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Seventh Edition

Kenneth L. Mattox, MD
Distinguished Service Professor
Baylor College of Medicine
Michael E. DeBakey Department of Surgery
Chief of Staff
Chief of Surgery
Ben Taub General Hospital
Houston, Texas

Ernest E. Moore, MD
Professor and Vice Chairman
Department of Surgery
University of Colorado at Denver and Health Sciences Center
Bruce M. Rockwell Distinguished Chair of Trauma Surgery
Rocky Mountain Regional Trauma Center
Chief of Surgery
Denver Health Medical Center
Denver, Colorado

David V. Feliciano, MD
Attending Surgeon, Atlanta Medical Center
Atlanta, Georgia
Attending Surgeon, Medical Center of Central Georgia
Macon, Georgia
Professor of Surgery
Mercer University School of Medicine
Macon, Georgia
Adjunct Professor of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland

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The editors of Trauma, Seventh Edition, gratefully dedicate this edition to our five unique
families: our spouses, children, grandchildren, and extended families; our trainees, who now
dot the globeour lasting legacy; our medical schools and academic anchors; our organizations
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Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix


1. Kinematics . . . . . . . . . . . . . . . . . . . . . . . . . 2 4. Trauma Systems, Triage, and Transport . . 54

John P. Hunt, Alan B. Marr, and Lance E. Stuke Raul Coimbra, David B. Hoyt, and Vishal Bansal

2. Epidemiology . . . . . . . . . . . . . . . . . . . . . 18 5. Injury Severity Scoring and

Thomas J. Esposito and Karen J. Brasel Outcomes Research . . . . . . . . . . . . . . . . . 77
Robert D. Becher, J. Wayne Meredith,
3. Injury Prevention. . . . . . . . . . . . . . . . . . . 36 and Patrick D. Kilgo
Ronald V. Maier and Charles Mock
6. Acute Care Surgery . . . . . . . . . . . . . . . . . 91
Gregory J. Jurkovich


7. Prehospital Care . . . . . . . . . . . . . . . . . . 100 13. Postinjury Hemotherapy

Jeffrey P. Salomone and Joseph A. Salomone III and Hemostasis . . . . . . . . . . . . . . . . . . . 216
Fredric M. Pieracci, Jeffry L. Kashuk,
8. Disaster and Mass Casualty . . . . . . . . . . 123 and Ernest E. Moore
Eric R. Frykberg and William P. Schecter

9. Rural Trauma . . . . . . . . . . . . . . . . . . . . . 140 14. Emergency Department Thoracotomy . . . 236

Clay Cothren Burlew and Ernest E. Moore
Charles F. Rinker II and Nels D. Sanddal

10. Initial Assessment and Management . . 154 15. Diagnostic and Interventional Radiology . . 251
Salvatore J.A. Sclafani
Panna A. Codner and Karen J. Brasel
16. Surgeon-Performed Ultrasound
11. Airway Management . . . . . . . . . . . . . . 167
Eric A. Toschlog, Scott G. Sagraves, in Acute Care Surgery . . . . . . . . . . . . . . 301
and Michael F. Rotondo Christopher J. Dente and Grace S. Rozycki

12. Management of Shock . . . . . . . . . . . . . 189 17. Principles of Anesthesia and

Louis H. Alarcon, Juan Carlos Puyana, Pain Management . . . . . . . . . . . . . . . . . 322
and Andrew B. Peitzman Dirk Younker

18. Infections . . . . . . . . . . . . . . . . . . . . . . . 330

Michael A. West and Daniel Dante Yeh
viii Contents


19. Injury to the Brain . . . . . . . . . . . . . . . . . 356 30. Injury to the Spleen . . . . . . . . . . . . . . . 561
Alexander F. Post, Thomas Boro, David H. Wisner
and James M. Ecklund
31. Stomach and Small Bowel . . . . . . . . . . 581
20. Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Lawrence N. Diebel
Petros E. Carvounis and Yvonne I. Chu
32. Duodenum and Pancreas . . . . . . . . . . . 603
21. Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 Walter L. Biffl
Robert M. Kellman
33. Colon and Rectal Trauma . . . . . . . . . . . 620
22. Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Demetrios Demetriades and Kenji Inaba
David V. Feliciano and Gary A. Vercruysse
34. Abdominal Vascular Injury . . . . . . . . . . 632
23. Vertebrae and Spinal Cord . . . . . . . . . . 430 Christopher J. Dente and David V. Feliciano
Maneesh Bawa and Reginald Fayssoux
35. Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
24. Trauma Thoracotomy: George C. Velmahos
Principles and Techniques . . . . . . . . . . . 461
Kenneth L. Mattox, Matthew J. Wall, Jr., 36. Genitourinary Trauma . . . . . . . . . . . . . . 669
and Peter Tsai Michael Coburn

25. Lung, Trachea, and Esophagus . . . . . . . 468 37. Trauma in Pregnancy . . . . . . . . . . . . . . 709
Joseph A. DuBose, James V. OConnor, M. Margaret Knudson and
and Thomas M. Scalea Daniel Dante Yeh
26. Heart and Thoracic Vascular Injuries . . . . 485 38. Trauma Damage Control . . . . . . . . . . . . 725
Matthew J. Wall, Jr., Peter Tsai, Amy D. Wyrzykowski and David V. Feliciano
and Kenneth L. Mattox
39. Upper Extremity . . . . . . . . . . . . . . . . . . 747
27. Trauma Laparotomy: Nata Parnes, Peleg Ben-Galim,
Principles and Techniques . . . . . . . . . . . 512 and David Netscher
Asher Hirshberg
40. Lower Extremity . . . . . . . . . . . . . . . . . . 783
28. Diaphragm . . . . . . . . . . . . . . . . . . . . . . 529 Philip F. Stahel, Wade R. Smith,
Kevin M. Schuster and Kimberly A. Davis and David J. Hak
29. Liver and Biliary Tract . . . . . . . . . . . . . . 539 41. Peripheral Vascular Injury . . . . . . . . . . . 816
Timothy C. Fabian and Tiffany K. Bee Michael J. Sise and Steven R. Shackford
Contents ix


42. Alcohol and Drugs . . . . . . . . . . . . . . . . . 850 49. Temperature-Related Syndromes:

Larry M. Gentilello Hyperthermia, Hypothermia,
43. The Pediatric Patient . . . . . . . . . . . . . . . 859 and Frostbite . . . . . . . . . . . . . . . . . . . . . 938
David W. Tuggle and Nathaniel S. Kreykes David H. Ahrenholz

44. The Geriatric Patient . . . . . . . . . . . . . . . 874 50. Organ Procurement for Transplantation . . . 944
Jay A. Yelon Aditya K. Kaza and Max B. Mitchell

45. Ethics of Acute Care Surgery . . . . . . . . . 886 51. Rehabilitation . . . . . . . . . . . . . . . . . . . . 950

Laurence B. McCullough Paul F. Pasquina, Caitlin L. McAuliffe,
and Kevin F. Fitzpatrick
46. Social Violence . . . . . . . . . . . . . . . . . . . 890
James W. Davis 52. Modern Combat Casualty Care . . . . . . . 964
Jay Johannigman, Peter Rhee, Donald Jenkins,
47. Wounds, Bites, and Stings. . . . . . . . . . . 896 and John B. Holcomb
Charles A. Adams, Jr., Daithi S. Heffernan,
and William G. Cioffi 53. Genomics and Acute Care Surgery . . . . 991
Grant E. OKeefe and J. Perren Cobb
48. Burns and Radiation . . . . . . . . . . . . . . . 922
Jong O. Lee and David N. Herndon 54. Trauma, Medicine, and the Law . . . . . . 997
Kenneth L. Mattox and Stacey A. Mitchell


55. Principles of Critical Care . . . . . . . . . . . 1006 59. Renal Failure . . . . . . . . . . . . . . . . . . . . 1084

Raul Coimbra, Jay Doucet, and Vishal Bansal Charles E. Lucas, Michael T. White,
and Anna M. Ledgerwood
56. Cardiovascular Failure . . . . . . . . . . . . . 1041
Mary Margaret Wolfe and Fred Luchette 60. Nutritional Support and Electrolyte
57. Respiratory Insufficiency . . . . . . . . . . . 1055 Management . . . . . . . . . . . . . . . . . . . . 1100
Kenneth A. Kudsk and Caitlin Curtis
Jeffrey L. Johnson and James B. Haenel

58. Gastrointestinal Failure . . . . . . . . . . . . 1073 61. Multiple Organ Failure. . . . . . . . . . . . . 1128

Angela Sauaia, Frederick A. Moore,
Rosemary A. Kozar and Frederick A. Moore
and Ernest E. Moore
x Contents


Introduction to the Atlas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148

Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
Thoracic Outlet and Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1155
Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
Vascular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1192

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1201

Charles A. Adams, Jr., MD, FACS Peleg Ben-Galim, MD

Assistant Professor of Surgery Assistant Professor
Alpert Medical School of Brown University Department of Orthopedic Surgery
Chief Baylor College of Medicine
Division of Trauma and Surgical Critical Care Houston, Texas
Department of Surgery Chapter 39: Upper Extremity
Rhode Island Hospital
Providence, Rhode Island Walter L. Biffl, MD
Chapter 47: Wounds, Bites, and Stings Professor of Surgery
Denver Health Medical Center
David H. Ahrenholz, MD, FACS University of Colorado School of Medicine
Associate Professor of Surgery Denver, Colorado
University of Minnesota Medical School Chapter 32: Duodenum and Pancreas
St. Paul, Minnesota
Chapter 49: Temperature-Related Syndromes: Hyperthermia, Thomas Boro, MD
Hypothermia, and Frostbite Chief Trauma Resident
Department of Surgery
Louis H. Alarcon, MD Inova Fairfax Hospital
Associate Professor of Surgery and Critical Care Medicine Falls Church, Virginia
Medical Director of Trauma Surgery Chapter 19: Injury to the Brain
University of Pittsburgh
Pittsburgh, Pennsylvania Karen J. Brasel, MD, MPH
Chapter 12: Management of Shock Professor of Surgery, Bioethics and Humanities
Medical College of Wisconsin
Vishal Bansal, MD, FACS Milwaukee, Wisconsin
Assistant Professor of Surgery Chapter 2: Epidemiology
Assistant Director Chapter 10: Initial Assessment and Management
Trauma Services
University of California, San Diego Clay Cothren Burlew, MD
San Diego, California Director
Chapter 4: Trauma Systems, Triage, and Transport Surgical Intensive Care Unit
Chapter 55: Principles of Critical Care Associate Professor of Surgery
Denver, Colorado
Maneesh Bawa, MD Chapter 14: Emergency Department Thoracotomy
San Diego Orthopaedic Associates/Mercy Hospital
San Diego, California Petros E. Carvounis, MD
Assistant Professor Assistant Professor
Chief of Trauma Spine Surgery Baylor College of Medicine
Emory University Department of Orthopaedic Surgery Houston, Texas
Atlanta, Georgia Chapter 20: Eye
Chapter 23: Vertebrae and Spinal Cord Yvonne I. Chu, MD
Robert D. Becher, MD Assistant Professor
Howard H. Bradshaw Surgical Research Fellow Baylor College of Medicine
Department of General Surgery Houston, Texas
Wake Forest University School of Medicine Chapter 20: Eye
Winston-Salem, North Carolina William G. Cioffi, MD
Chapter 5: Injury Severity Scoring and Outcomes Research J. Murray Beardsley Professor and Chairman
Tiffany K. Bee, MD Department of Surgery
Associate Professor of Surgery Alpert Medical School of Brown University
University of Tennessee Health Science Center Surgeon-in-Chief
Memphis, Tennessee Rhode Island Hospital
Chapter 29: Liver and Biliary Tract Providence, Rhode Island
Chapter 47: Wounds, Bites, and Stings

xii Contributors

J. Perren Cobb, MD, PhD Demetrios Demetriades, MD, PhD, FACS

Director Professor and Vice-Chairman of Surgery
Critical Care Center University of Southern California
Massachusetts General Hospital Director of Trauma
Associate Professor of Anaesthesia and Surgery Division of Emergency Surgery and Surgical Intensive Care Unit
Harvard Medical School Los Angeles County and University of Southern California
Boston, Massachusetts Medical Center
Chapter 53: Genomics and Acute Care Surgery Sierra Madre, California
Chapter 33: Colon and Rectal Trauma
Michael Coburn, MD
Professor and Chair Christopher J. Dente, MD, FACS
Scott Department of Urology Assistant Professor of Surgery
Baylor College of Medicine Emory University School of Medicine
Chief of Urology Associate Director of Trauma
Ben Taub General Hospital Grady Memorial Hospital
Houston, Texas Atlanta, Georgia
Chapter 36: Genitourinary Trauma Chapter 16: Surgeon-Performed Ultrasound in Acute Care Surgery
Chapter 34: Abdominal Vascular Injury
Panna A. Codner, MD, FACS
Assistant Professor Lawrence N. Diebel, MD
Department of Surgery Professor of Surgery
Medical College of Wisconsin Department of Surgery
Milwaukee, Wisconsin Wayne State University School of Medicine
Chapter 10: Initial Assessment and Management Detroit, Michigan
Chapter 31: Stomach and Small Bowel
Raul Coimbra, MD, PhD, FACS
The Monroe E. Trout Professor of Surgery Jay Doucet, MD, MSc, FRCSC, FACS
Executive Vice-Chairman Associate Professor of Clinical Surgery
Department of Surgery Director
Chief Surgical Intensive Care Unit
Division of Trauma, Surgical Critical Care, University of California, San Diego
and Burns San Diego, California
Director Chapter 55: Principles of Critical Care
Surgical Critical Care Fellowship Program
University of California San Diego School of Medicine Joseph A. DuBose, MD
San Diego, California Major
Chapter 4: Trauma Systems, Triage, and Transport USAF MC
Chapter 55: Principles of Critical Care University of Maryland Medical System
R Adams Cowley Shock Trauma Center
Caitlin Curtis, MD Air Force/C-STARS
Nutrition Support Pharmacist Baltimore, Maryland
University of Wisconsin Hospital and Clinics Chapter 25: Lung, Trachea, and Esophagus
Madison, Wisconsin
Chapter 60: Nutritional Support and Electrolyte Management James M. Ecklund, MD, FACS
James W. Davis, MD, FACS Department of Neurosciences
Professor of Clinical Surgery Inova Fairfax Hospital
University of California, San Francisco, Fresno Medical Director
Chief of Trauma Neurosciences
Community Regional Medical Center Inova Health System
Fresno, California Professor of Surgery
Chapter 46: Social Violence Uniformed Services University
Professor of Neurosurgery
Kimberly A. Davis, MD, FACS, FCCM George Washington University
Associate Professor of Surgery Professor of Neurosurgery
Vice Chair for Clinical Affairs Virginia Commonwealth University, School of Medicine Inova
Chief of the Section of Trauma, Surgical Critical Care Campus
and Surgical Emergencies Falls Church, Virginia
Department of Surgery Chapter 19: Injury to the Brain
Yale University School of Medicine
New Haven, Connecticut
Chapter 28: Diaphragm
Contributors xiii

