Evaluating trauma management approaches and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a retrospective cohort study

Background: In settings with limited resources, hemodynamically unstable patients with severe multiple injuries continue to have a high mortality rate due to trauma, which is a major preventable cause of death globally. This study evaluated determinants of in-hospital mortality in this population. Methods: This retrospective cohort study included 1000 hemodynamically unstable patients having an Injury Severity Score (ISS) of 16 or more, admitted to a tertiary care center in Tamil Nadu, India, between January 2024 and January 2026. Injury patterns, physiological parameters, trauma scores, management interventions, transfusion practices and outcomes were retrieved from hospital records. Independent predictors of in-hospital mortality were found using multivariable binary logistic regression, and adjusted odds ratios (AOR) with 95% confidence intervals (CI) have been calculated. Results: Mean age was 38.4 years and 77.6% were male. Road traffic accidents (63.5%) and blunt trauma (87.4%) predominated. In-hospital mortality was 35.0%, 24-hour mortality 11.4%, and exsanguination accounted for 7.0%. Independent predictors of death were higher ISS (AOR 1.12 per point; 95% CI 1.05 to 1.20), serum lactate above 6 mmol/L (AOR 3.84), Glasgow Coma Scale below 8 (AOR 3.12), delay to definitive haemostasis beyond 120 minutes (AOR 2.96), massive transfusion (AOR 1.58), mechanical ventilation (AOR 1.91) and vasopressor requirement (AOR 2.28). A ratio of 1:1 or higher between fresh frozen plasma and red blood cells was protective (AOR 0.42). Damage control surgery, interventional radiology and computed tomography before haemostasis were not independent predictors. Conclusions: Injury severity, depth of shock, delayed haemostasis and unbalanced transfusion were the principal determinants of mortality. Early risk stratification, rapid hemorrhage control and balanced transfusion may improve survival.