Definition/Introduction

In any given day in the United States, 320 individuals die abruptly from accidental death. Worldwide in certain populations such as young men, this represents a major cause of death and in children age 0 to 4 years the most common cause of death, with asphyxiation leading the list of particular mechanisms. This activity summarizes accidental death across populations.[1][2][3]

Issues of Concern

The United States and Canada

In the United States, accidental death, also described in the literature as “death from unintentional injury,” has in recent years comprised around 5% of all deaths for a total of 135,000 incidents annually. Overall rates of death related to firearms and transportation have declined since the turn of the 21st century. Rates of accidental death from falls and drowning have slightly increased, and an increase in opioid-related accidental overdose deaths have been noted in the same period. Drug overdose deaths as a whole were noted to have increased 23% from 2010 to 2014 in particular with oxycodone and heroin ranking highest in one study. In that same period, heroin overdose deaths tripled in number in the United States, and cocaine was ranked every year either second or third in the cause of overdose death, depending on the year.[4][5][6]

An increased risk of accidental death was noted in the very young and the very old, with one study reporting 38% of all pediatric deaths stemmed from the accidental injury. In 2013, accidental injuries were the eighth leading cause of death in adults over age 65.

According to the US Bureau of Labor Statistics, a review of occupational risk revealed that, as of 2015, the occupations with the highest mortality were logging with 110.0 deaths per 100,000 workers annually. This was followed by commercial fishing at 80.8, airplane piloting and flight engineering at 64, roofing at 47.4, garbage collection at 35.8, and farming and agriculture at 26.7. Men were found universally more likely to experience accidental death than women. This correlation was particularly true regarding occupational injury as cited above.  Accidental deaths, both occupational and non-occupational, were also found to be more common in African Americans than in other racial groups. This latter ethnic correlation of was most especially notable in terms of fire-related accidental death.

One notable finding by Daela et al. in 2016 reported that a particularly at-risk population of men for death by accidental injury is those who were diagnosed with prostate cancer and were recommended but did not receive definitive treatment.

Accidental death was also noted to be more common if deemed preventable in cause among those of lower socioeconomic status (SES) than among those of higher SES. Some postulate that this was in part accounted for by lack of access to safety-related information and equipment. For causes deemed non-preventable, there was no difference by SES. Similar patterns have been observed in Canada.

Marital status, when analyzed, showed a correlation with risk of accidental death. Multiple studies have reported increased rates of accidental death among the unmarried when compared with the married. This included the divorced, widowed, as well as the never married populations. One longitudinal study found that rates of accidental death from unintentional injury, when compared with the married population, was increased in the divorced population by 76%, the widowed population by 41%, and in the married population by 35%. The same study found unmarried men to be twice as likely as their unmarried female counterparts to die from unintentional injury and this was true for all types of accidents. Another remarkable finding was geographic in that those living in the northeastern United States were less likely to experience accidental death than in other parts of the nation.

In 2014 a survey of deaths by poisoning in the United States showed an increase in poisoning related mortality for those over 15 years of age by 6% per year on average since 1979. For poisoning deaths among Americans over age 15 in that year, there were no apparent differences in rates of increase across populations by gender or race although absolute numbers of cases were higher among males than females.

US opiate deaths, in particular, have been notably on the rise in recent decades. For one San Diego study in 2015, methadone-related deaths represented 18% of all prescription-related deaths, was the most common single drug to cause death and only 29% had registered methadone prescriptions in the California state database. Reporting by the US Department of Health and Human Services in 2016, however, reported a national decline in methadone-related deaths despite an increase in other opiate-related deaths with the largest increase being those related to heroin.

International

One study of working age (15 to 65 years old) Finnish residents found that long-term unemployment represented an independent risk factor for drug-related accidental death with a hazard ratio of 4.9 when compared to age-matched employed peers. Short-term underemployment and retirement also presented a correlation with an increased risk of drug-related death with hazard ratios of 3.9 and 5.8 respectively.

A study in Sweden of the previously incarcerated population with known substance abuse issues revealed that risk of death from an accidental drug overdose or accidental injury was correlated with male gender, heroin use, and cannabis use. From 2003 through 2012, Norway experienced an increase in accidental death by poisoning, led by opiate overdose most particularly methadone.

In England and Wales from 2001 through 2010, a study of 15 to 19-year-olds found an overall decrease in accidental deaths over this period although rates of accidental poisoning and accidental hangings did increase over time in this age group.

