Injury is the fourth leading killer of Americans and the single
greatest cause of death before the age of 45 years both in the U.S.
and internationally.1 In all countries the incidence
of death from injury increases more than threefold with increasing
poverty. For the 90% of patients who survive the initial
trauma, the burden of ongoing morbidity from traumatic brain injury,
loss of limb function, and ongoing pain is even more significant.
The major causes of death following trauma are head injury, chest
injury, and major vascular injury. Trauma care should be organized
according to the concepts of rapid assessment, triage, resuscitation,
diagnosis, and therapeutic intervention.2 Worldwide,
there are few countries or regions that have comprehensive systems
of trauma care, from roadside to rehabilitation, and that incorporate
effective injury prevention strategies.
A systems approach is required to reduce morbidity and mortality
that occur after traumatic injury, as illustrated by the roughly
trimodal distribution of the peak incidence of trauma mortality
Table 250-1 Trimodal
Distribution of Trauma Deaths |Favorite Table|Download (.pdf)
Table 250-1 Trimodal
Distribution of Trauma Deaths
|Peak||Environment||Injuries||Approaches to Reduce Mortality|
|First peak||Prehospital||Devastating head and vascular injuries||Comprehensive injury prevention program: |
|Safe road construction|
|Seat belt, helmet, airbag, drunk driving laws|
|Second peak||Minutes to hours after ED arrival||Major head, chest, and abdominal injuries||Rapid transport to appropriate hospital, prompt resuscitation
and identification of injuries needing surgical intervention|
|Third peak19||Intensive care unit||Systemic inflammatory response syndrome, sepsis, multiorgan
failure ||Evidence-based resuscitation practices|
Recognizing the need to establish a system to triage injured
patients rapidly to the most appropriate setting and the importance
of promoting collaboration among emergency medicine, trauma surgery,
and trauma care subspecialists, the U.S. Congress passed the Trauma
Care Systems Planning and Development Act of 1990.3 This
act provided for the development of a model trauma care system plan
to serve as a reference document for each state in creating its
own system. Each state must determine the appropriate facility for
treatment of various types of injuries. Trauma centers are certified
based on the institution’s commitment of personnel and
resources to maintain a condition of readiness for the treatment
of critically injured patients. Some states rely on a verification process
offered by the American College of Surgeons for the designation of
certain hospitals as trauma centers.2 In a well-run
trauma center, the critically injured patient undergoes a multidisciplinary
evaluation, and diagnostic and therapeutic interventions are performed
with smooth transitions between the ED, radiography or CT suite,
operating room, and postoperative intensive care setting. Table 250-2 details the requirements for
designation as a level 1 trauma center. A complete list of trauma center
requirements is available at http://www.facs.org/trauma/hospitallevels.pdf.
Table 250-2 Essential Characteristics
of Level 1 Trauma Centers
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