Thomas J. Esposito, MD, MPH James B. Haenel, RRT

Professor and Chief Surgical Critical Care Specialist
Division of Trauma, Surgical Critical Care & Burns Department of Surgery
Department of Surgery Denver Health Medical Center
Director Denver, Colorado
Injury Analysis & Prevention Programs Chapter 57: Respiratory Insufficiency
Loyola University Burn & Shock Trauma Institute
Loyola University Stritch School of Medicine David J. Hak, MD
Maywood, Illinois Professor
Chapter 2: Epidemiology Department of Orthopaedic Surgery
Denver Health Medical Center
Timothy C. Fabian, MD, FACS University of Colorado School of Medicine
Harwell Wilson Professor and Chairman Denver, Colorado
Department of Surgery Chapter 40: Lower Extremity
University of Tennessee Health Sciences Center
Memphis, Tennessee Daithi S. Heffernan, MD, AFRCSI
Chapter 29: Liver and Biliary Tract Department of Surgery
Division of Trauma and Surgical Critical Care
Reginald Fayssoux, MD Rhode Island Hospital
Eisenhower Medical Center Assistant Professor of Surgery
Rancho Mirage, California Brown University
Chapter 23: Vertebrae and Spinal Cord Providence, Rhode Island
Chapter 47: Wounds, Bites, and Stings
David V. Feliciano, MD
Attending Surgeon, Atlanta Medical Center David N. Herndon, MD
Atlanta, Georgia Jesse H. Jones Distinguished Chair in Burn Surgery
Attending Surgeon, Medical Center of Central Georgia Professor of Surgery
Macon, Georgia Chief of Staff
Professor of Surgery Shriners Hospitals for Children
Mercer University School of Medicine University of Texas Medical Branch
Macon, Georgia Galveston, Texas
Adjunct Professor of Surgery Chapter 48: Burns and Radiation
Uniformed Services University of the Health Sciences
Bethesda, Maryland Asher Hirshberg, MD, FACS
Chapter 22: Neck Professor of Surgery
Chapter 34: Abdominal Vascular Injury SUNY Downstate College of Medicine
Chapter 38: Trauma Damage Control Director
Emergency Vascular Surgery
Kevin F. Fitzpatrick, MD Kings County Hospital Center
Physiatrist Brooklyn, New York
Inova Fairfax Hospital Chapter 27: Trauma Laparotomy: Principles and Techniques
Falls Church, Virginia
Major John B. Holcomb, MD, FACS
U.S. Army Medical Corps Vice Chair and Professor of Surgery
Walter Reed Army Medical Center Chief
Washington, District of Columbia Division of Acute Care Surgery
Chapter 51: Rehabilitation Director
Center for Translational Injury Research
Eric R. Frykberg, MD, FACS Jack H. Mayfield, M.D. Chair in Surgery
Professor of Surgery University of Texas Health Science Center
University of Florida College of Medicine Houston, Texas
Chief Chapter 52: Modern Combat Casualty Care
Division of General Surgery
Shands Jacksonville Medical Center David B. Hoyt, MD
Jacksonville, Florida Executive Director
Chapter 8: Disaster and Mass Casualty American College of Surgeons
Chicago, Illinois
Larry M. Gentilello, MD Chapter 4: Trauma Systems, Triage, and Transport
Professor of Surgery
University of Texas John P. Hunt, MD, MPH
Texas Professor of Surgery
Chapter 42: Alcohol and Drugs Louisiana State University Health Science Center
New Orleans, Louisiana
Chapter 1: Kinematics
xiv Contributors

Kenji Inaba, BS, MS, MD, FRCSC, FACS Patrick D. Kilgo, MS

Assistant Professor of Surgery Senior Associate Faculty
University of Southern California Department of Biostatistics
Medical Director Emory University School of Public Health
Surgical Critical Care Fellowship Program Atlanta, Georgia
Division of Trauma, Emergency Surgery and Chapter 5: Injury Severity Scoring and Outcomes Research
Surgical Intensive Care Unit
Los Angeles and University of Southern California Medical Center M. Margaret Knudson, MD
Los Angeles, California Professor of Surgery
Chapter 33: Colon and Rectal Trauma University of California, San Francisco
San Francisco, California
Donald Jenkins, MD Chapter 37: Trauma in Pregnancy
Division of Trauma, Critical Care and General Surgery Rosemary A. Kozar, MD
Associate Professor of Surgery Professor of Surgery
College of Medicine The University of Texas Medical School at Houston
Medical Director Houston, Texas
Trauma Center Chapter 58: Gastrointestinal Failure
Mayo Clinic Nathaniel S. Kreykes, MD
Rochester, Minnesota Surgeon
Chapter 52: Modern Combat Casualty Care Pediatric Surgical Associates, LTD
Jay Johannigman, MD Minneapolis, Minnesota
Professor of Surgery Chapter 43: The Pediatric Patient
University of Cincinnati College of Medicine Kenneth A. Kudsk, MD
Cincinnati, Ohio Professor of Surgery
Chapter 52: Modern Combat Casualty Care University of Wisconsin-Madison
Jeffrey L. Johnson, MD Madison, Wisconsin
Associate Professor of Surgery Chapter 60: Nutritional Support and Electrolyte Management
University of Colorado Denver Anna M. Ledgerwood, MD
Denver, Colorado Professor of Surgery
Chapter 57: Respiratory Insufficiency Wayne State University School of Medicine-Trauma
Gregory J. Jurkovich, MD Medical Director
Professor of Surgery Detroit Receiving Hospital
University of Washington Detroit, Michigan
Chief of Trauma Chapter 59: Renal Failure
Harborview Medical Center Jong O. Lee, MD
Seattle, Washington Associate Professor of Surgery
Chapter 6: Acute Care Surgery Annie Laurie Howard Chair in Burn Surgery
Jeffry L. Kashuk, MD, FACS University of Texas Medical Branch
Associate Professor of Surgery Attending Surgeon
University of Colorado Shriners Hospitals for Children
Denver Health Medical Center Galveston, Texas
Trauma, Acute Care Surgery and Surgical Critical Care Chapter 48: Burns and Radiation
Denver, Colorado Charles E. Lucas, MD
Chapter 13: Postinjury Hemotherapy and Hemostasis Professor
Aditya K. Kaza, MD Department of Surgery
Assistant Professor of Surgery Wayne State University
University of Utah and Primary Childrens Medical Center Detroit, Michigan
Salt Lake City, Utah Chapter 59: Renal Failure
Chapter 50: Organ Procurement for Transplantation Fred Luchette, MD
Robert M. Kellman, MD, FACS The Ambrose and Gladys Bowyer Professor of Surgery
Professor and Chair Loyola University Chicago Stritch School of Medicine
SUNY Upstate Medical University Maywood, Illinois
Syracuse, New York Chapter 56: Cardiovascular Failure
Chapter 21: Face
Contributors xv

Ronald V. Maier, MD, FACS Charles Mock, MD, PhD

Jane and Donald D. Trunkey Professor and Vice Chair Professor
Department of Surgery Department of Surgery and Department of Epidemiology
University of Washington Harborview Injury Prevention and Research Center
Surgeon-in-Chief University of Washington
Harborview Medical Center Seattle, Washington
Seattle, Washington Chapter 3: Injury Prevention
Chapter 3: Injury Prevention
Ernest E. Moore, MD
Alan B. Marr, MD, FACS Professor and Vice Chairman
Professor of Clinical Surgery Department of Surgery
Vice Chairman of Education and Informatics University of Colorado at Denver and Health Sciences Center
Louisiana State Univeristy Health Sciences Center at New Orleans Bruce M. Rockwell Distinguished Chair of Trauma Surgery
Attending in Trauma and Critical Care Rocky Mountain Regional Trauma Center
Medical Center of Louisiana in New Orleans Chief of Surgery
New Orleans, Louisiana Denver Health Medical Center
Chapter 1: Kinematics Denver, Colorado
Chapter 13: Postinjury Hemotherapy and Hemostasis
Kenneth L. Mattox, MD Chapter 14: Emergency Department Thoracotomy
Distinguished Service Professor Chapter 61: Multiple Organ Failure
Baylor College of Medicine
Michael E. DeBakey Department of Surgery Frederick A. Moore, MD
Chief of Staff Professor of Surgery
Chief of Surgery The Methodist Hospital Research Institute
Ben Taub General Hospital Chief, Division of Acute Care Surgery and Critical Care
Houston, Texas The Methodist Hospital
Chapters 24: Trauma Thoracotomy: Principles and Techniques Houston, Texas
Chapters 26: Heart and Thoracic Vascular Injuries Chapters 58: Gastrointestinal Failure
Chapters 54: Trauma, Medicine, and the Law Chapters 61: Multiple Organ Failure

Caitlin L. McAuliffe, BS David Netscher, MD

Research Assistant Clinic Professor
Center for Neuroscience and Regenerative Medicine Division of Plastic Surgery
Uniformed Services University of the Health Sciences Professor
Bethesda, Maryland Department of Orthopedic Surgery
Chapter 51: Rehabilitation Chief of Hand Surgery
Baylor College of Medicine
Laurence B. McCullough, PhD Houston, Texas
Dalton Tomlin Chair in Medical Ethics and Health Policy Chapter 39: Upper Extremity
Center for Medical Ethics and Health Policy
Baylor College of Medicine James V. OConnor, MD, FACS
Houston, Texas Trauma Medical Director
Chapter 45: Ethics of Acute Care Surgery CaroMont Health
Gastonia, North Carolina
J. Wayne Meredith, MD Chapter 25: Lung, Trachea, and Esophagus
Richard T. Myers Professor and Chair
Department of General Surgery Grant E. OKeefe, MD
Director Professor
Division of Surgical Sciences Department of Surgery
Wake Forest University School of Medicine University of Washington
Winston-Salem, North Carolina Harborview Medical Center
Chapter 5: Injury Severity Scoring and Outcomes Research Seattle, Washington
Chapter 53: Genomics and Acute Care Surgery
Max B. Mitchell, MD Nata Parnes, MD
Professor of Surgery
University of Colorado at Denver and
Tri-County Orthopaedics
Childrens Hospital Colorado Heart Institute
Carthage Area Hospital
Aurora, Colorado
Carthage, New York
Chapter 50: Organ Procurement for Transplantation
Chapter 39: Upper Extremity
Stacey A. Mitchell, DNP, MBA, RN, SANE-A, SANE-P
Forensic Nursing Services
Harris County Hospital District
Houston, Texas
Chapter 54: Trauma, Medicine, and the Law
xvi Contributors

Paul F. Pasquina, MD Scott G. Sagraves, MD, FACS

Colonel Chief
U.S. Army Medical Corps Division of Trauma and Surgical Critical Care
Chief Associate Professor of Surgery
Department of Orthopaedics and Rehabilitation Brody School of Medicine at East Carolina University
Walter Reed National Military Medical Center Greenville, North Carolina
Washington, District of Columbia Chapter 11: Airway Management
Chapter 51: Rehabilitation
Jeffrey P. Salomone, MD, FACS, NREMT-P
Andrew B. Peitzman, MD Associate Professor of Surgery
Mark M. Ravitch Professor Emory University School of Medicine
Executive Vice-Chair Deputy Chief of Surgery
Department of Surgery Grady Memorial Hospital
University of Pittsburgh Atlanta, Georgia
Pittsburgh, Pennsylvania Chapter 7: Prehospital Care
Chapter 12: Management of Shock
Joseph A. Salomone III, MD, FAAEM
Fredric M. Pieracci, MD, MPH Associate Professor of Emergency Medicine
Assistant Professor of Surgery University of Missouri Kansas City School of Medicine
Denver Health Medical Center EMS Medical Director
University of Colorado School of Medicine Kansas City Fire Department
Denver, Colorado Kansas City, Missouri
Chapter 13: Postinjury Hemotherapy and Hemostasis Chapter 7: Prehospital Care
Alexander F. Post, MD Nels D. Sanddal, MS, REMT-B
Assistant Professor President and CEO
George Washington University and Virginia Commonwealth University Critical Illness and Trauma Foundation
Pediatric Neurosurgery Bozeman, Montana
Department of Neuroscience
Chapter 9: Rural Trauma
Inova Fairfax Hospital
Falls Church, Virginia Angela Sauaia, MD, PhD
Chapter 19: Injury to the Brain Associate Professor of Medicine
Public Health and Surgery
Juan Carlos Puyana, MD, FACS, FACCP, FRCSC Department of Surgery
Director University of Colorado Denver, School of Medicine
Global Health Surgery Aurora, Colorado
Associate Professor Surgery and Clinical Translational Science Chapter 61: Multiple Organ Failure
University of Pittsburgh
President Pan-American Trauma Society Thomas M. Scalea, MD
Pittsburgh, Pennsylvania Physician-in-Chief
Chapter 12: Management of Shock R Adams Cowley Shock Trauma Center
Baltimore, Maryland
Peter Rhee, MD, MPH, FACS, FCCM, DMCC Chapter 25: Lung, Trachea, and Esophagus
Professor of Surgery
Chief of Trauma, Critical Care, Emergency Surgery William P. Schecter, MD, FACS
University of Arizona Professor of Clinical Surgery
Tucson, Arizona University of California, San Francisco
Chapter 52: Modern Combat Casualty Care San Francisco General Hospital
San Francisco, California
Charles F. Rinker II, MD, FACS Chapter 8: Disaster and Mass Casualty
Adjunct Clinical Professor of Medicine
Montana State University Kevin M. Schuster, MD, FACS
Bozeman, Montana Assistant Professor of Surgery
Chapter 9: Rural Trauma Section of Trauma, Surgical Critical Care and Surgical Emergencies
Department of Surgery
Michael F. Rotondo, MD, FACS Yale University School of Medicine
Professor and Chair New Haven, Connecticut
Department of Surgery Chapter 28: Diaphragm
Brody School of Medicine at East Carolina University
Greenville, North Carolina Salvatore J.A. Sclafani, MD
Chapter 11: Airway Management Professor and Chairman of Radiology
Professor of Clinical Surgery and Clinical Emergency Medicine
Grace S. Rozycki, MD, RDMS, FACS State University of New York Health Science Center at Brooklyn
Professor of Surgery Brooklyn, New York
Emory University School of Medicine and Grady Memorial Hospital Chapter 15: Diagnostic and Interventional Radiology
Atlanta, Georgia
Chapter 16: Surgeon-Performed Ultrasound in Acute Care Surgery
Contributors xvii

