e-ISSN: 2722-3558 Sriwijaya Journal of Surgery [SJS] https://sriwijayasurgery.
Determinants of In-Hospital Mortality Following Pelvic Ring Fractures: A 4.
5-Year Analysis from a Developing Country's Trauma Center Jaya Ndaru Prasetio1*.
Ismail Bastomi2.
Theodorus3 1Surgery Study Program.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia 2Department of Orthopaedics and Traumatology.
Dr.
Mohammad Hoesin General Hospital.
Palembang.
Indonesia 3Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia.
ARTICLE
ABSTRACT
INFO
Keywords:
Developing country Mortality Pelvic fracture Risk factors Sociodemographic factors *Corresponding author:
Jaya Ndaru Prasetio E-mail address:
jayandarup@gmail.
All authors have reviewed and approved the Anal version of the manuscript.
https://doi.
org/10.
37275/sjs.
Introduction: Pelvic ring fractures are calamitous injuries with high While clinical risk factors are well-defined in high-income countries, there is a scarcity of data from low- and middle-income countries (LMIC.
, where socioeconomic factors may critically influence survival.
This study sought to explore the sociodemographic and clinical factors associated with in-hospital mortality following pelvic fractures at a tertiary trauma center in Indonesia.
Methods: A retrospective cohort study was performed on all patients (N=.
admitted with traumatic pelvic fractures to Dr.
Mohammad Hoesin General Hospital between January 2021 and June 2025.
Data on patient demographics, socioeconomic variables, injury mechanisms, and clinical management were analyzed.
The primary outcome was inhospital mortality.
Given the exploratory nature of the study and the small sample size, bivariate analysis using Pearson's Chi-Square and FisherAos Exact tests was conducted to identify potential associations.
Results: The overall in-hospital mortality rate was 9.
7% .
of 31 patient.
The cohort was primarily young adults .
3% aged 20-59 year.
injured in traffic accidents .
1%).
The only variable found to have a statistically significant association with mortality was occupation.
All three fatalities occurred in patients from the informal employment sector, corresponding to a 37.
5% mortality rate within this subgroup .
=0.
No significant association was found for established clinical predictors, including Young-Burgess fracture classification .
=0.
, a finding likely attributable to the study's limited statistical power.
Conclusion: This study, though limited by its sample size, identified a powerful association between informal sector employment and mortality after pelvic fracture.
This finding generates the critical hypothesis that in an LMIC setting, socioeconomic vulnerability is a paramount driver of poor outcomes, likely mediated through delays in care and presentation with more severe physiological derangement.
These results underscore the need for a socio-clinical approach to trauma care and highlight a crucial area for future, more definitive research.
Introduction viscera, and anchors a dense network of major Pelvic ring fractures, resulting from the violent vascular and neural structures.
2 Its traumatic failure transfer of energy to the human body, represent a is thus frequently accompanied by life-threatening hemorrhage and a high incidence of devastating These injuries, most often sustained in motor vehicle collisions or falls from height, involve morbidity and mortality rates that range from 5% to more than mere skeletal damage.
they signify a over 30% in the global literature.
The pathophysiology profound disruption of a critical anatomical and of early mortality in pelvic trauma is a well-understood The pelvis provides structural but formidable cascade, primarily driven by acute integrity to the axial skeleton, shields abdominopelvic hemorrhagic shock.
3 The mechanical disruption of the pelvic ring can expand the retroperitoneal space, surgical expertise may be limited, particularly outside negating its natural tamponade effect and permitting of major urban centers.
In such settings, it is plausible that a patient's surfaces of fractured bone and, more critically, from socioeconomic reality becomes a dominant factor in the sheared presacral and internal iliac venous their survival.
8 Social determinants of healthAithe 4 This massive volume loss rapidly triggers conditions in which people live and workAimay exert a the "lethal triad" of trauma: hypothermia from powerful influence.
Occupation in unregulated, high- exposure and infusion of cool fluids, acidosis from risk sectors can increase trauma exposure, while tissue hypoperfusion and anaerobic metabolism, and limited education and health literacy can delay the coagulopathy as the enzymatic clotting cascade fails in recognition of a life-threatening injury.
9 Most critically, the cold, acidic environment.
5 This self-perpetuating financial barriers and the lack of comprehensive health insurance can create devastating delays in management of these patients.
