID.[21] Our finding compares with the report of heart failure as the most common (40.9%) autopsy-determined immediate cause of death in persons suspected to have died of cardiovascular cause in a university hospital in Brazil.[17] Heart failure was also the predominant (40.6%) autopsy-determined immediate cause of death in a subset of patients whose deaths were sudden in that study.[17] In both instances, the mean ages of the patients, 63 years and 62 years, respectively, were comparable with ours.[17] In contrast to our finding, however, coronary artery disease was the more common cause of death among BID cases of variable ages in Pakistan, Glasgow – the UK and China.[7],[14],[61] The relative rarity of coronary artery disease in Nigeria may explain this disparity.[62] Stroke was the most common central nervous system condition that caused death similar to its common occurrence in other BID studies.[6],[7],[13] Haemorrhagic stroke was the most common subtype, also similar to previous report, and in keeping with the higher mortality associated with it.[18],[63] However, tonsillar herniation was the most common single specific pathology of the central nervous system that caused death unlike intracerebral haemorrhage that was reported for deaths in the ED.[18]

In 17% of our cases, the immediate cause of death was classified as unspecified circulatory collapse. This compares with the 12.1%, 15.6%, 31.0% and 35.0% of various sudden death victims in China, Brazil, Australia and the United States, respectively, in whom the causes of death remained unspecified following autopsy.[17],[61],[64],[65] This uncertainty has prompted the proposal for the routine inclusion of molecular genetic testing in autopsy cases with uncertain findings to reduce the proportion in this classification.[61] The proportion of unspecified circulatory collapse in our study is, however, lower than the 40.8% and 46% reported among BID cases in Ghana and Nepal, respectively, when the cause of death determination was based on clinical assessment only, rather than on autopsy.[6],[13] This is in keeping with the greater limitation of clinical assessment only, compared with autopsy for cause of death determination in persons BID.[14],[15],[17]

The observation that 10.7% of persons BID died of haemorrhagic shock, all of whom were in their prime, underscores the need for emergency mobile blood transfusion services that are subjected to regular quality assurance testing.[66]

This study has a few limitations despite the important trends identified. First, the retrospective data sourcing from an autopsy database precluded determination and/or verification of the prior health status and immediate care received before death. This additional information would have been beneficial in identifying risk factors for BID status. Second, the small numbers in some of the subgroup analysis may affect the statistical power. As such, the statistical conclusions should be interpreted in this context. Studies with larger sample sizes may be required to further clarify these findings.


  Conclusion Top


Non-communicable diseases are the leading causes of death in persons BID. Deaths from medical conditions, especially heart failure, occurred mainly in the elderly. Deaths from trauma and haemorrhage occurred predominantly in the young. There is a need to raise awareness on the early recognition of these conditions, improve access to healthcare facilities and establish pre-hospital care with access to blood transfusion services.

Financial support and sponsorship

This study was self-funded by authors.

Conflicts of interest

There are no conflicts of interest.



 
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