Steven R. Shackford, MD George C. Velmahos, MD, PhD, MSEd

Professor of Surgery Emeritus John F. Burke Professor of Surgery
University of Vermont School of Medicine Chief
Director Trauma Graduate Medical Education Division of Trauma, Emergency Surgery, and Surgical Critical Care
Scripps Mercy Hospital Harvard Medical School
San Diego, California Massachusetts General Hospital
Chapter 41: Peripheral Vascular Injury Boston, Massachusetts
Chapter 35: Pelvis
Michael J. Sise, MD, FACS
Clinical Professor of Surgery Gary A. Vercruysse, MD
UCSD School of Medicine Assistant Professor of Surgeon
Trauma Medical Director Emory University School of Medicine
Scripps Mercy Hospital Co-Director
San Diego, California Burn Center
Chapter 41: Peripheral Vascular Injury Attending Surgeon
Grady Memorial Hospital
Wade R. Smith, MD, FACS Atlanta, Georgia
Professor Chapter 22: Neck
Department of Orthopaedics
University of Colorado School of Medicine Matthew J. Wall, Jr., MD
Englewood, Colorado Professor of Surgery
Chapter 40: Lower Extremity Michael E. DeBakey Department of Surgery
Baylor College of Medicine
Philip F. Stahel, MD, FACS Deputy Chief of Surgery/Chief of Thoracic Surgery
Professor of Orthopaedics and Neurosurgery Ben Taub General Hospital
University of Colorado (CU) Chairman of the Executive Medical Board
School of Medicine Ben Taub General Hospital
Denver Health Medical Center Houston, Texas
Denver, Colorado Chapters 24: Trauma Thoracotomy: Principles and Techniques
Chapter 40: Lower Extremity Chapters 26: Heart and Thoracic Vascular Injuries
Lance E. Stuke, MD, MPH Michael A. West, MD, PhD, FACS, FCCM
Assistant Professor of Surgery Professor and Vice Chair
Department of Surgery Department of Surgery
Louisiana State University Health Science Center University of California, San Francisco
New Orleans, Louisiana Chief of Surgery
Chapter 1: Kinematics San Francisco General Hospital
Eric A. Toschlog, MD, FACS, FCCM San Francisco, California
Associate Professor of Surgery Chapter 18: Infections
Director Michael T. White, MD
Surgical Critical Care Assistant Professor of Surgery & Director
Brody School of Medicine at East Carolina University Burn Center
Greenville, North Carolina Detroit Receiving Hospital
Chapter 11: Airway Management Department of Surgery
Peter Tsai, MD Detroit Medical Center/Wayne State University
Assistant Professor of Cardiothoracic Surgery Detroit, Michigan
Michael E. DeBakey Department of Surgery Chapter 59: Renal Failure
Baylor College of Medicine David H. Wisner, MD
Staff Surgeon Professor and Chairman
Ben Taub General Hospital Department of Surgery
Houston, Texas University of California, Davis
Chapters 24: Trauma Thoracotomy: Principles and Techniques Sacramento, California
Chapters 26: Heart and Thoracic Vascular Injuries Chapter 30: Injury to the Spleen
David W. Tuggle, MD Mary Margaret Wolfe, MD
Chief Assisstant Clinical Professor of Surgery
Pediatric Surgery University of California, San Francisco - Fresno
The University of Oklahoma College of Medicine Fresno, California
Oklahoma City, Oklahoma Chapter 56: Cardiovascular Failure
Chapter 43: The Pediatric Patient
xviii Contributors

Amy D. Wyrzykowski, MD Jay A. Yelon, DO, FACS, FCCM

Assistant Professor of Surgery Chairman
Emory University School of Medicine Department of Surgery
Grady Memorial Hospital Lincoln Medical Center
Atlanta, Georgia Bronx, New York
Chapter 38: Trauma Damage Control Chapter 44: The Geriatric Patient

Daniel Dante Yeh, MD Dirk Younker, MD

Clinical Instructor Shelden Professor and Vice-Chairman
Harvard Medical School Department of Anesthesiology and Perioperative Medicine
Massachusetts General Hospital University of Missouri at Columbia
Boston, Massachusetts Chapter 17: Principles of Anesthesia and Pain Management
Chapter 18: Infections
Chapter 37: Trauma in Pregnancy

Almost 30 years ago, two ambitions and competitive surgeons, history. During the past 30 years, Trauma has been the
both of whom had received some specialized advanced training dominant textbook in its field throughout the world. It led in
in cardiovascular surgery and surgical research, were acquiring the fields of surgical critical care and acute care surgery, long
reputations in the exploding field of trauma. before these were disciplines. This Seventh Edition marks a
Physicians and physiologists have been interested in the milestone in a textbook that continues to be the best seller in
field of trauma for thousands of years, as manifest by the its field and have the same three medical editors.
earliest of surgical writings, the Edwin Smith Surgical Since the mid-1980s, we have seen many changes in our
Papyrus, in which almost all case studies focused on the society, medicine, and surgery, in general. HIV and AIDS
injured patient. The explosion of interest in trauma during introduced new immunological and treatment dilemmas.
the 1970s and 1980s was brought about by the simultaneous Inflammatory mediators, cytokines, and immunomodulation
juxtaposition of many factors: have grown into scientific fields, all their own. The wars in the
Middle East have underscored the contemporary changes in
EMS development
trauma management. We have witnessed the emergence of
Emergency medicine as a specialty
damage control surgery and staged treatment. The most
Critical care as a discipline
pronounced aspect of this concept is the ability to transport
Increased sophistication in human physiological
combat causalities across continents after initial damage control
treatment, administer intermediate treatment in a European
Advances in blood banking and hemotherapy
military hospital, and then transport, again, in a literal flying
Advances in vascular surgery
ICU. During the growth and development of Trauma,
Surgeons returning from the Vietnam conflict
trauma center verification, designation, and recognition have
Broadening the scope of military medicine via the
become widespread. The terms Level I, Level II, and Level III
Uniformed Services University of the Health Sciences
Trauma Centers are now commonplace, and society expects
Last, but far from least, a large group of young, aggressive,
every major city to have appropriate trauma treatment capability.
eager surgeons who enjoyed the challenge of taking care of
Tenets of aggressive crystalloid resuscitation, precontrol
acutely injured patients with severe anatomic and
elevation of the blood pressure, and other traditional aggressive
physiological derangements
resuscitation cultures have changed dramatically.
During the 1970s and early 1980s, trauma textbooks available Each edition of Trauma is different from the previous one.
to an aspiring academic surgeon or a practicing community In preparing for the Seventh Edition and this preface, I
surgeon seeking to master new techniques were few and rather reviewed each edition, chapter by chapter. For this edition, as
limited in scope. Most recommendations contained therein in previous ones, we have invited new authors for many
were based on expert opinion and trial and error, rather than chapters, and we requested that the number of references be
any evidence-based approach. Injury classification was in its reduced to less than 50, when feasible for the subject, with both
infancy, and quality management matrix analyses had yet to be historic and recent citations. We have again attempted to avoid
described. Almost simultaneously, Doctor Kenneth Mattox, in duplication of a subject or conflicting opinion, recognizing that
Houston, and Doctor Ernest Eugene (Gene) Moore, in Denver, this is not always possible when we also ask that each author
recognized there has to be a better way and a better textbook. make original contributions.
Doctors Moore and Mattox, independently and unbeknownst For this edition, we are very excited about the inclusion of a
to each other, began to construct outlines for a practical trauma Trauma Atlas of anatomic drawings and recognized surgical
book employing the leading trauma surgeons of the day to approaches. The three editors selected the drawings we believe
contribute. best illustrate our current best practice for exposure and
While both were in the challenging convincing stages with reconstruction. The descriptors with each drawing are short
their respective publishers, they were assembling a group of and succinct.
authors to participate in their respective endeavors. At this Finally, and most importantly, the authors acknowledge the
point, they discovered, they were pursuing similar projects and assistance of many people who make it possible to successfully
recruiting similar authors. A major merger followed, and at our accomplish this major endeavor, edition after edition. We are
initial meeting, the current format for the book Trauma was grateful to the authors who have contributed their knowledge,
born. David Feliciano was invited to be the third editor, and experience, writing talent, and valuable time. The expertise of
the legacy began. We agreed to rotate the first editor spot with the support personnel at all levels at McGraw-Hill Publishers is
each subsequent edition, and the subsequent six editions are essential and appreciated at each step for each edition. Each

xx Preface

editor has office assistants who have performed many tasks, the very first concept formulation meeting, when Trauma
from interacting with authors to pushing the editors to meet was just a dream, and has been present at all editorial meetings
deadlines. Mary Allen, in Kenneth Mattoxs office, Jo Fields in since. Thank you, Mary, for your significant efforts in this and
E. Eugene (Gene) Moores office, and Samantha Buckner in all previous editions of Trauma.
David Felicianos office all worked diligently to support this
project. As assistant to the senior editor of the Seventh Edition, Kenneth L. Mattox, MD
Mary Allen was tireless in coordinating the work of editors and Ernest E. Moore, MD
authors to bring this project to fruition. Mary was present at David V. Feliciano, MD



John P. Hunt, Alan B. Marr, and Lance E. Stuke

Kinematics (kn-mtks) n: The branch of mechanics that deals BASIC PRINCIPLES

with pure motion without reference to the masses or forces
involved in it. From Greek knma, knmat-, movement.1 Newtons Laws, Impulse,
As can be presumed from the derivation of the word kine- Momentum, Energy and Work,
matics, its essence revolves around motion. All injury is Elastic and Inelastic Collisions
related to the interaction of the host and a moving object.
Newtons first law states that every object will remain at rest or
That object may be commonplace and tangible, such as a
in uniform motion in a straight line unless compelled to change
moving vehicle or speeding bullet or more subtle as in the case
its state by the action of an external force. This is the definition
of the moving particles and molecules involved in injury from
of inertia. Newtons second law builds on the first and further
heat, blasts, and ionizing radiation. Newtonian mechanics,
defines a force (F ) to be equal to the product of the mass (m)
the basic laws of physics, and the anatomic and material prop-
and acceleration (a).
erties of the human body explain many of the injuries and
injury patterns seen in blunt and penetrating trauma. Injury F  ma.
is related to the energy of the injuring element and the inter-
The application of a force does not occur instantaneously,
action between that element and the victim. Although most
but over time. If we multiply both sides of the above equation
patients suffer a unique constellation of injuries with each
by time
incident, there are quite definable and understandable energy
transfer patterns that result in certain predictable and specific Fdt  ma(t).
injuries. Knowing the details of a traumatic event may aid the
The product of force and time is known as impulse and
treating physician to further investigative efforts to uncover
multiplying acceleration by time yields velocity. Momentum (p)
occult but predictable injuries.
is defined to be the mass (m) of an object times its velocity (v).
This chapter has been organized in a stepwise fashion.
First, the basic laws of physics and materials that dictate the p  mv,
interaction between the victim and the injuring element are
reviewed. This is followed by a more detailed examination
of penetrating and blunt trauma and a synopsis of mechanisms impulse  change in momentum.
specific to organs and body regions. It is hoped that
The important fact is that a force or impulse will cause a
this will offer the reader a better understanding of specific
change in momentum and, likewise, a change in momentum
injury patterns, how they occur, and which injuries may
will generate a force.2 This folds into Newtons third law, which
Kinematics 3

states that for every action or force there is an equal and oppo- passenger compartment. If the momentum of car A was
site reaction.3 For instance, when two objects of equal velocity greater than that of car B by having a greater mass or velocity,
and mass strike each other, there velocities are reduced to zero the resultant mass C will have momentum in the previous
(at the moment of impact). This change in velocity and, hence, direction in which car A was traveling.

momentum was caused by each object applying a force to the In T-bone type crashes the directions of the momentum of
other. During impact the forces are equal and opposite. cars A and B are perpendicular. Therefore, in the momentum
Recalling Newtons second law, a force is associated with a axis of car A, car B has 0 momentum and, in the momentum
change in momentum. In this system, the net force is zero and, axis of car B, car A has no momentum. The conglomerate C

therefore, the change in momentum is zero. This illustrates the conserves momentum in both the A and B axes with the resul-
law of conservation of momentum. The total momentum of a tant direction as shown in Fig. 1-1(B). As a consequence, the
system will remain constant unless acted upon by an external changes in momentum and force generated are far less than
force. The momentum of this two object system is the same that of a head-on collision. Also, C continues to have a veloc-
after a collision as it was prior to impact.4 ity and, as such, kinetic energy. This means that some of the
The next important basic principles are those of work and initial kinetic energy was not converted to work, and less
energy. Work (W) is defined as a force exerted over a distance damage to the automobiles will occur. In general, the closer to
and is frequently written as a head-on collision the greater the change in momentum and,
thus, the greater the force generated.
W  Fdx,
In rear-end collisions the momentum of both cars is typi-
with F  ma and a  vdv/dx cally in the same direction, Fig. 1-1(C). Therefore, the changes
W  mvdv/dx (dx),
which after integration yields the familiar formula for kinetic
energy: 1/2mv2 A C B

W  1/2mv  1/2mv .

Therefore, the work being done by a moving object, which

interacts with a second object, equals the kinetic energy of the A. Frontal collisions

first object prior to doing work minus the kinetic energy after
the interaction. In other words, the work done is equal to the
change in kinetic energy of the first object.5 When this interac-
tion sets the other body in motion, the second body now has A
kinetic energy of its own, equal to the work done. James Joule
described the first law of thermodynamics in 1840, which sim-
ply states that energy can be neither created nor destroyed.6 B
Interactions in which both momentum and energy are con-
served are termed elastic.
In trauma most collisions are inelastic. Inelastic collisions
conserve momentum, but not kinetic energy. In these instances
the kinetic energy does work in the deformation of materials
B. T-bone collision
even to the point where objects can conglomerate and form a C
single object. This is the hallmark of the inelastic collision. This
energy transfer or work done is what is typically responsible for
the injury sustained by the host.
Energy transfer and momentum conservation can be illus-
trated in the collision of two cars. Fig. 1-1(A) represents a A B C
head-on collision of two cars with equal mass and velocity
and, thus, equal kinetic energy and momentum. The momen-
tums are equal, but in opposite directions. Thus, the total
momentum for the system is 0 prior to the crash and, by the C. Rear-end collision

law of conservation of momentum, must be 0 after the crash. FIGURE 1-1 Energy and momentum available in various motor
Upon impact, both cars will come to rest. It is as if one of the vehicle crash scenarios. (A) Frontal collisions have the greatest
cars struck an immovable wall. Recalling Newtons second change in momentum over the shortest amount of time and
and third laws, this sudden change in momentum represents hence the highest forces generated. (B) T-bone collision. When
a force, which is equally applied to both cars. Because the cars A and B collide their resultant momentum directs them
toward their final position C; the individual momentums in the x
final velocity is 0, the final kinetic energy is 0, meaning that and y axis are dissipated over a greater time resulting in smaller
all the kinetic energy has been converted to work that stops forces then head-on collision. (C) Rear-end collision. Since these
the other car and causes deformation such as breaking glass, vehicles move in the same direction the change in momentum
bending metal, and causing physical intrusion into the and forces generated are smaller.
4 Trauma Overview

in momentum and resultant forces generated are typically small

TABLE 1-1 Velocity and Kinetic Energy Characteristics
as is the conversion of kinetic energy to work. These principles
of Various Guns
apply to all collisions whether they are a bullet penetrating a
victim, a car hitting a pedestrian, or a driver impacting the Velocity Muzzle Energy

windshield. Caliber (ft/s) (ft-lb)