Consequently, pathophysiology of shock to progress to an irreversible predominantly from high-income countries (HIC.
, has It is in this complex interplay between injury, been dedicated to identifying predictors of mortality to physiology, and socioeconomic context that the battle refine resuscitation protocols and guide surgical for survival is often decided.
10 The novelty of this study decision-making.
6 This research has consistently lies in its dedicated analysis of mortality predictors for identified several key risk factors: anatomical factors, pelvic ring fractures within a tertiary trauma center in such as mechanically unstable fracture patterns (APC- a developing Southeast Asian nation.
By examining a II/i.
VS) defined by the Young-Burgess classification, which are directly linked to greater hemorrhage.
sociodemographic variables, this research provides a clinical factors, such as hemodynamic instability upon rare and critical perspective from a healthcare and physiological factors, captured by environment where socioeconomic realities may exert scoring systems like the Injury Severity Score (ISS), a powerful influence on patient survival, potentially which quantifies the patient's total injury burden.
challenging the primacy of purely anatomical injury However, this established paradigm is built on data classifications established in high-income country from well-resourced trauma systems.
A profound The primary aim of this exploratory study knowledge gap persists for low- and middle-income was, therefore, to identify potential sociodemographic countries (LMIC.
, which bear a disproportionately high burden of global traumatic injury.
In nations like mortality among patients with traumatic pelvic ring Indonesia, the context of trauma is fundamentally fractures treated at Dr.
Mohammad Hoesin General Rapid industrialization and motorization Hospital in Palembang.
Indonesia.
We hypothesized have created an epidemic of high-energy road traffic that in this setting, indicators of socioeconomic injuries, particularly among young adults.
These vulnerability would emerge as significant potential patients, while often possessing the physiological predictors of mortality, generating a crucial foundation reserve of youth, encounter a healthcare landscape for future, more definitive research.
in-hospital beset by unique challenges.
The "three delays" model of careAidelays in seeking care, reaching a facility, and Methods receiving adequate careAiis highly relevant.
Prolonged A retrospective cohort study was conducted to pre-hospital transport, especially from extensive rural analyze patients with traumatic pelvic fractures.
The areas, is common.
Access to advanced diagnostics, study was set at Dr.
Mohammad Hoesin General Hospital in Palembang, the capital city of South Sumatra.
Indonesia.
This institution functions as the occurring during the index hospitalization for the province's primary tertiary referral hospital and pelvic fracture.
The independent variables, considered academic medical center, providing the highest level of as potential predictors, were organized into two trauma care for a large and diverse population from both the urban metropolis and surrounding rural Captured as a continuous variable and subsequently The study protocol received ethical exemption categorized for analysis into three clinically relevant Board groups: adolescent .
Ae19 year.
, adult .
Ae59 year.
, (No.
DP.
03/D.
XVi.
08/ETIK/191/2.
, and it and elderly (Ou60 year.
Gender: Documented as male was performed in adherence to the ethical principles or female.
Education Level: The highest level of formal outlined in the Declaration of Helsinki.
Given the education achieved, categorized as Primary School, retrospective nature of the data collection, the Junior requirement for individual patient consent was waived Occupation:
by the ethics committee.
The study population socioeconomic groups: Formal Sector .
ndividuals with consisted of all patients admitted to Dr.
Mohammad stable employment, such as government or private Hoesin General Hospital with a primary diagnosis of a company employee.
Informal Sector .
ndividuals with traumatic pelvic fracture between January 1st, 2021, less stable employment, such as merchants, day and June 30th, 2025.
Potential cases were identified by laborers, construction workers, and driver.
, and Not querying the hospitalAos electronic medical record Working system and the departmental orthopedic surgery registry using relevant International Classification of Residence: Defined by the location of the traumatic Diseases.
Tenth Revision (ICD-.
codes for pelvic incident, categorized as occurring within the urban The sole inclusion criterion for the study limits of Palembang city or in the surrounding was admission to the hospital with a radiologically rural/regional areas outside Palembang.
Clinical confirmed diagnosis of an acute traumatic fracture Variables: Mechanism of Injury: Classified based on involving the pelvic ring.
The only exclusion criterion the narrative description in the medical record as was the presence of medical records that were traffic accident, fall from height, blunt force/crush incomplete or inaccessible to the extent that key injury, or a low-energy fall.
