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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. For persons under age 30, trauma is responsible for more deaths than all other diseases combined. 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 one-third of all traffic deaths are alcohol related. The financial costs of injury are astounding and exceed $400 billion annually. Regrettably, nearly 40% of all trauma deaths could be avoided by injury prevention measures (50% 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 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.

Figure 13–1.

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 by 30%.

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 epidemiology of these deaths. During the first week, refractory intracranial hypertension following severe head injury is now responsible for a significant number of these deaths. Improvements in critical care management ...

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