0.25 in. 810 73
Penetrating Trauma and Ballistics 0.32 in. 745 140

Although the above principles were elaborated in the setting of 0.357 in. 1,410 540
blunt trauma, they are equally applicable to penetrating trauma. 0.38 in. 855 255
The study of ballistics details the energy of projectiles as they 0.40 in. 985 390
leave the firearm and the energy transfer once the bullet strikes 0.44 in. 1,470 1,150
the victim. Theodore Kocher first proposed that the kinetic 0.45 in. 850 370
energy possessed by the bullet was dissipated in the four follow- 9 mm 935 345
ing ways: namely, heat, energy used to move tissue radially 10 mm 1,340 425
outward, energy used to form a primary path by direct crush of
the tissue, and energy expended in deforming the projectile.7 Long guns/military weapons
Despite limited techniques for studying ballistics, Kocher was 0.243 Winchester 3,500 1,725
for the most part correct. Our more extensive knowledge of the M-16 3,650 1,185
behavior of projectiles in a host comes from the observed per- 7.62 NATO 2,830 1,535
formance of bullets in gelatin, which has properties similar to Uzi 1,500 440
that of muscle and is thought to reflect the way in which energy AK47 3,770 1,735
is transferred through tissue. From such experiments several
characteristics of a projectile piercing tissue have been described.
These include the following: (a) penetration (the distance the
projectile passes through tissue is reflected in the distance from
the cut edge of the gelatin block to where the projectile comes be transferred to the target). The characteristics of damage cre-
to rest); (b) fragmentation (the pattern is assessed by biplaner ated along the track of a bullet are divided into two components,
x-rays and the degree reflected in the difference of the weight of the temporary and the permanent cavities. The temporary cavity
the prefired projectile minus the weight of the collected is the momentary stretch or movement of tissue away from the
fragments); (c) permanent cavity (the tissue disintegrated by path of the bullet. This could be construed as an area of blunt
direct contact with the missile and preserved in the gelatin); trauma surrounding the tract of the projectile. The temporary
and (d) temporary cavity (the amount of stretch caused by the cavity increases in size with increasing velocity. The largest por-
passing projectile). This is reflected by the distance from the tion of the temporary cavity is on the surface where the velocity
edge of the permanent cavity to the outer perimeter of of the striking missile is the greatest.12 The concept of the tem-
the cracks within the gelatin.8 porary cavity has been used to advocate excessive tissue debride-
The performance of the bullet and the injury sustained is ment in high-velocity wounds. In truth, postinjury observation
reliant upon velocity, construction of the bullet, and composi- of wound healing and animal experiments involving microscopic
tion of the target.9 The energy and construction characteristics examination of tissue in the temporary cavity demonstrate that
of the projectile will be discussed here while target properties the momentary stretch produced does not usually cause cell
will be reviewed in the section on biomaterials. The prominent death or tissue destruction.13 As such, debridement of high-
18th-century surgeon John Hunter stated, If the velocity of the velocity injuries should be confined to obviously devitalized tis-
ball is small, then the mischief is less in all, there is not so great sue. Bullets can be constructed to alter their performance and
a chance of being compounded with fractures of bones etc.10 increase the permanent cavity after they strike their target. This
This astute observation reflects the exponential importance of can be enhanced in four ways that all work by increasing the
velocity in determining the amount of kinetic energy that a surface area of the projectiletissue interface that facilitates the
particular projectile is capable of transmitting to a given target transfer of kinetic energy to the target. These include the follow-
(kinetic energy  1/2mv 2). As such, high-velocity missiles will ing: (a) yaw, the deviation of the projectile in its longitudinal axis
generally cause more tissue destruction than their lower velocity from the straight line of flight; (b) tumbling, the forward rota-
counterparts. The velocities and kinetic energies11,12 of common tion around the center of mass; (c) deformation, a mushrooming
handguns and rifles are listed in Table 1-1. of the projectile that increases the diameter of the projectile, usu-
The amount of energy imparted (or work) to the tissue by a ally by a factor of 2, increases the surface area, and, hence, the
projectile is equal to the kinetic energy of the missile as it enters tissue contact area by four times; hollow point, soft nose, and
the tissue minus the kinetic energy as it leaves the tissue. Bullets dumdum bullets all promote deformation; and (d) fragmenta-
are extremely aerodynamic, causing little disturbance while pass- tion, in which multiple projectiles can weaken the tissue in
ing through the air. To some extent, this is similar in tissue (i.e., multiple places and enhance the damage rendered by cavitation.
if the projectile moves with the point forward and passes in and This usually occurs in high-velocity missiles. Nonfragmenting
out of the tissue, only a small portion of its kinetic energy will bullets will have a deeper penetration, whereas a fragmented
Kinematics 5

as the wavefront pressure generated above ambient pressure.

A This peak overpressure is a function of the energy released from
the blast and the distance from the point of detonation, and its
decay is expressed as a scaling function17

(W/W1)1/3  D/D1
where W/W1 is a ratio of weights of a given explosive and D/D1
B a ratio of distances from the epicenter. A compilation of exper-

imental results showed that if a peak overpressure for one
weight of explosive occurred at one distance, the same overpres-
sure could be produced with a smaller weight of explosive at a
shorter distance and for a larger weight of explosives at a longer
distance (Fig. 1-3A). This relationship is known as the cube
root rule or Hopkinsons rule, and has been demonstrated to
hold true for numerous modern-day explosive materials.18
At any given distance from the explosion there will be a
distinct pressuretime curve with an abrupt increase in over-
pressure. Peak overpressure is dictated by the cube root rule and
a decay in pressure that varies with the particular explosive
compound and the time past the initial blast wavefront. As the
wave moves past a given point, this positive pressure phase will
be followed by a negative pressure phase19 (Fig. 1-3B). Pressure
FIGURE 1-2 Yaw, tumble, deformation, and fragmentation. is a force applied per unit area. When a force is applied over a
(A) Yaw describes deviation from flight path along the longitudinal
axis. (B) Tumble is deviation in a head over heels manner.
(C) Deformation occurs on impact and increases the actual surface A. The Scaling Laws
area of the projectile. (D) Fragmentation involves the bullet
scattering. All of these increase surface area of the projectile/
tissue interface. Epicenter

projectile will not penetrate as deeply, but will affect a larger
cross-sectional area.1416 If the bullet deforms, yaws, tumbles, or
Blast waves
fragments, it will cause more tissue destruction. This occurs in
deeper structures, not at the surface (Fig. 1-2). Wounds caused
by knives are of very low energy and cause only a permanent B. The Pressure-Time relationship at any given
cavity. With little energy transferred to the tissue, serious injury distance from the epicenter
is caused by directly striking vital structures such as the heart, Peak overpressure
major vessels, lung, or abdominal organs.

Positive phase
Blast Injury and Ionizing Radiation

The transfer of energy that results from explosions follows the

previously stated rules of physics, but also has additional
dimensions that deserve mention. The transmission of energy
from an explosive blast is best understood in the context of Negative phase
wave mechanics. All conventional explosions have in common
several characteristics in that they all involve a solid or liquid Time
mixture that undergoes a rapid chemical reaction producing a
gaseous by-product and a large amount of released energy. This FIGURE 1-3 Physical characteristics of an explosive blast.
release of energy pushes gaseous molecules from the explosion (A) The Scaling Laws relate the overpressure at specific
and within the atmosphere radially away from the explosion distances to the ratio of distances from the epicenter of a blast
center producing a spherical wave of compressed gas, known as and the cube root of the ratios of corresponding weights of the
the blast wave, with increased density, pressure, and tempera- charges. (B) The Pressuretime relationship at any given distance
from the epicenterthe peak overpressure represents the
ture when compared with the ambient air. The movement passing wave front with a subsequent decrease in pressure until
of these molecules creates what is known as a blast wind, and ambient pressure is reached. This is known as the positive phase.
the compression of these molecules into a given space increases The passing wave will then cause a decrease in pressure below
the density and pressure. This blast overpressure is defined baseline resulting in a relative vacuum, or negative pressure phase.
6 Trauma Overview

given time, an impulse is present and has the ability to change

momentum. This force when applied across a distance has the
ability to transfer energy and do work.
Nuclear blast waves have a similar pressuretime relation-

ship, but their positive phase may last several seconds as

compared to the milliseconds of conventional munitions.20
The energy released from a nuclear explosion is on the order
of thousands of times greater than conventional explosives

with a corresponding increase in overpressure. The energy
available is dictated by Einsteins massenergy equivalency
E  mc2.
A large portion of this energy is released in the form of C
kinetic energy that dictates the wave characteristics of the blast.
Also, there is the production of high-energy subatomic parti-
cles, such as gamma radiation, which has the ability to cause
destruction at the cellular level. Where h  Plancks constant,
the energy of these particles is directly related to their frequency
(v).22 D

E  hv
FIGURE 1-4 Biomechanical mechanisms of injury. (A) Tensile
They can be released at the time of the blast, but also for a strainOpposite forces stretching along the same axis. (B) Shear
period of time after the explosion as unstable products of a strainOpposite forces compress or stretch in opposite direction
nuclear reaction undergo radioactive decay. Therefore, a nuclear but not along the same axis. (C) Compressive strainStress
explosion has the ability to transfer energy to a victim and do applied to a structure usually causing simple deformation.
damage long after the initial blast. (D) OverpressureA compressive force increases the pressure
within the viscus passing the breaking point of the wall.

structure and cause a decrease in the volume of the structure.
Stress, Strain, Elasticity, Following Boyles law:
and Youngs modulus P1V1  P2V2
When a force is applied to a particular material, it is typically
referred to as a stress, which is a load or force per unit area. This The product of the pressure and the volume prior to an
stress will cause deformation of a given material. Strain is the applied force must be equal to the product afterward.4
distance of the deformation caused by the stress, divided by the Therefore, a decrease in its original volume will increase the
length of the material to which the stress was applied.23 pressure inside that viscus. If the rise in pressure, which is a
Strain can be tensile, shear, compressive, or overpressure force, overcomes the tensile strength of the viscus, it will
(a relative of compressive strain) (Fig. 1-4). Tensile strain of a rupture.25
particular structure or organ occurs as opposing forces are When stress is plotted on the same graph as strain, there are
applied to the same region. The forces are opposite and concen- several clear and distinct aspects to the curve. The elastic
trated upon a particular point. This essentially interrupts the modulus is that part of the curve in which the force does not
integrity of the structure by pulling it apart. Shear strain occurs cause permanent deformation, and a material is said to be more
as opposing forces are applied to a particular structure, but at elastic if it restores itself more precisely to its original configu-
different points within that structure. This can be caused by an ration.26 The portion of the curve beyond this is called the
application of opposing external forces or can arise from a plastic modulus and denotes when an applied stress will cause
relative differential in the change of momentum within a single permanent deformation.27 The tensile, compressive, or shear
structure or between structures that are attached to one strength is the level of stress at which a fracture or tearing
another.24 occurs.28 This is also known as the failure point. The area
Compressive strain is the direct deformation that occurs as a under the curve is the amount of energy that was applied to
result of impact. The energy involved with a particular force achieve the given stress and strain (Fig. 1-5).29
does work on the structure causing a crushing-type injury How well tissue tolerates a specific insult varies with the type
resulting in deformation and interruption of the structural of force applied and the tissue in question. In blunt and pene-
integrity of the injured organ. Overpressure is a type of com- trating trauma, the higher the density of a particular tissue, the
pressive strain that is applied to a gas- or fluid-filled cavity. The less elastic it is and the more energy is transferred to it in a col-
energy applied to a gas- or fluid-filled viscus can deform that lision. Lung is air-filled and extremely elastic. In lower velocity
Kinematics 7

L striking object. Other variables that complicate care include

the larger surface area over which the energy is dispersed as
compared to penetrating trauma and the multiple areas of
contact that can disperse energy to different regions of the

victims body. The interactions and directions of these lines of
force and energy dispersion are often instrumental in causing
specific kinds of injury.

Tensile strain = L/L
Motor Vehicle Crashes
Although there are frequently confusing vectors for energy
transfer and force in a victim of a motor vehicle crash, mortality
is directly related to the total amount of energy and force avail-
able. Mortality from motor vehicle crashes is accounted for in
large part by head-on collisions with mortality rates up to 60%.
Strength Side impact collisions (2035%) and rollovers (815%) have
Plastic Modulus progressively lower mortality rates with rear-end collisions
Elastic Modulus (35%) having the lowest.3132 Rollover crashes have a lower
than expected mortality because the momentum is dissipated,

and forces generated and projected to the passenger compart-

Energy ment are in a random pattern that frequently involves many
different parts of the car. Although there are certain forces and
patterns of energy exchange that occur in a motor vehicle crash,
the vehicle itself does offer some degree of protection from the
direct force generated by a collision. Patients who are ejected
Strain from their vehicle have the velocity of the vehicle as they are
FIGURE 1-5 The concept of stress, strain, elastic modulus, plastic ejected and a significant momentum. They typically strike a
modulus, tensile strength and energy as demonstrated by a relatively immobile object or the ground and undergo serious
tensile stress applied to a given structure. The tensile strain loads. Trauma victims who were ejected from the vehicle were
is the change in length under a stress divided by the original four times more likely to require admission to an intensive
length. This concept is applicable to compressive and shear care unit, had a 5-fold increase in the average Injury Severity
strain. In the stress/strain relationship the elastic modulus is the Score, were three times more likely to sustain a significant
portion of the curve where permanent deformation does not
injury to the brain, and were five times more likely to expire
occur as opposed to the plastic modulus where it does fracture
or tearing occurs at the tensile strength. The energy applied is secondary to their injuries in one study.33
the area under the curve. Understanding the changes in momentum, forces gener-
ated, and patterns of energy transfer between colliding vehicles
is important. For example, the principal direction of force in a
head-on collision is affected by the degree of overlap of the
blunt trauma, energy tends to be dissipated across the lung vehicles.34 Yet, the behavior of the occupants of the passenger
easily, while in penetrating trauma the actual destruction of the compartment in response to this is what helps identify specific
permanent cavity and stretch caused by the temporary cavity patterns of injury. In frontal collisions the front of the vehicle
are better tolerated because of the elasticity of the lung. In con- decelerates as unrestrained front-seat passengers continue to
trast, solid organs such as spleen, liver, or bone tend to absorb move forward in keeping with Newtons first law. Lower
energy and will have greater tissue destruction as a conse- extremity loads, particularly those to the feet and knees, occur
quence.30 In blast injury it is the air-filled structures of the lung early in the crash sequence and are caused by the floorboard
and bowel that tend to be injured because of their ability to and dashboard that are still moving forward. Therefore, rela-
transmit the blast wave and cause localized pressure increases tive contact velocity and change in momentum are still low.
that overcome the structural failure point of the organ.20 Contact of the chest and head with the steering column and
windshield occurs later in the crash sequence; therefore, con-
tact velocities and deceleration, change in momentum, and
contact force are higher.31,35
Types of injuries are dependent on the path the patient
The transfer of energy and application of forces in blunt takes. The patient may slide down and under the steering wheel
trauma is often much more complex than that of penetrating and dashboard. This may result in the knee first impacting the
trauma. The most frequent mechanisms of blunt trauma dashboard causing a posterior dislocation and subsequent
include motor vehicle crashes, autopedestrian crashes, and injury to the popliteal artery. The next point of impact is the
falls from a significant height. In these instances there are upper abdomen or chest. Compression and continued move-
typically varying energies and forces in both the victim and the ment of solid organs results in lacerations to the liver or spleen.
8 Trauma Overview