Fracture Classification: All demographic or clinical variables could not be reliably pelvic ring fractures were classified by an orthopedic During the study period, all identified patients met the inclusion criteria and had sufficiently according to the Young-Burgess classification system.
complete records for analysis.
therefore, no patients This system categorizes fractures based on the injury were excluded.
vector into Anteroposterior Compression (APC) types I- Institutional School.
Classified Senior High Age:
School.
meticulously designed to ensure consistent and Shear (VS), reflecting the degree of mechanical comprehensive data collection from patient medical Associated Injuries: Recorded as a simple A primary investigator, trained in medical binary variable .
es/n.
indicating the presence of any record review, performed the data extraction.
other significant traumatic injury documented in the patient's record.
Type of Management: Categorized as independently audited a random 10% sample of the operative if the patient underwent any surgical abstracted records, with any discrepancies resolved by procedure for pelvic stabilization .
xternal fixation, consensus review of the source document.
The ORIF) or non-operative if managed with conservative primary outcome variable was in-hospital mortality, a measures like bed rest and traction.
High Variables:
Lateral Compression (LC) types I-i, or Vertical Sociodemographic Review binary variable defined as death from any cause All abstracted data were entered and managed in a significant portion .
5%).
This age distribution secure database.
Statistical analysis was conducted strongly suggests that the primary etiology of these using IBM SPSS Statistics for Windows.
Version 26.
fractures is not fragility from old age, but rather high- (Armonk.
NY: IBM Cor.
Descriptive statistics, energy trauma, a fact that is consistent with the including frequencies and percentages, were used to manuscript's data on traffic accidents being the characterize the study cohort.
The primary analysis leading mechanism.
The gender distribution is nearly equal, with a slight male predominance .
6% male between each independent variable and the outcome 4% femal.
This near-parity is notable, of in-hospital mortality.
The Pearson Chi-Square test suggesting that exposure to the high-risk activities was used for this purpose.
In instances where any cell leading to these injuries is not confined to one gender in the contingency table had an expected frequency of less than five, the FisherAos Exact test was substituted to ensure statistical accuracy.
For 2x2 contingency Perhaps one of the most informative tables.
Odds Ratios (OR) and their corresponding 95% demographic details presented in Figure 1 is the confidence intervals (CI) were calculated.
A p-value of geographic origin of the patients.
A significant majority less than 0.
05 was set as the threshold for statistical of the cohort, nearly two-thirds .
5%), were from rural areas outside the main city.
This finding is critical, as it implies that a large proportion of these Results critically injured patients faced potentially prolonged Figure 1 provides a comprehensive and immediate pre-hospital transport times and logistical challenges overview of the patient cohort, effectively summarizing in reaching the definitive care offered at this tertiary the critical demographic characteristics and the trauma center.
This geographic disparity in patient ultimate in-hospital outcome of the 31 individuals origin points towards access to care as a potentially with pelvic ring fractures included in this study.
The powerful, unmeasured variable that could significantly most striking and clinically significant piece of influence the clinical trajectory and ultimate survival information is the overall in-hospital mortality rate, of these patients, providing a crucial lens through which stands at a substantial 9.
This means that which all other findings should be viewed.
nearly one in every ten patients admitted with this synthesis.
Figure 1 effectively establishes the profile of injury did not survive their hospitalization.
While the the typical patient in this study: a young adult from a vast majority of patients .
3%, n=.
ultimately rural area who, after sustaining a severe pelvic survived, this mortality figure immediately frames fracture, faces a nearly 10% chance of dying in the pelvic ring fractures not as simple orthopedic injuries, life-threatening Figure 2 provides a powerful clinical narrative, considerable risk of a fatal outcome.
This baseline moving from the cause of injury to its anatomical The primary and most dominant piece of characterize this cohort.
The demographic profile information is the mechanism of injury.
As shown in Figure 2, a staggering 87.
1% of all pelvic fractures overwhelmingly on the young and economically were the result of traffic accidents.
This single data productive members of society.
As illustrated in Figure point is the cornerstone of the entire clinical picture, 1, the cohort is predominantly composed of adults between 20 and 59 years of age .
3%), with overwhelmingly high-energy.
Figure 1.
Overall mortality and cohort demographics.
distribution of fracture patterns reveals a broad miscellaneous injuries, but as victims of violent, high- spectrum of pelvic instability.
