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 younger persons, trauma is responsible for more deaths than all other diseases combined, and results in the loss of more working years than all other causes of death. The prevalence of injury in the elderly population is also significant; 6% of Medicare inpatient admissions have traumatic injury as their primary diagnosis. The 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 substantial, exceeding $671 billion annually (fatal inquiries, $214 billion; nonfatal injuries, $457 billion). Regrettably, nearly 40% of all trauma deaths could be avoided by injury-prevention measures, alcohol cessation, and by the establishment of regional trauma systems that would expedite the evaluation and treatment of seriously injured patients.
Trauma deaths have classically been described as having a trimodal distribution (Figure 14–1a), with peaks that correspond to the types of intervention that would be most effective in reducing mortality. However, with advancements in care and maturation of trauma systems, the trimodal concept no longer applies. The incidence of late deaths has declined from 20% to 7%–8% of all deaths, and early deaths have shifted toward the left, creating a bimodal distribution (Figure 14–1b). Early deaths still predominate, with the remainder dying at a slow rate over many days. Immediate deaths represent 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.
Mortality timing: Periods of peak mortality after injury. A: Historical. B: Current. (Modified with permission from Greenfield LJ, Mulholland MW, Oldham KT, et al: Surgery, Scientific Principles and Practice, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.)
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%.
Late deaths consist of patients who die days or weeks after ...