Compression of the chest can result in rib fractures, cardiac are pushed forward they will act as a fulcrum bringing the
contusion, or a pneumothorax from the lung being popped like trunk and head forcefully down on the hood of the car apply-
a paper bag. Finally, the sudden stop can cause shear forces on ing a secondary force to those regions, respectively. The typical
the proximal descending thoracic aorta resulting in a partial- or injury pattern in this scenario is a tibia and fibula fracture or

full-thickness tear. The other common path is for the occupant dislocation of the knee joint, injury to the trunk such as rib
to launch up and over the steering wheel. The head then fractures or rupture of the spleen, and injury to the brain.38,39
becomes the lead point and strikes the windshield resulting in a
starburst pattern on the windshield. The brain can sustain

direct contusion or can bounce within the skull causing brain Falls
shearing and a contrecoup injury. Once the head stops, forces Falls from height can result in a large amount of force trans-
are transferred to the neck that may sustain hyperflexion, mitted to the victim. The energy absorbed by the victim at
hyperextension, or compression injuries, depending on the impact will be the kinetic energy at landing. This is related to
angle of impact. Once the head and neck stop, the chest and the height from which the victim fell. The basic physics for-
abdomen strike the steering wheel with similar injuries to the mula describing the conservation of energy in a falling body
down and under path. states that the product of mass, gravitational acceleration, and
Lateral collisions, specifically those that occur on the side of height, the potential energy prior to the fall, equals the kinetic
a seated passenger, can be devastating because of the small energy as the object strikes the ground. With mass and gravi-
space between the striking car and the passenger. Therefore, tational acceleration being a constant for the falling body,
resistance to slow momentum of the striking car prior to con- velocity, and, therefore, momentum and kinetic energy are
tact with the passenger is limited. If the side of the car provides directly related to height.4 The greater the change in momen-
minimal resistance the passenger can be exposed to the entire tum upon impact the larger the load or force applied to the
momentum change of the striking car. These loads are usually victim. Injury patterns will vary depending upon which por-
applied to the lateral chest, abdomen, and pelvis and, as tion of the victim strikes the ground first and, hence, how the
such, injuries to the abdomen and thorax are more frequent load is distributed.
in lateral collisions than in frontal collisions.35 Injuries to the The typical patient with injuries sustained in a free fall has
chest include rib fractures, flail chest, and pulmonary contu- a mean fall height of just under 20 ft. One prospective study
sion. Lateral compression often causes injuries to the liver, of injury patterns summarized the effects of falls from heights
spleen, and kidneys, as well. Finally, the femoral head can be ranging between 5 and 70 ft. Fractures accounted for 76.2%
driven through the acetabulum. of all injuries, with 1922% of victims sustaining spinal frac-
Rear-end collisions are classically associated with cervical tures and 3.7% developing a neurological deficit.40 Nearly 6%
whiplash-type injury and are a good example of Newtons of patients had intra-abdominal injuries, with the majority
first law at work. When the victims car is struck from requiring operative management for injury to a solid organ.
behind, the body, buttressed by the seat, undergoes a Bowel and bladder perforation were observed in less than 1%
forward acceleration and change in momentum that the of injuries.41
head does not. The inertia of the head tends to hold it in a
resting position. The forward pull of the victims trunk
causes a backward movement on the head leading to hyper- ANATOMIC CONSIDERATIONS
extension of the neck. Similarly, this injury pattern can also
be seen in head-on collisions where a sudden deceleration of Injury to the Head
the victims trunk with a continued forward movement of (Brain and Maxillofacial Injury)
the head is followed by a backward rotation resulting from The majority of closed-head injuries are caused by motor
recoil.36,37 vehicle collisions (MVCs), with an incidence of approximately
1.14 million cases each year in the United States.42,43 The
severity of traumatic brain injury represents the single most
Pedestrian Injuries important factor contributing to death and disability after
Pedestrian injuries frequently follow a well-described pattern trauma and may contribute independently to mortality when
of injury depending on the size of the vehicle and the victim. coexistent with extracranial injury.37,44,45 Our knowledge of the
Nearly 80% of adults struck by a car will have injuries to the biomechanics of injury to the brain comes from a combination
lower extremities. This is intuitively obvious as the level of a of experiments conducted with porcine head models, biplaner
cars bumper is at the height of the patients knee and this is high-speed x-ray systems, and computer-driven finite element
the first contact point in this collision sequence. A victim models.46
struck by a truck or other vehicle with a higher center of mass There are a multitude of mechanisms that occur under the
will more frequently have serious injuries to the chest and broad heading of traumatic brain injury. All are a consequence
abdomen because the initial force is applied to those regions. of loads applied to the head resulting in differing deceleration
In the carpedestrian interaction, the force applied to the knee forces between components of the brain. Brain contusion can
region causes an acceleration of the lower portion of the body result from impact and the associated direct compressive
that is not shared by the victims trunk and head, which tend strain. The indirect component of injury to the brain on the
to stay at rest, by Newtons first law. As the lower extremities side opposite to that of impact is known as the contrecoup
Kinematics 9

injury. This occurs because the brain is only loosely connected Musculoskeletal injury in the chest is dependent upon both
to the surrounding cranium. As a result, after a load is applied the magnitude and rate of the deformation of the chest wall
to the head causing a compressive strain at the point of impact and is usually secondary to compressive strain from the applied
and setting the skull in motion along the line of force, the load. Patterns of injury for the internal organs of the thorax

motion of the brain lags behind the skull. As the skull comes frequently reflect the interactions between organs that are fixed
to rest, or even recoils, the brain, still moving along the line of and those that are relatively mobile and compressible.
the initial load, strikes the calvarium on the opposite side and This arrangement allows for differentials in momentum
another compressive strain is generated. The existence of the between adjacent structures that lead to compressive, tensile,

coupcontrecoup injury mechanism is supported by clinical and shear stresses.
observation and has been confirmed by a three-dimensional The sternum is deformed and rib cage compressed with a
finite element head model and pressure-testing data in blunt force to the chest. Depending on the force and rate of
cadavers.47 It is even suspected that this forward acceleration of impact in a collision, ribs may fracture from compressive
the brain relative to the skull may set up a tensile strain in the strain applied to their outer surface and consequent tensile
bridging veins causing their laceration and formation of a sub- strain on the inner aspects of the rib. Indirect fractures may
dural hematoma.48 occur due to stress concentration at the lateral and posterolat-
Injury to the superficial regions of the brain is explained by eral angles of the rib. Furthermore, stress waves may propa-
these linear principles; however, injury to the deep structures gate deeper into the chest resulting in small, rapid distortions
of the brain, such as diffuse axonal injury (DAI), is more or shear forces in an organ with significant pressure differen-
complicated. Several authors have tried to explain DAI as a tial across its parenchymal surface (i.e., the air and tissue
result of shear strain between different parts of the brain, but interface of the lung). This is thought to be the mechanism
there is also another model known as the stereotactic phe- causing a pulmonary contusion.
nomenon. This model relies more on wave propagation and Blunt intrusion into the hemithorax and a pliable lung
utilizes the concavity of the skull as a collector, which could also result in overpressure and cause a pneumothorax. A
focuses multiple wave fronts to a focal point deep within the direct load applied to the chest compresses the lung and
brain, causing disruption of tissue even in the face of minimal increases the pressure within this air-filled structure beyond the
injury at the surface of the brain.49 This wave propagation failure point of the alveoli and visceral pleura. This overpressure
through deeper structures within the brain, such as the retic- mechanism may also be seen with fluid (blood) instead of air in
ular-activating system, with subsequent disruption of their a blunt cardiac rupture. High-speed cine-radiography in an
structural integrity is thought to account for a loss of con- anterior blunt chest trauma model in the pig has demonstrated
sciousness, the most frequent serious sign after blunt trauma that the heart can be compressed to half of its pre-crash diam-
to the brain.50 Current research characterizes DAI as a pro- eter with a doubling of the pressure within the cardiac cham-
gressive process induced by the forces of injury, gradually bers.52 If the failure point is reached, rupture occurs with
evolving from focal axonal alteration to eventual disconnec- disastrous results.
tion. Traumatically induced focal axolemmal permeability There are several examples of indirect injury secondary to
leads to local influx of Ca2 causing the release of proteases asynchronous motion of adjacent, connected structures and
that digest the membrane skeleton. This ultimately leads to development of shear stress at sites of attachment.53 Mediastinal
local axonal failure and disconnection.51 An injury caused by vascular injury and bronchial injury are examples of this
shear strain is a laceration or contusion of the brainstem. This mechanism. Rupture or transection of the descending tho-
is explained by opposing forces applied to the brain and the racic aorta is a classic deceleration injury mediated by shear
spinal cord perpendicular to their line of orientation, with the forces. This injury can occur in frontal or lateral impacts and
spinal cord and brainstem being relatively fixed in relation to occurs because of the continued motion of the mobile and
the mobile brain. compressible heart in relation to an aorta that is tethered to
Maxillofacial injuries are associated with injuries to the more fixed structures.54 In frontal and lateral impacts the
head and brain in terms of mechanism and are a common heart moves in a horizontal motion relative to an aorta that is
presentation after motor vehicle crashes. The classic force vec- fixed to the spinal column by ligamentous attachments. This
tor that results in mid-face fractures is similar to that of trau- causes a shear force applied at the level of the ligamentum
matic brain injury and occurs when a motor vehicle occupant arteriosum. When the stress is applied in a vertical direction,
impacts the steering wheel, dashboard, or windshield. Nearly such as a fall from a height in which the victim lands on the
all of these subtypes of injury are secondary to compressive lower extremities, the relative discrepancy in momentum is in
strain. This mechanism is associated with the greatest morbid- that plane and a tensile strain is generated at the root of the
ity for the driver and front-seat passenger, while the forces are ascending thoracic aorta (Fig. 1-6). Injury to a major bron-
attenuated for the back-seat passenger impacting the more chus is another example of this mechanism. The relatively
compliant front seat. pliable and mobile lung generates a differential in momentum
in a horizontal or vertical plane depending on the applied
load as compared to the tethered trachea and carina. This cre-
Thoracic Injury ates a shear force at the level of the mainstem bronchus and
The primary mechanism of blunt trauma to the chest wall explains why the majority of blunt bronchial injuries occur
involves inward displacement of the body wall with impact. within 2 cm of the carina (Fig. 1-7).
10 Trauma Overview

Shear Abdominal Injury

Force Abdominal organs are more vulnerable than those of the tho-
Reactive rax because of the lack of protection by the sternum and ribs.

Force A number of different mechanisms account for the spectrum

of injury observed in blunt trauma to the abdomen. With
regard to the solid abdominal organs, a direct compressive
Reactive force with parenchymal destruction probably accounts for

Initial most observed injuries to the liver, spleen, and kidney. Shear
Force strain can also contribute to laceration of these organs. As with
the previous description of strain forces, a point of attachment
is required to exacerbate a differential in movement. This can
occur at the splenic hilum resulting in vascular disruption at
the pedicle or at the ligamentous attachments to the kidney
Force and diaphragm. Shear forces in the liver revolve upon the
attachments of the falciform ligament anteriorly and the
Horizontal Deceleration Vertical Deceleration
hepatic veins posteriorly, explaining injuries to the paren-
FIGURE 1-6 Various mechanisms of injury for thoracic aorta chyma in these areas. Another significant injury related to this
injury. In a horizontal deceleration the heart and arch move mechanism is injury to the renal artery. The renal artery is
horizontally away from the descending aorta causing shear strain attached proximally to the abdominal aorta, which is fairly
and tearing at the ligamentum arteriosum. A vertical deceleration
causes caudad movement of the heart, causing a strain at the
immobile secondary to its attachments to the spinal column,
root of the ascending aorta. and distally to the kidney, which has more mobility. A discrep-
ancy in momentum between the two will exact a shear stain on
the renal artery resulting in disruption.55 This same relation to
the spinal column occurs with the pancreas (Fig. 1-8). The
relatively immobile spine and freely mobile pancreatic tail

Falciform Hilum


Shear Strain Hepatic


of Treitz

Initial Load

FIGURE 1-7 Mechanisms of injury for bronchial injury. Terminal

The carina is tethered to the mediastinum and spinal
complex while the lungs are extremely mobile, setting up FIGURE 1-8 Points of shear strain in blunt abdominal trauma. All
shear strain in the mainstem bronchus upon horizontal or of these points occur where a relatively fixed structure is adjacent
vertical deceleration. to a mobile structure.
Kinematics 11

predispose to a differential in momentum between the two in The type and extent of injury is determined by the momen-
a deceleration situation leading to fracture in the neck or body tum and kinetic energy associated with impact, underlying tis-
of the pancreas. The biomechanics of such injuries suggest that sue characteristics, and angle of stress of the extremity.
the bodys tolerance to such forces decreases with a higher High-energy injuries can involve extensive loss of soft tissue,

speed of impact, resulting in an injury of greater magnitude associated neurovascular compromise, and highly comminuted
from a higher velocity collision.29 fracture patterns. Low-energy injuries are often associated with
Perforation of a hollow viscus in blunt abdominal trauma crush or avulsion of soft tissue in association with simple frac-
occurs in approximately 3% of victims.56 The exact cause is a tures. Injuries to soft tissue are usually secondary to compres-

matter of debate. Some believe that it is related to compressive sive strain with crush injury as an example. Tensile and shear
forces, which cause an effective blowout through generation strain mechanisms, however, are present with degloving and
of significant overpressure, whereas others believe that it is avulsion injuries, respectively.
secondary to shear strains. Both explanations are plausible, and Most of that written about musculoskeletal injury involves
clinical observations have supported the respective conclu- fractures of long bones. Although each fracture is probably a
sions. Most injuries to the small bowel occur within 30 cm of consequence of multiple stresses and strains, there are four basic
the ligament of Treitz or the ileocecal valve, supporting the biomechanisms (Fig 1-9). In a lateral load applied to the mid
shear force theory57 (Fig. 1-8). Yet, injuries do occur away from shaft of a long bone, bowing will occur and compressive strain
these points of fixation. Also, experiments have documented occurs in the cortex of the bone where the load is applied. The
that a pseudo-obstruction or temporarily closed loop under cortex on the opposite side of the bone will undergo tensile
a load can develop bursting pressures as described by the over- strain as the bone bows away from the load. Initially, small
pressure theory.58 Clinically, this is confirmed by the largest fractures will occur in the cortex undergoing tensile strain
percentage of small intestinal injuries being of the blowout because bone is weaker under tension than it is under
variety.59 Most likely, both proposed mechanisms are applica-
ble in individual instances. The most common example of the
pseudo-obstruction type is blunt rupture of the duodenum,
Lateral Load Longitudinal Load W/Bowing
where the pylorus and its retroperitoneal location can prevent
adequate escape of gas and resultant high pressures that over-
come wall strength.
Another important example of overpressure is rupture of
the diaphragm. The peritoneal cavity is also subject to Boyles
law, which states that volume of a gas is inversely proportional Compressive Tensile Tensile
to pressure. A large blunt force, such as that related to impact Strain Strain Strain
with the steering wheel, applied to the anterior abdominal wall
will cause a temporary deformation and decrease in the volume
of the peritoneal cavity. This will subsequently raise intra- Load
abdominal pressure. The weakest point of the cavity is the Compressive
diaphragm with the left side being the preferred route of pres-
sure release as the liver absorbs pressure and protects the right Load

hemidiaphragm. The relative deformability of the lung on the

other side of the diaphragm facilitates this. Longitudinal Load Torsional Load

Musculoskeletal Injury
By far, the most common type of blunt injury in industrialized
nations is to the musculoskeletal system. The ratio of orthope-
dic operations to general surgical, thoracic, and neurosurgical
operations is nearly 5:1. As stated earlier, seatbelts and air bags
have significantly decreased the incidence of major intracranial
and abdominal injuries; however, they have not decreased the
Compressive Load
incidence of musculoskeletal trauma. Although these are not Strain
usually fatal injuries, they often require operative repair and
rehabilitation and can leave a significant proportion of patients Load
with permanent disability.60 With the advent of seatbelt laws,
improved restraint systems, and air bags in motor vehicles, the
incidence of lower extremity trauma, in particular, has increased. FIGURE 1-9 Fracture mechanics. A lateral load causing bowing
will create tensile strain in the cortex opposite the force and
It is thought that these patients in the past may have suffered compressive strain in the adjacent cortex. If a longitudinal stress
fatal injuries to the brain or torso and, therefore, their associ- caused bowing a similar strain pattern occurs. If no bowing
ated fractures of the femur, tibia, and fibula were not included occurs the strain is all compressive. A torsion load will cause a
in the overall list of injuries. spiral fracture.
12 Trauma Overview

compression.61 Once the failure point is reached on the far side nerve roots or the spinal cord. Patients typically experience
from the load, the compressive strain increases markedly and neck pain and muscle spasm, although an additional spectrum
the failure point for the side near the applied load is reached, of symptoms has been described.63 The etiology of whiplash
also, resulting in a complete fracture. This mechanism can be probably relates to acceleration and extension injury, with some

seen in passengers in lateral collisions, pedestrians struck by a rotational component in nonrear-impact crashes. Factors
passenger car in the tibia and fibula region, or in the upper related to poor recovery following whiplash injury are a combi-
extremities from direct applied force in victims of assault with nation of sociodemographic, physical, and psychological, and
a blunt instrument. include female gender, low level of education, high initial neck