While more stable velocity impacts.
This prevalence of road trauma sets the expectation for complex, multi-system injuries and Anteroposterior Compression (APC) II are the most moves the clinical focus from a simple fracture to a frequent individual Young-Burgess cumulative burden of mechanically unstable fractures Fracture Classification data details the anatomical is substantial.
When combined, the more severe destruction wrought by these high-energy events.
The patterns (LC II.
LC i.
APC II.
APC i, and Vertical The Lateral Compression types .
ach (LC) 8%), the Shea.
constitute a significant majority of the cases.
This anatomical data, as presented in Figure 2, understanding the cohort's overall mortality risk.
confirms that these are not minor injuries.
they are Finally, the management type is the logical clinical severe disruptions of the pelvic ring that carry a high consequence of the preceding data.
With a cohort risk of hemorrhage and long-term disability.
Perhaps defined by high-energy mechanisms and severe, multi- the most clinically sobering data point in the figure is system injuries, it is clinically consistent that a the revelation that 100% of the patients had significant associated injuries, classifying the entire group as a This high rate of surgery reflects the "Polytrauma Cohort.
" This is a critical finding.
necessity of restoring pelvic stability, not only for the fundamentally shifts the clinical perspective from healing of the fracture itself but as a critical treating a broken pelvis to managing a critically ill patient with multiple life-threatening injuries.
The mobilization of a severely injured patient.
In synthesis, pelvic fracture, in this context, is merely one Figure 2 masterfully illustrates a clear and grim component of a devastating constellation of trauma clinical pathway: high-energy road traffic accidents that could involve the head, chest, abdomen, and lead to severe, unstable pelvic disruptions in the This universal presence of polytrauma, shown context of universal polytrauma, necessitating a high so starkly in Figure 2, underscores the complexity of rate of complex surgical management.
Figure 2.
Injury and management characteristics.
Figure 3 presents the central and most compelling Figure 3 masterfully communicates the findings of this study, offering a stark visual narrative core statistical narrative of the study: while many about the factors associated with in-hospital mortality.
Figure 3 clearly illustrates a dramatic disparity in outcomes: the mortality rate among patients employed occupationAiemerged as a powerful and statistically in the informal sector was an alarming 37.
This is significant predictor of death.
oneAia contrasted sharply with a 0% mortality rate for patients in both the formal sector and the "not working" category.
This is not a subtle trend.
it is a Discussion This exploratory study from a tertiary trauma dramatic life-or-death difference.
The inclusion of the statistically significant p-value .
= 0.
anchors preliminary, window into the complex determinants of this visual observation in rigorous scientific evidence, survival after pelvic ring fracture in an LMIC setting.
confirming that this association is highly unlikely to The be due to random chance.
This part of the figure does informal sector was the only factor significantly more than just present data.
it tells a powerful story associated with in-hospital deathAiis a profound and about socioeconomic vulnerability.
It visually argues sobering observation.
11 It suggests that in this that in this cohort, the most dangerous risk factor for environment, the socioeconomic circumstances of a a patient with a pelvic fracture was not the nature of patient's life may project a stronger signal for mortality their injury, but the nature of their employment.
than the anatomical details of their injury.
The stark Complementing this primary result is the Analysis of finding that all fatalities occurred among informal Other Factors (Non-Significan.
This section is crucial sector workers serves as a powerful illustration of the for providing scientific context and honesty.
As clearly theory of social determinants of health in the context summarized in Figure 3, a range of other, more of acute surgical care.
12 "Occupation" in this analysis variablesAi should not be viewed as a direct causal factor but including the patient's age, gender, residence, the rather as a powerful proxy variable for a host of mechanism of their injury, the anatomical severity of their fracture, and the type of management they informal sector in Indonesia, as in many LMICs, is receivedAiwere not found to have a statistically defined by precarity: inconsistent wages, a lack of significant association with mortality.
The graphical formal contracts, and a near-total absence of social representation using horizontal bars provides an safety nets like employer-provided health insurance or intuitive at-a-glance comparison of the mortality rates paid sick leave.
This economic vulnerability can within these subgroups.
For instance, one can quickly directly translate into delayed access to care, which is see that the mortality rate was higher in urban a critical modulator of outcome in hemorrhagic residents .
