trauma , a preventable condition , is the leading cause of death in the first four decades of life.1 trauma care starts from the first few minutes at the scene after an accident and continues on the way to the hospital where more definitive care is given . mortality in the first hour depends on several factors among which are trauma severity and pre - hospital care . the objectives of this study are : 
 to determine the rank of road traffic accident ( rta ) among other causes in patients who were already dead on arrival ( doa ) at the emergency department ( ed ) in our region.to determine the characteristics of populations involved in rta and seen as doa.to determine the type of injuries in the doa victims . 
  to determine the rank of road traffic accident ( rta ) among other causes in patients who were already dead on arrival ( doa ) at the emergency department ( ed ) in our region . to determine the characteristics of populations involved in rta and seen as doa . to determine the type of injuries in the doa victims the information derived from this study , hopefully , will help health personnel to establish a system by which the injured are managed properly from the time of accident till arrival in hospital . in addition , it will advise the law enforcement agency and legislators in particular in enacting and enforcing laws that will lead to the prevention of rta and/or reduction of the mortality and morbidity rates . the data of all rta victims who were dead on arrival at the emergency department ( ed ) of assir central hospital ( ach ) , abha , saudi arabia , between the months of 02 -1410 ( august 1989 ) and 12 , 1414 ( may 1994 ) were obtained from the medical records of the emergency room . the nationality , sex , and age of the victims , time and month of arrival in the ed and types of injuries clinically encountered , were analyzed . the dates used in this study are according to both hegira and gregorian calendars , since the hegira calendar is the standard used in file keeping at the ach , abha , and it also a good indicator of the public holidays in saudi arabia , while , the gregorian calendar is a better guide to the seasons . during the four and half - year period , 574 patients were doa in the ed ; 303 ( 53% ) of them were victims of rta . of these 303 victims , 283 ( 93.4% ) were males and 20 ( 6.6% ) females giving a male to female ratio of 14:1 . the age range was 3 months to 85 years , with a mean age of 34.25 years . the peak age was between the third and fifth decades of life ( 21 - 49 years ) ( fig . the commonest period of presentation at the ed , regardless of the time of accidents , was between 12:00 and 18:00 hours ( 116 patients ; 38.3% ) followed by 18:00 hours to 24:00 hours ( 88 patients ; 29% ) fig . 2 . the distribution of patients seen in various months of the hegira year is shown in fig . the year of 1413 hegira had the highest number of the rta doa victims as shown in fig . the summer season in the gregorian calendar has a significant rise of the rta doa compared to the winter season ( p < 0.05 ) ( fig . head and neck injuries ( exclusive of skull fractures ) accounted for 45% of the injuries followed by chest injuries ( 39% ) . thirty - five percent ( 35% ) of the victims had skull fractures ( table 1 ) . age group distribution of doa victims due to rta distribution of time of arrival of d o a victims due to r t a hegira month distribution of d o a victims due to r t a year distribution of d o a victims due to r t a seasonal presentation of victims of d o a due to r t a type & rate of injuries in 303 ( n ) patients of r t a the diagnoses were all clinically made without the benefit of certainty of pathology from autopsy examination since autopsies are not usually performed in the kingdom of saudi arabia2 . rta is a major cause of instant death in this region since it consists of more than half of the cases brought doa into our ed . the predominance of male victims ( 93% ) is mainly due to the exposure and the activity of the males ; females do not drive in saudi arabia . in a study from the united states of america ( usa ) there is a large number of saudis in this study because the population is mainly saudi in this part of saudi arabia . the population of saudi arabia is about 16.9 million , 12.3 million ( 72.7% ) of whom are saudis and 4.6 million ( 27.3% ) are non - saudis4 . assir region , in which this study was conducted , has a population of about one million . although it has long been recognized that the mortality rate from injury is much higher in the elderly56 , elderly people are much less exposed to the types of trauma that are fatal to younger people . the highest incidence of trauma occurs in the most active and productive age group ( 21 -49 years ) and lower in the older age group ( fig . 1 ) , the maximum number of cases were seen during the daylight hours between 12:00 and 18:00 hours ( 38% ) . this includes the rush hour period when people are returning home from work or travelling to neighboring towns and villages . seasonal variation was also noticed in this study . there is a significant correlation with the summer holidays and public holidays . the population in this part of the country almost doubles when many tourists flock to this region during the summer months because of its mild weather . the assir region is situated at a high altitude of about 2200 meters above sea level . the fog in this area which usually affects visibility , however , was not found to be a significant factor in this study since the incidence of rta doa victims during the winter period is about the lowest . there seems to be no clear explanation for this and further investigation into this is therefore required . all the victims were polytraumatized , and the types of injuries were severe . the majority of victims had a combination of severe head , neck , chest and lower extremities injuries typical of driving without a hasness on coupled with high speeds.7 the enormity of the impact of trauma can be estimated from the skull fracture ( 105 ; 35% ) , with brain matter extruding from the skull in 61 ( 20.3% ) patients . there is documentation in the international studies of the fact restraining that devices plays a significant role in the reduction in mortality of drivers and passengers810 . shawan et al showed in a local study on the attitude to the wearing of seat belts found that the commonest reason for not wearing a seat belt was that of complacency and 90% of the people interviewed thought that a legislation on seat belts would be useful12 . a similar study by bener et al in the united arab emirate had similar results13 road traffic accident is the first major cause of death among dead on arrival cases affecting the most active and productive age group ; most of the accidents occur during daylight hours and correlate well with public and summer holidays . although we can not prevent all deaths from road traffic accident , we can reduce the number of deaths , since it was noted in previous studies that 20% - 30% of trauma related deaths are preventable.14 we , therefore , strongly recommend the following : 
 the introduction of legislation for the mandatory fitting and wearing of seat - belts , and the intensification of the current educational program and law enforcement especially during public and summer holidays.the implementation of pre - hospital emergency medical system.1516 this can be done by introducing the well established pre - hospital life support programs17 , like emergency medical technician- ambulance ( emt - a),18 emergency medical technician - intermediate ( emt - i)19 , emergency medical technician - paramedic ( emt - p)20 
  the introduction of legislation for the mandatory fitting and wearing of seat - belts , and the intensification of the current educational program and law enforcement especially during public and summer holidays . the implementation of pre - hospital emergency medical system.1516 this can be done by introducing the well established pre - hospital life support programs17 , like emergency medical technician- ambulance ( emt - a),18 emergency medical technician - intermediate ( emt - i)19 , emergency medical technician - paramedic ( emt - p)20