When a longitudinal load is placed on a long bone, bowing pain, more severe disability, increased levels of somatization,
can also occur, and the compressive and tensile strain patterns and sleep difficulties.64
will be similar to that previously described. If bowing does not
occur, then only a compressive strain is seen and a compression
fracture can occur. In the case of the femur this usually occurs Kinematics in Prevention
distally with the shaft being driven into the condyles. These The ideas of William Haddon have become the cornerstone of
mechanisms can be seen in falls from a height, but are more injury prevention, and approximately a third of his strategies
frequently seen in head-on collisions resulting in fractures of involve altering the interaction of the host and the environ-
the femur or tibia. In these cases deceleration occurs and the ment.65 Understanding forces and patterns of energy transfer
drivers or passengers feet receive a load from the floorboard or have allowed the development of devices to reduce injury. Most
the knee receives a load from the dashboard upon deceleration. of this understanding has been applied to the field of automo-
This causes a longitudinal force to be applied to the tibia or tive safety.
femur, respectively. A torsional load will cause the bone to frac- The first set of design features revolve around the concept of
ture in a spiral pattern. decreasing the force transmitted to the passenger compartment.
This includes the crumple zone, which allows the front and
rear ends of a car to collapse upon impact. The change in
Injury to the Spine and Whiplash momentum the passenger compartment undergoes in a colli-
Injury to the vertebral column and spinal cord can be devas- sion will, therefore, occur over a longer period. Going back to
tating and is frequently the result of a complex combination the impulse and momentum relation, this means less force will
of specific anatomic features and transmitted forces. These be transmitted to the passenger compartment. In terms of
can cause a wide variety of injury patterns distributed through energy, work is done in the crumple zone and energy is
the different portions of the vertebral column. Deceleration expended before reaching the passenger compartment.66 The
forces in motor vehicle crashes, such as impact with the wind- second design feature directs the engine and transmission
shield, steering assembly, and instrument panel, inertial dif- downward and not into the passenger compartment decreasing
ferences in the head and torso, or ejection are responsible for intrusion into the passenger compartment.
both flexion and hyperextension injuries. Although the Passenger restraint systems, which include safety harnesses
biomechanics of transmission of force can be readily and child car seats, keep the passengers velocity equal to that of
demonstrated for the vertebral columns individual compo- the car and prevent the passengers from generating a differential
nents (disks, vertebrae, etc.), a model demonstrating injury in momentum and striking the interior of the car. Also, they
patterns in the intact spinal unit is lacking.36 The cervical more evenly distribute loads applied to the victim across a
spine is most frequently injured in motor vehicle crashes, due greater surface area thus decreasing stress.
to its relatively unprotected position compared to the thoracic Even with restraint systems the occupants of a car can
and lumbar regions. Injuries are related to flexion, extension, develop relative momentum and kinetic energy during a
or lateral rotation, along with tension or compression forces crash. This energy and momentum can be dissipated by air
generated during impact of the head. The direction and bags, which convert it into the work of compressing the gas
degree of loading with impact account for the different injury within the device. The helmets used by cyclists and bicyclists
patterns in trauma to the cervical spine.29 Approximately 65% work on a similar principle in that a compliant helmet absorbs
of injury is related to flexioncompression, about 30% to some of the energy of impact, which is therefore not transmit-
extensioncompression, and 10% to extensiontension inju- ted to the brain. Many studies have demonstrated the benefits
ries.62 Fracture dislocations of the vertebrae are related to of using seatbelts and air bags with mortality reductions rang-
flexion and extension mechanisms, whereas fractures of the ing from 41 to 72% for seatbelts, 63% for air bags, 80% for
facets are related to lateral-bending mechanisms. In contrast both, and 69% for child safety seats.61 Seatbelts and air bags
to trauma to the cervical spine, injury to the thoracic or lum- have also significantly reduced the incidence of injuries to the
bar spine is more likely related to compressive mechanisms. cervical spine, brain, and maxillofacial region by keeping the
The rib cage and sternum likely provide stabilizing forces in forward momentum of the passenger to a minimum and pre-
motor vehicle crashes and lessen the risk of injury in these venting the head from striking the windshield.46 Also worth
regions. mentioning is the headrest that has decreased whiplash-type
Whiplash refers to a pattern of injury seen often in MVCs injury by 70% by preventing a difference in momentum
with a rear-end impact. The injury is usually a musculoliga- between the head and body and hyperextension of the neck in
mentous sprain, but may be combined with injury to cervical rear-end collisions.67
Kinematics 13

Despite their effectiveness, air bags can be responsible for torque and acceleration stress in the higher cervical spine
injury in motor vehicle crashes. Approximately 100 air bag during injury, as well. Young children have high rates of dislo-
related deaths were confirmed by National Highway Traffic cations and spinal cord injury without radiographic abnormal-
Safety Administration (NHTSA) over a 5-year period, many ity (SCIWORA), and these are more likely to be seen at the

associated with improper restraint of small adults or children in upper cervical levels. As older children have a low fulcrum of
front-seat locations. Additionally, a spectrum of minor injuries cervical motion (C5C6) and more ossification and maturity
such as corneal abrasions and facial lacerations have been seen of the vertebral bodies and interspinous ligaments, they have a
in low-speed impacts. Injuries can occur from the use of safety high incidence of fractures in the lower cervical spine.73

belts, as well. Lap seatbelts can cause compressive injuries such SCIWORA is associated with 1525% of all injuries to the
as rupture of the bowel, pelvic fractures, and mesenteric tears cervical spine in pediatrics and represents a transient vertebral
and avulsions. They can also act as a fulcrum for the upper por- displacement and realignment during injury, resulting in dam-
tion of the trunk and be associated with hyperflexion injuries age to the spinal cord without injury to the vertebral column.
such as compression fractures of the lumbar spine. As a conse- Childhood obesity is recognized as a leading public health
quence, newer automobiles are required to have the more exten- issue in the United States. Childhood obesity is defined as an
sive and protective lap and shoulder harness style belts. Even age and sex-specific body mass index at the 95th percentile or
still, shoulder harnesses can cause intimal tears or thrombosis of higher. Based on this definition, 1417% of all children were
the great vessels of the neck and thorax and fracture and disloca- obese from 1999 to 2004.69 When compared to their nonobese
tion of the cervical spine in instances of submarining, where the counterparts, obese children between the ages of 2 and 5 who
victim slides down under the restraint system.68 Even when a are injured in a MVC are at an increased risk for major injuries
shoulder harness system works as intended, clavicular and rib to the brain and chest. Obese children above the age of 5
fractures or perforations of hollow viscera in the abdomen sec- involved in an MVC are at an increased risk for major thoracic
ondary to a compressive-type mechanism can occur.69, 70 and lower extremity injuries in comparison to nonobese chil-
dren of the same age and sex.74
Nothing has reduced the incidence of injury to children and
SPECIAL CONSIDERATIONS infants more than the mandatory use of safety belts and
restraints. The problem still to be faced is the different contours
Pediatrics and shapes with infant restraints. Also, there has been increased
Differences have been noted between adults and children in interest in the issue of pediatric restraint systems because of a
both patterns of injury and physiological responses to injury. In number of injuries related to air bags. It is recommended that
one analysis of adults and children sustaining comparable restrained infants and children not be placed in a front seat and
degrees of injury from blunt trauma, significant differences that all children under age 12 ride in the rear seat. Injuries
were noted in the incidence of thoracic, spinal, and pelvic inju- related to air bags have ranged from minor orthopaedic trauma
ries in children. Although the overall incidence of injury to the to fatal injury to the brain.75
brain is higher in blunt pediatric trauma, thoracic and pelvic Unfortunately, child abuse is a reality in the pediatric
injuries occur less frequently.71 population and must be considered when evaluating a child
Overall mortality is generally higher for adults than it is for who has been injured in less than clear circumstances or has
children sustaining comparable degrees of injury. When assessed multiple injuries of varying ages. Although injury to soft tis-
by mechanism, however, mortality is slightly higher for chil- sue is the most common presentation, fractures follow as a
dren in motor vehicle crashes.72 close second. There is a high rate of spiral fractures of the
The most significant difference between adults and children humerus and femur secondary to a torsional force, applied by
is in the compliance of the bony structures. This difference is an adult grabbing the childs extremity in a twisting motion.
seen commonly in the resilience of the chest wall. The inci- Injury to the brain is the third most common injury, with
dence of rib fractures, flail chest, hemo-pneumothorax, and skull fractures thought to be secondary to direct blows to the
injury to the thoracic aorta in children is significantly less than childs head or the dropping and throwing of the child.
that in adults, though the incidence of pulmonary contusion is Intracranial hemorrhage has been noted in the shaken impact
higher. Because of this resilience, the chest wall can absorb a syndrome and is thought to result from significant accelera-
greater impact in children while demonstrating less external tion and deceleration forces followed by direct force transfer
sign of injury. In children the index of suspicion for a pulmo- with impact. Subdural and subarachnoid hemorrhages can
nary contusion, in the absence of rib fractures, must be higher often result, as blood vessels between the brain and skull are
than in an adult. ruptured. Retinal hemorrhage may also be identified in this
Injury to the spinal cord is rare in children, representing pattern of injury and occurs in approximately 3% of cases.
only 12% of all pediatric trauma. The cervical spine is injured Impact injury to the abdomen is common in child abuse and
in the majority of cases (6080%), compared to 3040% in can result in injury to solid organs (liver, spleen, or kidney),
adult injury. The immature spinal column has incomplete duodenal hematoma (sometimes with delayed symptoms of
ossification, a unique vertebral configuration, and ligamentous intestinal obstruction), pancreatitis, injury to the colon or
laxity, which accounts for this difference in pattern of injury. rectum, or mesenteric bleeding. In addition, falls from even
The proportionally larger head and less developed neck mus- very small heights may cause severe intracranial hemorrhage
culature of younger children (10 years old) account for more in the infant or child.76
14 Trauma Overview

Pregnancy noted an average of 182 annual injuries and 23 annual deaths

Injury to pregnant women in motor vehicle crashes is estimated from explosive incidents in the United States from the period
to account for 1500 to 5000 fetal deaths each year. There has of 2004 to 2006.82
Blast injuries are broadly categorized as primary, secondary,

been little investigation into specific forces and the kinematics

of injury in pregnancy. Several studies have demonstrated that tertiary, quaternary, and quinary, based on a taxonomy of
the most common cause of fetal demise in motor vehicle explosive injuries published by the Department of Defense in
crashes with a viable mother is placental abruption. The biome- 2006.83 The trauma practitioner should be familiar with each of
these patterns of injury and be able to predict associated inju-

chanics of this injury involves generation of tensile and shear

forces, with the circumferential forces in the uterine wall induc- ries from each category (Table 1-2).
ing a shear strain across the placental surface, resulting in pla- Primary blast injuries occur when the blast overpressure
cental strain and subsequent abruption. Shorter women have a transmits forces directly onto a person, causing tissue damage.
higher incidence of fetal demise with automotive crashes The air-filled organs are the most likely affected by a primary
because of their close proximity to the steering wheel. As in blast injury and include the tympanic membrane, lungs, and
other populations, restraints have been demonstrated to increase gastrointestinal tract.84 Primary blast injuries are less common
survival in both mother and fetus.77 in open-space explosions but are increased in situations where
the explosion occurs within a confined space, which allows the
blast wave to reflect off of fixed structures.85 Rupture of the
Geriatrics tympanic membrane is the most common manifestation of
Trauma remains a disease of the young, though there is a sig- primary blast injury, occurring in up to one half of patients
nificant incidence of morbidity and mortality in the elderly injured in an explosion.84 Some have considered an intact tym-
population. Death from trauma represents the fifth leading panic membrane to be a strong negative predictor of severe
cause of mortality in persons over 65 years of age. The most blast injury, although this has proven not to be the case.86, 87
common mechanisms of injury in the elderly are falls, fires, and The orientation of the patient to the blast wave (perpendicular
vehicular trauma. vs. parallel), the presence or absence of cerumen in the ear
When patients with similar injury levels are compared with canal, and whether the patient was wearing hearing protection
respect to age and mortality, the incidence of fatality in older at the time of the blast will all work to alter the true impact of
persons is 5- to 10-fold higher than it is in the younger popula- the blast on the tympanic membrane.84 Therefore, an intact
tion. It is not the severity of injury that is crucial, but rather the tympanic membrane does not rule out blast injury.
incidence of comorbid factors in this population, especially car- The most common fatal injury among blast victims is to the
diac and vascular disease. Most likely it is the patients inability to lung, often referred to as blast lung injury. The blast wave
demonstrate a cardiovascular reserve that is a contributing factor causes tissue disruption at the capillaryalveolar interface,
to their subsequent increased morbidity and mortality. The Injury resulting in pulmonary edema, pneumothorax, parenchymal
Severity Score and other predictors of outcome do not hold up in hemorrhage, and, occasionally, air embolus from alveolovenous
the geriatric or pediatric populations. Another significant finding fistulas.84 Clinical diagnosis of blast lung injury is dependent on
in this population is that most (as many as 88%) of these patients the presence of the triad of hypoxia, respiratory distress, and
never return to their previous level of independence.78 bilateral or central infiltrates on a chest radiograph.88 The infil-
The incidence of falls in the geriatric population is high, trates are usually present on admission and can worsen with
with an annual incidence of approximately 30% in those over aggressive fluid resuscitation. These central infiltrates are also
65, and approximately 50% in those over 80 years of age. Falls referred to as butterfly or batwing infiltrates and are pathog-
account for approximately half the cases of geriatric trauma. nomonic for blast lung injury, in contrast to the peripheral
Most falls in the elderly occur from standing with mortality infiltrates commonly seen with pulmonary contusions from
secondary to the comorbid factors mentioned earlier.79 The blunt injury. Management of the ventilated patient with blast
propensity for fracture is also increased secondary to a loss of lung injury includes avoidance of positive pressure ventilation,
bone density with aging, with hip fractures being one of the minimization of positive-end expiratory pressure (PEEP), and
most common injuries. judicious fluid resuscitation.84 Fluid management in these
patients will often be challenging due to associated injuries from
secondary and tertiary blast effects, which often require greater
amounts of intravenous fluid for adequate resuscitation.
Secondary blast injuries are created by debris from the
Blast injuries are among the most dramatic and devastating explosive device itself or from surrounding environmental par-
wounds encountered by the trauma community. The National ticles. Many devices contain additional munitions consisting of
Counterterrorism Center documented approximately 11,800 nails, pellets, ball bearings, and scrap metal designed to increase
terrorist attacks in 2008, resulting in over 54,000 deaths and the lethality of the explosion. Fragments from the surrounding
injuries.80 Although the number of terrorist incidents decreased environment, including glass and small rocks, can become sec-
from the previous year, overall fatalities had increased.80, 81 ondary missiles, as well. Secondary blast injuries are more com-
The vast majority of these attacks occurred in the Middle and mon than primary blast injuries as the debris and added
Far East, but the United States was not immune from blast fragments travel over a much greater distance than does the
incidents. The Bureau of Alcohol, Tobacco, and Firearms shock wave from the primary blast.89 Lacerations, penetrating
Kinematics 15