2%) than in rural residents, but the 13 A day laborer or small merchant who sustains accompanying p-value .
immediately informs a severe injury faces an immediate and catastrophic the viewer that this difference was not statistically financial dilemma.
The fear of incurring debilitating This transparent presentation of the non- hospital bills and the certainty of losing income for significant findings is critical.
it prevents over- every hour not worked can lead to a fatal delay in the interpretation of minor trends and reinforces the decision to seek professional medical help.
Indonesia findingAithat The exceptional nature of the significant finding related to Figure 3.
Bivariate analysis of factors associated with mortality.
This phenomenon, often termed "financial toxicity," may lead patients to first attempt local or traditional to postpone condition becomes undeniably critical.
This delay is represent plausible mechanisms that connect a patientAos social standing to their clinical trajectory.
The temporal element introduced by care delays is the crucial window during which the pathophysiology of trauma can progress from a potentially reversible an ongoing event, not a static one.
From the moment state to one of irreversible A pelvic fracture is Furthermore, of injury, the clock is ticking as blood silently fills the occupation is linked to health literacy and social The physiological decompensation Individuals with lower educational attainment, follows a predictable and lethal path.
Systemic who are disproportionately represented in the informal hypoperfusion from blood loss leads to cellular oxygen sector, may have a less acute understanding of the life- debt and a switch to anaerobic metabolism, generating threatening nature of a pelvic fracture.
Once at the lactate and causing a profound metabolic acidosis.
hospital, they may lack the social network and This acidic state, combined with the hypothermia induced by environmental exposure and resuscitation with cool fluids, cripples the coagulation cascade.
overwhelming medical bureaucracy.
While our study Clotting could not measure these factors directly, they optimally only within a narrow physiological range of temperature and pH.
In the cold, acidic trauma activation, a patient, they function poorly, leading to a dilutional mobilization of surgical or interventional radiology and consumptive coagulopathy.
This is the lethal triad If systemic constraintsAisuch as long of trauma.
A patient who presents to the hospital transport times or limited hours after their injury is not merely dehydrated.
uniform delay or a ceiling on the level of care for all are acidotic, hypothermic, and coagulopathic.
16 Their blood will not clot, their heart function is depressed by acidosis, and their cellular machinery is failing.
At this patterns may be washed out.
In such a scenario, the in-hospital primary determinant of survival shifts from the resuscitation may be futile.
Our finding suggests that specific anatomical injury to the patient's intrinsic ability to tolerate a prolonged period of shock.
This resourcesAiimpose a advanced, irreversible stage of shock.
Their mortality importance but highlights that its predictive power is is not sealed by the fracture pattern itself, but by the dependent on the health system in which it is applied.
unmitigated physiological destruction that occurs Figure 4 serves as the conceptual and explanatory protocol, and disproportionately arriving at the hospital at this heart of this manuscript, moving beyond statistical It is also plausible that this population possesses a diminished physiologic reserve due to narrative of causation.
The "High-Energy Trauma" component, represented by the icon of a car crash, physical labor, making them less resilient to the immediately grounds the discussion in the reality of traumatic insult and accelerating their decline.
the cohort.
These are not minor injuries.
they are the to propose a The finding that the Young-Burgess classification result of immense kinetic forces, a fact substantiated was not associated with mortality is perhaps as by the manuscript's data showing that the vast informative as the finding that occupation was.
majority of cases were due to traffic accidents.
This countless large-scale studies from HICs, mechanically initial physical insult is the direct cause of the unstable patterns are powerful predictors of death.
anatomical disruptionAithe fractured pelvic ring, the Our studyAos failure to replicate this finding should not torn ligaments, and the sheared blood vessels.
It is the be interpreted as evidence that fracture anatomy is genesis of the primary threat to life: hemorrhage.
From irrelevant in the Indonesian context.
Instead, it is a a purely biomedical perspective, this is the beginning textbook example of a Type II statistical error and end of the story.
However, the model powerfully stemming from a critically underpowered sample.
With argues that this is only half of the equation.
Positioned only 31 patients and three deaths, the study had alongside the physical trauma is the "Socioeconomic virtually no statistical power to detect a true Vulnerability," defined here by employment in the association unless the effect size was astronomically informal sector.
This is the manuscript's most critical .