An examination of deaths among Chinese under the age of 4 years revealed that 10% of reported deaths were attributable to the accident. Leading causes were asphyxia, drowning, and traffic accidents followed by poisonings and falls.

Australian studies showed an increase in heroin-related deaths from 2001 to 2012 with two-thirds of incidents represented by males age 15 to 74 years old with unintentional death increasing over that period while intentional opiate death rates remained stable.

Turkey reported a series of accidental hangings of children most commonly the result of a scarf-like implement popular for use wrapped around cradles to prevent infant falls.

Pediatrics

Sudden Unexpected Infant Death (SUID), previously known as Sudden Infant Death Syndrome or SIDS, has been described as the leading cause of infant death for some time in the United States and as recently as 2017. This typically occurs between the second and fourth month after birth. Risk factors for SUID include infant sleeping in a position other than supine, co-sleeping of the infant with an adult, maternal tobacco use during pregnancy, late or absent prenatal care, preterm birth with low birth weight and loose objects such as pillows or blankets in the infant’s crib. It has also been noted that while second-hand smoke exposure is a risk factor for SUID, maternal tobacco use during pregnancy carried an even greater risk for SUID. An 8-year study of pediatric deaths in South Dakota, in particular, starting in 2000 revealed that the most common cause of infant death was accidental suffocation.

Factors that appear to lower infant risk of SUID include supine sleeping position, a firm sleep surface free of soft objects such as pillows and bumper pads, room sharing between infants and parents without bed sharing, the use of fans to prevent overheating, vaccination as recommended for tetanus, diphtheria and pertussis, breastfeeding, and pacifier use at bedtime. Contrary to any popularity they may hold, home cardiorespiratory monitors have not been shown to confer any benefit in avoiding SUID.[7]

Clinical Significance

Prevention Strategies

Clinician intervention to prevent fatal accidents includes addressing the pain control needs of the chronic pain patient and specifically the use of opioids. One study of 816 Colorado overdose cases found that risk of opioid overdose was positively correlated with multiple prescribers and multiple pharmacies and negatively correlated with the prescription of naltrexone. This same study cited an increased risk of overdose correlated with the prescription associated with prescribing methadone as a first-line opioid and ever more so if another opioid was discontinued and replaced with methadone. Conflicting reports in the international literature exist at the time of this writing as regards this latter finding as other studies show a decrease in overdose death overall associated with the prescription of methadone. Physician knowledge of and liberal referral to treatment programs for those patients suffering from opioid dependence is also an important strategy in preventing potential opioid overdose death.[8][9][10]

In pediatrics, education on safe sleeping practices for newborns has shown itself effective with the most profound change in the rate of SUID deaths from encouraging sleeping of newborns in the supine position. Counseling for expectant mothers regarding tobacco use is also another preventative measure in which physicians may engage to prevent the future accidental deaths of newborns.

Screening for and encouragement of basic safety practices such as the use of bicycle helmets and seat belts as well as appropriate child restraints in automobiles is encouraged as a regular part of medical practice.

Pregnancy

A recent review of deaths of pregnant women in Clark County, Nevada found in 1 year that 38% of all of what the authors described as unnatural deaths of pregnant women were deemed accidental death.  The most common cause in this series was motor vehicle trauma followed by overdose and drowning. An examination of pregnant or recently pregnant (within the last year) women in North Carolina found that between 1996 through 2007 an increase in prescription opiate-related deaths was noted over the period; although, this trend was not observed in this population for cocaine or heroin.

Autoerotic Activity

Numerous case reports and series have been reported in those engaging in autoerotica, mostly the result of asphyxiation in the context of autoerotic asphyxiation. These cases are all essentially entirely comprised of cases of males. Other causes of accidental death in this circumstance have included subarachnoid hemorrhage, left heart failure, hypothermia, and drowning. Less typical mechanisms included death from air embolism traveling to the central circulation via the penile circulation from the use of an air compressor to insufflate the urethra under pressure.

The majority of fatal injuries can be prevented by the education of the public, thus an interprofessional team approach is necessary. The public should be educated on prescription medications and their safe use, avoidance of illicit drugs, wearing seat belts and storing firearms safely in the home. Unfortunately, compliance with such matters is low among the public and that is one reason why fatal accidents continue to occur at an alarming rate.[11]