TABLE 1-2 Department of Defense Classification of Blast Injuries from Explosive Devices
Classification Definition Common Injuries
Primary Blast overpressure injury (blast wave) Tympanic membrane rupture

Direct tissue damage from the shock wave Blast lung
Air-filled organs at highest risk (ears, lungs, Gastrointestinal tract
gastrointestinal tract) perforation/hemorrhage

Secondary Primary fragmentsfrom the exploding device Lacerations
(either from pieces of the device itself or Penetrating injury
from projectiles placed intentionally into the Significant soft tissue injury (including
device to increase the lethality of the device) traumatic amputations)
Secondary fragmentsfrom the environment Ocular
(glass, small rocks, etc.)
Tertiary Acceleration/deceleration of the body onto Blunt trauma
nearby objects or displacement of large Traumatic amputation
nearby objects onto an individual Crush injury
Quaternary Injuries due to other explosive products Burns
effectsheat, toxidromes from fuel and Inhalation injury
metals, and so on
Quinary Clinical consequences from postdetonation Radiation
environmental contaminants including bacteria, Sepsis
radiation, and tissue reaction to fuels and metals

injury, and significant soft tissue defects are the most common 3. Newton I. Philosophiae Naturalis Principia Mathematica. New York:
Prometheus Books; 1995.
injuries seen from secondary blast injuries. 4. Cutnell J, Johnson K. Physics. 4th ed. New York: John Wiley and Sons;
Tertiary blast injuries are caused by the body being physi- 1997.
cally thrown a distance or from a solid object falling onto a 5. Sears FW, Zemansky MW. University Physics. Reading, MA: Addsion-
Wesley; 1949.
person as a result of the explosion. Most tertiary injuries are 6. Reif F. Statistical Physics. New York: McGraw-Hill; 1967.
from a blunt mechanism, and crush injuries or traumatic 7. Fackler ML, Dougherty PJ. Theodor Kocher and the Scientific Foundation
amputations are not uncommon. Quarternary and quinary of Wound Ballistics. Surg Gynecol Obstet. 1991;172(2):153160.
8. Fackler ML, Malinowski JA. The wound profile: a visual method for
blast injuries have only recently been defined. They are miscel- quantifying gunshot wound components. J Trauma. 1985;25(6):
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due to other mechanisms, such as burns, inhalation injuries, 9. Williams M. Practical Handgun Ballistics. Springfield, IL: Charles C.
Thomas; 1980.
and radiation effects. 10. Hunter J. A Treatise on the Blood, Inflammation and Gunshot Wounds.
Children injured by explosions suffer a different injury pat- London: John Richardson; 1794.
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Penetrating Trauma. Media, PA: Williams & Wilkens; 1996:105.
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wounds. The adolescent injury pattern resembles that of the 250254.
13. Fackler ML. Wound ballistics. A review of common misconceptions.
adult, although they are more likely to have fewer internal inju- JAMA. 1988;259(18):27302736.
ries, more contusions, and have a higher risk of requiring surgi- 14. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE. Bullet
cal intervention for mild or moderate wounds when compared fragmentation: a major cause of tissue disruption. J Trauma. 1984;24(1):
to adults. 15. Swan KG, Swan RC. Gunshot Wounds: Pathophysiology and Management.
Littleton, MA: PSG Publishing; 1980.
16. Fackler ML, Bellamy RF, Malinowski JA. A reconsideration of the
wounding mechanism of very high velocity projectilesimportance of
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Kinematics 17

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treatment. Crit Care Med. Jul 2008;36(7 Suppl):S311317.


Thomas J. Esposito and Karen J. Brasel

From the public health perspective, injury is not considered an health approach applied to injury control seek to modulate
accident but rather a disease, much like malaria, tuberculosis factors related to the host and agent and/or their interactions
and other public health scourges, or cancer and heart disease. within the environment utilizing a number of strategies. These
Injury, like other diseases, has variants such as blunt or strategies encompass engineering, education, the enactment
penetrating. It has degrees of severity, rates of incidence, and enforcement of laws, and economic incentives and
prevalence, and mortality that can differ by race and other disincentives.
sociodemographic factors. Injuries have a pattern of occur- Injuries can result from acute exposure to physical agents
rence related to age, gender, alcohol and other drugs, and such as mechanical energy, heat, electricity, chemicals, and
again, sociodemographic factors, among others. ionizing radiation in amounts or rates above or below the
When public health concepts are applied to this disease of threshold of human tolerance.2 The transfer of mechanical
injury, it, like the aforementioned public health diseases, can be energy accounts for more than three quarters of all injuries.3
controlled to a socially acceptable level. The first step, however, The extent and severity of injury is largely determined by the
is to characterize the disease such that control strategies can be amount of energy outside the threshold of human tolerance.
applied. Epidemiology is the study of patterns of disease occur- Both the exposure to energy and the consequences of that expo-
rence in human populations and the factors that influence these sure are greatly influenced by a variety of factors both within
patterns.1 and beyond individual or societal control.4
Descriptive epidemiology refers to the distribution of dis- The public health approach as it applies to injury was first
ease over time, place, and within or across specific subgroups of conceptualized by William Haddon in the late 1960s.2 He
the population. It is important for understanding the impact developed and promulgated a phase-factor matrix that incorpo-
of injury in a population and identifying opportunities for rated the classic epidemiological framework of host, agent, and
intervention. environment in a time sequence that encompasses three phases:
Analytic epidemiology, in contrast, refers to the more pre-event, event, and post-event. Factors related to the host,
detailed study of the determinants of observed distributions of agent, or environment in the pre-event phase determine
disease in terms of causal factors. The epidemiological frame- whether the event will occur (e.g., motor vehicle crash). Factors
work traditionally identifies these factors as related to the host in the event phase determine whether an injury will occur as a
(i.e., characteristics intrinsic to the person), the agent (physical, result of the event and the degree of injury severity. Factors in
chemical, nutritive, or infectious), and the environment the post-event phase influence the outcome from, or conse-
(i.e., characteristics extrinsic to the individual that influence quences of, any injuries of any severity that do occur.
exposure or susceptibility to the agent). The environment can An example of the Haddon Matrix applied to an actual
be physical or sociocultural. injury event is depicted in Table 2-1. The addition of potential
It is the understanding of how these multiple factors interact control strategies to the matrix in a three-dimensional fashion
to increase the risk of injury and their influence on injury out- results in an injury control cube, suggesting that injury
come that exemplifies the epidemiological approach to the prevention and control are not unidimensional or unifactorial
study of disease and injury. By studying patterns of occurrence and that the greater the number of sections of the cube that
across and within populations of individuals, one can learn how are addressed, the greater the control of the injury event
best to potentially mitigate them. The concepts of the public (Fig. 2-1A). For example, gun control laws focus on only the
Epidemiology 19

TABLE 2-1 Haddon Matrix Conceptually Applied to a Motor Vehicle Crash Incident
Pre-event Event Post-event
Host Avoidance of alcohol use Use of safety belts Care delivered by bystander

Vehicle Antilock brakes Deployment of air bag Assessment of vehicle characteristics
that may have contributed to event
Environment Speed limits Impact-absorbing barriers Access to trauma system

Source: Reproduced with permission from ATLS Course, 8th ed. Chicago, IL: American College of Surgeons.

agent, in the pre-event phase, using a legislative strategy ages 1524 are injury related and more deaths among the
(Fig. 2-1B). However, there are many other counter measures young ages 134 are attributable to injury than all other
that can be applied in other phases and to the host or environ- causes of death in that age group combined. Trends in annual
ment (Table 2-2). The public health approach to injury control rates of death due to the nine leading causes among persons
will be detailed further in Chapter 3. ages 2544 over time are shown in Fig. 2-2.
Specific trends for injuries over the past several decades show
an overall decline in the death rate from unintentional causes
primarily due to advances in traffic and work place safety.
Intentional injuries, particularly those related to firearms, have
Injuries rank fourth as a cause of death for all age groups in fluctuated over the last decade. Homicide deaths are predomi-
this country. It is the leading cause of death among children, nantly responsible for the fluctuations, as suicide deaths have
adolescents, and young adults ages 134 (Table 2-3).5 In remained relatively stable.
2009 nearly 150,000 persons died in the United States as a The societal impact of injury is further emphasized when
result of an injury. This yields an overall death rate of 54.4 comparing the total years of potential life lost before age 65
injury deaths per 100,000 population translating into over across the leading causes of death (Fig. 2-3). Intentional and
400 injury deaths per day with nearly 50 of these being chil- unintentional deaths account for over 30% of the total years of
dren. Approximately 8 of every 10 deaths in young people potential life lost for all deaths occurring in that age range.




Economic Incentives/Disincentives

Host Education
Legislation Enactment/Enforcement
A Pre-event Event Post-event
FIGURE 2-1 (A) Injury control cube graphic depictiongeneral concept.
20 Trauma Overview




Economic Incentives/Disincentives

Host Education
Legislation Enactment/Enforcement
B Pre-event Event Post-event
FIGURE 2-1 (continued) (B) Positioning of gun control laws in the injury control cube model.

Therefore, injuries account for more premature deaths than statistics for 2004. Injuries account for an estimated 6% of all
cancer, heart disease, or HIV infection.5 hospital discharges and 30% of all ED visits annually. Many of
Previously, trauma deaths were characterized as having a these nonfatal injuries have far-reaching consequences with
trimodal distribution.6 However, more recent studies suggest a potential for reduced quality of life and high costs accrued to
bimodal pattern with a reduction in late deaths7,8 The majority the health care system, employers, and society. The estimated
of all deaths still occur within minutes of the injury, either at total lifetime costs associated with both fatal and nonfatal
the scene prior to arrival of emergency medical services (EMS), injuries occurring in any 1 year amount to over 406 billion
en route to the hospital, or in the first hours of care. These dollars9,10 (Table 2-4).
immediate deaths are typically the result of massive hemorrhage The costs associated with injury deaths account for a dispro-
or severe neurological injury. Many fatalities succumb primarily portionate share of total injury costs. Estimates show that
due to central nervous system (CNS) injury within several deaths account for less than 1% of all injuries but account for
hours to several days of the event. Far fewer than in original 31% of total injury costs. The majority, or the remaining 69%
studies now die of infection or multiple organ failure many of costs due to injury, is associated with nonfatal injuries. These
days to weeks after the injury (Fig. 2-4 A and B). costs include direct expenditures for health care and other
Currently, even the best EMS and trauma systems are goods and services purchased as a result of the injury. Direct
largely ineffective in preventing those deaths that occur at the expenditures account for approximately 30% of the total cost
scene of the incident. Efforts at preventing the occurrence of of injury. The value of lost productivity due to temporary and
the injury event or reducing the severity of the injuries permanent disabilities is also taken into account and represents
incurred by the incident will be the most effective means of 41% of the total costs. It is often mentioned that these are
reducing this large number of immediate deaths. Continued merely the financial costs and do not take account the pain and
efforts at developing trauma systems that foster rapid and suffering to the patients, their families and associates that are
efficient means of triage and transfer to higher levels of care, the sequelae of nonfatal injuries.
and efforts at clinical and translational research in the area of
trauma, hemorrhage, and infection will eventually serve to
reduce the delayed and late deaths.
Deaths represent only one small aspect of the injury disease
burden. Each year, over 1.5 million people are hospitalized as Injury is a disease predominantly affecting young males.
the result of an acute injury and survive to discharge. Another Seventy percent of injury deaths and over half of nonfatal
28 million are treated and released from emergency depart- injuries occur among males.3,5,8 In every age group except ages
ments (EDs) or urgent care centers.8 Fig. 2-5 depicts these 09, the rate of injury death for males is more than twice as
TABLE 2-2 The Ten Leading Causes of Death by Age Group and Rank
Age Groups
Rank 1 14 59 1014 1524 2534 3544 4554 5564 65 All Ages
1 Congenital Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Malignant Malignant Heart Heart
Anomalies Injury Injury Injury Injury Injury Injury Neoplasms Neoplasms Disease Disease
5,785 1,588 965 1,229 15,897 14,977 16,931 50,167 103,171 496,095 616,067
2 Short Gestation Congenital Malignant Malignant Homicide Suicide Malignant Heart Heart Malignant Malignant
4,857 Anomalies Neoplasms Neoplasms 5,551 5,278 Neoplasms Disease Disease Neoplasms Neoplasms
546 480 479 13,288 37,434 65,527 389,730 562,875
3 SIDS 2,453 Homicide Congenital Homicide Suicide Homicide Heart Unintentional Chronic Low. Cerebro- Cerebro-
398 Anomalies 213 4,140 4,758 Disease Injury Respiratory vascular vascular
196 11,839 20,315 Disease 115,961 135,952
4 Maternal Malignant Homicide Suicide Malignant Malignant Suicide Liver Disease Unintentional Chronic Low. Chronic Low.
Pregnancy Neoplasms 133 180 Neoplasms Neoplasms 6,722 8,212 Injury Respiratory Respiratory
Comp. 364 1,653 3,463 12,193 Disease Disease
1,769 109,562 127,924
5 Unintentional Heart Heart Congenital Heart Heart HIV Suicide Diabetes Alzheimers Unintentional
Injury Disease Disease Anomalies Disease Disease 3,572 7,778 Mellitus Disease Injury
1,285 173 110 178 1,084 3,223 11,304 73,797 123,706
6 Placenta Cord Influenza & Chronic Low. Heart Congenital HIV Homicide Cerebro- Cerebro- Diabetes Alzheimers
Membranes Pneumonia Respiratory Disease Anomalies 1,091 3,052 vascular vascular Mellitus Disease
1,135 109 Disease 54 131 402 6,385 10,500 51,528 74,632
7 Bacterial Sepsis Septicemia Influenza & Chronic Low. Cerebro- Diabetes Liver Diabetes Liver Influenza & Diabetes
820 78 Pneumonia Respiratory vascular Mellitus Disease Mellitus Disease Pneumonia Mellitus
48 Disease 64 195 610 2,570 5,753 8,004 45,941 71,382
8 Respiratory Perinatal Benign Influenza & Diabetes Cerebro- Cerebro- HIV Suicide Nephritis Influenza &
Distress Period Neoplasms Pneumonia Mellitus vascular vascular 4,156 5,069 38,484 Pneumonia
789 70 41 55 168 505 2,133 52,717
9 Circulatory Benign Cerebro- Cerebro- Influenza & Congenital Diabetes Chronic Low. Nephritis Unintentional Nephritis
System Neoplasms vascular vascular Pneumonia Anomalies Mellitus Respiratory 4,440 Injury 46,448
Disease 59 38 45 163 417 1,984 Disease 4,153 38,292
10 Neonatal Chronic Low. Septicemia Benign Three Liver Septicemia Viral Septicemia Septicemia Septicemia
Hemorrhage Respiratory 36 Neoplasms Tied Disease 910 Hepatitis 4,231 26,362 34,828

597 Disease 57 43 160 384 2,815

Source: From WISQARS. Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
Atlanta, GA: Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System.