=0.
and novel insight, and Figure 4 visualizes it as an represents an "absence of evidence," not an "evidence insult of equal importance to the physical one.
This is of absence.
" However, this statistical limitation may not just a demographic descriptor.
it is an active risk also hint at an underlying clinical reality.
The This vulnerability represents a complex web of prognostic utility of an anatomical classification system is highest in a health system that can deliver a insurance, precarious income that is lost the moment rapid and graded response.
18 In an optimized system, a patient stops working, potentially lower health a patient identified with a VS fracture immediately literacy, and reduced social capital to navigate a complex medical system.
The non-significant p-value responseAia Figure 4.
The hypothesized pathophysiological cascade to mortality.
A patient with a severe pelvic fracture is at high 19 This initial stage masterfully reframes the a patient with a severe pelvic fracture and clinical problem, insisting that we cannot understand socioeconomic vulnerability is at profoundly higher the patient's prognosis without understanding their life.
Financial toxicityAithe healthcare costsAican lead to a fatal hesitation in hemorrhage worsens the acidosis, and the acidosis seeking care.
Low health literacy may cause a patient worsens both the coagulopathy and cardiac function.
or their family to underestimate the severity of the This is the death spiral of trauma.
The model's key injury, hoping it will resolve without expensive medical argument is that the socioeconomically vulnerable And logistical barriers, particularly for patient is far more likely to be deep within this spiral the rural majority of the cohort, can turn what should upon arrival at the hospital, not because their initial be a rapid transit to a trauma center into a prolonged injury was necessarily worse, but because the delay in and dangerous journey.
The delay is the point at which social determinants of health are transmuted into a uninterrupted time to accelerate.
The patient who has tangible, physiological threat.
Every minute that been subjected to the dual insult of severe trauma and passes with an unstable, bleeding pelvic fracture is a social vulnerability, who has experienced a critical minute in which the patient's physiological reserves delay in care, and who has consequently descended are being depleted, and their body is sliding further into the irreversible physiological collapse of the lethal down the slope towards irreversible shock.
This stage triad, is the patient who is most likely to die.
Figure 4 is, in essence, the "ticking clock" of trauma, a clock is far more than a simple diagram.
It is the intellectual that this model argues ticks faster and more core of the manuscript.
It provides a compelling, dangerously for the socioeconomically vulnerable.
The patient, having lost body heat from environmental explanation for the study's surprising statistical exposure and the administration of room-temperature It visualizes the invisible forces that shape a fluids, becomes cold.
This is more than a simple drop trauma patient's destiny, arguing that the patient's in temperature.
it is a catastrophic failure of journey to the hospital door is as important as the care As the body cools, the enzymes that drive they receive once inside.
It transforms a statistical the coagulation cascadeAithe complex series of protein correlation into a human story, a story of how poverty interactions that form a blood clotAibegin to function and disadvantage can amplify a physical injury into a The ongoing hemorrhage leads to profound fatal event.
It is a hypothesis that demands further tissue hypoperfusion.
Cells, starved of oxygen, switch investigation and a powerful call to action for a more to anaerobic metabolism, producing lactic acid as a equitable and socially aware approach to the practice This accumulation of acid in the blood of trauma surgery.
grounded, and lowers the body's pH, creating a state of metabolic The study relied on data not collected for research This acidic environment further cripples the This introduced the risk of missing data and inconsistent documentation, particularly for nuanced contractility of the heart muscle, worsening the shock.
physiological parameters that are critical in trauma Coagulopathy is the final common pathway and the The sample size of 31 is the most significant point of no return.
Fueled by the hypothermia and It severely restricts the reliability of the acidosis, and exacerbated by the consumption of statistical tests and is the most likely reason for the clotting factors at the injury site and their dilution by failure to detect associations for known clinical risk resuscitation fluids, the patient's blood loses its ability factors, leading to a high probability of Type II error.
This trauma-induced coagulopathy means The lack of consistently recorded data to calculate the that even if the source of bleeding is surgically ISS or to analyze admission physiology .
actate, base addressed, the patient will continue to ooze from all deficit.
Glasgow Coma Scal.
is a critical flaw.
Without surfaces, a condition that is almost universally fatal.
adjusting for the overall injury burden (ISS) and the The hypothermia worsens the coagulopathy, the patient's physiological state on arrival, the observed association significant and unmeasured confounding.
Due to the References