As a “disease,” trauma is a major public health
problem. In the United States, it is the leading cause of death
among people aged 1–45 and the fifth leading cause of death
for all age groups. For persons under age 30, trauma is responsible
for more deaths than all other diseases combined. Each year, 160,000
lives are lost because of injuries and homicide. Because trauma adversely
affects a young population, it results in the loss of more working
years than all other causes of death. Presence of alcohol is a significant
contributor to trauma fatalities, and 41% of all traffic deaths
in 2006 were alcohol related. The financial costs of injury are
staggering and exceed $500 billion annually. Regrettably,
nearly 40% of all trauma deaths could be avoided by injury
prevention measures (55% of passenger vehicle occupants
killed were unrestrained), alcohol cessation, and by the establishment
of regional trauma systems that would expedite the evaluation and
treatment of seriously injured patients.
Trauma deaths have been classically described as having a trimodal
distribution (Figure 13–1), with
peaks that correspond to the types of intervention that would be
most effective in reducing mortality. The first peak, the immediate
deaths, represents patients who die of their injuries before
reaching the hospital. The injuries accounting for these deaths include
major brain or spinal cord trauma and those resulting in rapid exsanguination.
Few of these patients would have any chance of survival even with access
to immediate care because almost 60% of these deaths occur at the same time as the injury. Prevention remains the major strategy to reduce these deaths.
Periods of peak mortality after injury. (Modified from Hoyt DB, Coimbra R: Trauma: Introduction. In: Greenfield LJ, Mulholland MW, Oldham KT, et al: Surgery, Scientific Principles and Practice, 3rd ed. Lippincott Williams & Wilkins, 2001; p. 271.)
The second peak, the early deaths, are those that
occur within the first few hours after injury. Half are caused by internal
hemorrhage, and the other half, by central nervous system injuries. Almost
all of these injuries are potentially treatable. However, in most
cases, salvage requires prompt and definitive care of the sort available
at a trauma center, which is a specialized institution that can provide
immediate resuscitation, identification of injuries, and access
to a ready operating room 24 hours a day. Development of well-organized
trauma systems with rapid transport and protocol-driven care can reduce the mortality in this time period from 30% to less than 10%.
The third peak, the late deaths, consists of patients
who die days or weeks after injury. Ten percent to 20% of all
trauma deaths occur during this period. Mortality for this period
has traditionally been attributed to infection and multiple organ
failure. However, development of trauma systems has changed the ...