22 Trauma Overview

TABLE 2-3 Counter Measures Available for Controlling Firearm-related Injury

Part I-FLCOT-Injury Prevention Part II-FLCOT-Injury Prevention
Countermeasures in Injury Control Countermeasures in Injury Control

Prevent creation of the hazard Interpose material barriers between hazard and host
Ban manufacture of guns/ammunition Bulletproof vest
Reduce amount of hazard Bulletproof glass
Limit manufacture and sale Modify basic qualities of the hazard
Guns buy-back programs Small gauge ammunition
Prevent release of existing hazard Nonfragmenting bullets
Trigger locks Nonlethal chemical ammunition
Storage Lessen effects of hazard after occurrence
Alternative conflict resolution EMS access and care
Modify rate or spatial distribution of hazard release Hospital care
from source Rehabilitation
Lower caliber/velocity
No automatic weapons
Separate host and agent in time or space

high as the rate for females. For nonfatal injuries, males are only ED visits.3,5,8 Hospitalizations and ED visits also follow this
1.3 times as likely as females to be affected. This gender-related pattern of a bimodal peak related to age and a predominance
risk reverses after the age of 65 with females being 1.3 times as among the male gender.
likely as males to suffer nonfatal injury in that age category. The elderly, while being less likely to be injured, are more
The disease of injury has a bimodal distribution of mortality likely to be hospitalized or die from those injuries with a lesser
that peaks for both genders in the 16- to 40-year-old age group degree of severity than their younger counterparts. The rate of
and then again in those older than 65 years of age. Persons injury death among persons age 65 and older is 113/100,000
under the age of 45 account for 53% of all injury fatalities population and for persons age 75 and older it is 169/100,000.
(Fig. 2-6), just over 50% of hospitalizations, and nearly 80% of The elderly are overrepresented in the pool of injury fatalities

Trends in annual rates of death due to the 9 leading causes

among persons 2544 years old, United States, 19872006

Unintentional injury
Deaths per 100,000 population

30 Cancer
Heart disease
25 Homicide
HIV disease
20 Chronic liver disease
15 Stroke


1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Note: For comparison with data for 1999 and later years, data for 19871998 were modified to account for
ICD-10 rules instead of ICD-9 rules.
FIGURE 2-2 Trends in annual rates of death due to the nine leading causes of death in the United States for those age 2544 (19872006).
(From Centers for Disease Control and Prevention, Atlanta, Georgia.)
Epidemiology 23

Years of Potential Life Lost (YPLL) Before Age 65

2007 United States
All Races, Both Sexes
All Deaths

YPLL Percent
of Death

All Causes 11,795,817 100.0%

2,371,575 20.1%
1,858,935 15.8%

Heart Disease 1,395,829 11.8%

Perinatal Period 947,061 8.0%

Suicide 703,199 6.0%

Homicide 605,158 5.1%

491,957 4.2%

Liver Disease 247,188 2.1%

Cerebrovascular 243,667 2.1%

222,303 1.9%

All Others 2,708,945 23.0%

FIGURE 2-3 Comparison of years of potential life lost before age 65 stratified by disease/condition. (From Centers for Disease Control
and Prevention, Atlanta, Georgia.)

and hospitalized patients. Although representing only 3% of The classification system most often used in describing the
the U.S. population, those over the age of 65 accounted for specific mechanism and intent of injury is the international
approximately 26% of all injury deaths and 30% of all injury- classification of disease (ICD). This classification system was
related hospitalizations. The proportion of citizens over the age developed and promulgated by the World Health Organization
of 65 is projected to increase to nearly 20% by the year 2030.11 and is now in its tenth edition.12,13 The E-Code, which is the
This has significant implications for the future of health care as acronym for external cause of injury code, provides detailed
over the next several decades it is expected that the elderly will information about the circumstances associated with injury-
account for approximately 40% of all injury deaths and hospi- related ED visits and hospitalizations. These codes are consid-
talizations. ered essential to the epidemiology of injury and its accurate
study. They provide critical public health information for
monitoring health status, setting injury prevention priorities,
and developing and evaluating injury prevention programs at
the local, state, and national levels. E-Codes are also useful for
Injuries are typically categorized by their mechanism, intent, injury-related quality-of-care assessments (e.g., risk of falls
and place of occurrence. Mechanism refers to the external agent among older persons) in the emergency care, hospital, assisted
or particular activities that were associated with the injury (e.g., living/nursing care, and home health care settings. As an
motor vehicle related, falls, firearm related, etc.). Intent of the example, fall prevention (e.g., reducing fall-related hip frac-
injury is classified as either unintentional (often referred to as tures) is one of the priority areas for quality and patient safety
an accident) or intentional. initiatives relevant to the present-on-admission (POA) Codes
Injuries that are intentionally inflicted can be further subcat- required for billing by the federal government (Center for
egorized into interpersonal (e.g., homicide) or intrapersonal Medicare and Medicaid Services [CMS]).
(e.g., suicide). Intent may not be always determinable. Injuries E-Codes can also be useful for other quality initiatives asso-
resulting from legal interventions and operations of war are ciated with injury-related claims (e.g., motor vehicle crash-
typically classified separately as an other intent category. related injuries) that may assist CMS in making payment
24 Trauma Overview



# of patients
80 80
60 0
<1hr 2hrs 3hrs 4hrs 11%



< 1 hr 1-4 hrs 5-12 hrs 13-24 hrs 25-48 hrs 3-7 days 2nd week 3rd week 4th week 5th week > 5 weeks
Time from injury to death

CNS Exsanguination Other causes




# of patients




< 1 hr 1-4 hrs 5-12 hrs 13-24 hrs 25-48 hrs 3-7 days 2nd week 3rd week 4th week 5th week > 5 weeks
B Time from injury to death
FIGURE 2-4 (A) Temporal distribution of trauma deaths, excluding individuals who were found dead by police. (B) Temporal distribution
of trauma deaths caused by blunt and penetrating injuries, excluding individuals who were found dead by police. (Reproduced with
permission from Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: A reassessment. J Trauma. 1995;38:185.)

decisions. Hence, numerous professional organizations, includ- delineate place of occurrence (e.g., home, street/highway, resi-
ing the American College of Surgeons Committee on Trauma, dential, institution, etc.).
the American College of Emergency Physicians, the Emergency The distribution of injuries by mechanism varies for deaths,
Nurses Association, and the National Safety Counsel, have hospitalizations, and ED visits. The two leading mechanisms of
published position statements to endorse the need for improv- injury death are related to motor vehicles and firearms. Using
ing E-Coding in state mortality and morbidity data systems. 2007 statistics from the Centers for Disease Control and
They have also urged that the capture of at least three codes as Prevention (CDC), it appears there were over 182,000 deaths
part of the electronic health record that is being proposed by caused by injuries.5 Approximately 46,000 of these (25%) were
CMS be essential. Two of the E-Code fields can be used for traffic related with just over 31,000 (17%) related to firearms.
coding the precipitating and immediate causes (e.g., the mech- Another 23,000 (13%) were related to falls. In contrast, using
anism/intent of injury such as falls, motor vehicle traffic, fire/ 2008 statistics, of the nearly 30 million nonfatal injuries
burn, cut/pierce, assault, self-harm, etc.) and one other field to reported to the CDC, approximately 8.5 million (29%) were
Epidemiology 25

Injuries in the United States, 2004

167,184 injury
deaths (7%)
1.9 million hospital

discharges for injury (6%)
31 million initial
emergency department
Deaths 35 million initial visits
visits for injury (32%)
for injury to physician
offices and outpatient
departments (12%)


33 million episodes
of medically-attended Initial physician office
injuries were reported and outpatient
in a national household department visits

FIGURE 2-5 Injuries in the United States, 2004. (From Centers for Disease Control and Prevention, National Center for Health Statistics,
Atlanta, Georgia. Injuries in the United States; 2007 Chartbook, Figure 1.)

related to falls whereas approximately 4 million (14%) were Injury in the workplace also constitutes a not uncommon
traffic-related injuries. Less than 1% of reported nonfatal inju- occurrence. A total of 5,071 fatal work injuries were recorded
ries were related to firearms. When all intents are considered, in the United States in 2008. This represents 3.6 fatal work
burns account for approximately 2% of all injury deaths and injuries per 1,000,000 full-time equivalent workers.14 Overall,
1.4% of nonfatal injuries reported by the CDC.5 transportation-related incidents accounted for the majority
These differences in distribution by cause and class of injury (40%) of occupational injury deaths. Assaults and violent
underscore the lethality of injuries involving firearms and acts accounted for 16% of fatalities, contacts with objects
motor vehicles. Perhaps also emphasizing this point are statis- and equipment 18%, and falls 13%. Ten percent of occupa-
tics on intentionality of injury, which reveal that 93% of non- tional-related deaths in 2008 were a result of homicide, with
fatal injuries are unintentional whereas 68% of fatal injuries are firearm-related fatalities compromising 80% of these homi-
unintentional. cides. Five percent of deaths were a result of self-inflicted
Nearly 30% of all injury deaths are violence related. In injuries.
2007 over 18,000 deaths were a result of homicide (34% of all In addition to the fatalities associated with work-related activi-
violence related deaths) and over 34,000 deaths were caused by ties, there were a total of 4.6 million nonfatal injuries recorded by
successful suicide attempts (66% of all violent deaths). the Bureau of Labor Statistics (3.9 cases per 100 workers).15

TABLE 2-4 Incidence and Cost of Injury in the United States, 2000
Incidence Medical Costs Productivity Losses Total Costs
Fatal 149,075 $1 billion $142 billion $143 billion
Hospitalized 1,869,857 $34 billion $59 billion $92 billion
Nonhospitalized 48,108,166 $45 billion $125 billion $171 billion
Total 50,127,098 $80 billion $326 billion $406 billion

Cost estimates based on 2000 data. Finkelstein et al. (2006)

Source: From the Incidence and Economic Burden of Injuries in the United States. Atlanta, GA: Centers for Disease Control
and Prevention.
26 Trauma Overview

Injury deaths and injury death rates

by age, 20032004
90 350

Injury deaths as percent of total deaths 300

Deaths per 100,000 population


Percent 50

40 150
Injury death rate

0 0
Under 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
1 and
Age in years over
FIGURE 2-6 Injury death and injury death rates by age, 20032004. (From Centers for Disease Control and Prevention, National Center
for Health Statistics, Atlanta, Georgia. Injuries in the United States; 2007 Chartbook, Figure 3.)

Seventy-one percent of these occurred in service providing accounting for 4050% of the total number of deaths. The
industries and nearly half produced disability. second ranking cause tends to be hemorrhage, accounting for
an additional 3035%.
DISTRIBUTION OF INJURIES More recent and reliable data from the CDC confirms that
BY NATURE AND SEVERITY traumatic brain injury (TBI) is a serious public health issue in
America.22 TBI resulting from many mechanisms poses a serious
Cataloging and analyzing the distribution of injuries by their public health problem contributing to a substantial number of
nature and severity is important to efforts at establishing pri- deaths and cases of permanent disability each year. Like other
orities for prevention as well as treatment and trauma system injuries, TBI can range from mild to severe with many of the
development. Several systems for classifying the nature and mild cases going undiagnosed. An estimated 1.7 million TBI-
severity of injury exist and a number of these are described related deaths, hospitalizations, and ED visits occur in the United
elsewhere in this textbook. States each year. As suggested by autopsy studies, TBI is a con-
The international collaborative effort on injury statistics has tributory factor in nearly one third of all injury-related deaths in
published an injury diagnosis matrix that provides a uniform the United States or about 52,000 deaths annually (Fig. 2-7).
framework for using the ICD codes in categorizing injury diag- The distribution of all nonfatal injuries by nature and sever-
nosis by the body region involved and the specific nature of the ity is somewhat different from that described for fatal injuries.
injury.16 The most prevalent source of national data on the Many injuries occurring each year affect isolated body systems
nature of injury death is death certificate data. However, these and are associated with a low severity. Even among injuries that
data have significant limitations due to variations and inaccu- result in hospitalization, only one quarter have an Abbreviated
racy in the diagnosis listed as cause of death, terminology, and Injury Scale (AIS)23 score of 3 or greater on a scale of 06.
reporting practices for injury by geographic region and over Injuries to the lower and upper extremities constitute the
different time periods.17,18 The National Trauma Data Bank leading cause of hospitalizations and ED visits related to non-
(NTDB)19 also provides some insight as to the nature, severity, fatal injury. They account for over half (56%) of all nonfatal
and types of injuries encountered utilizing a nonscientific occurrences and 47% of all injury hospitalizations.8,9 Slightly
sample of trauma centers that voluntarily contribute data to the over one third of hospitalizations for extremity injuries are for
data bank. Some of what is known about the overall nature of moderately severe to severe injuries as measured by an AIS
trauma deaths is based on a limited number of studies con- score of 3 or more.9 For many of these injuries, recovery can
ducted in selected geographic regions using coroners reports be protracted and costly. Even optimal treatment can result
and autopsy records.20,21 These types of records, much like the in permanent impairment and disability.2426
death certificates that are often based upon them, are variable The second ranking cause of nonfatal injury hospitalization
in completeness, accuracy, and utility. Although the results of is head injury, accounting for 1015% of total hospitalizations
autopsy studies vary, they do suggest a trend that implicates for injury.27 Mild head injuries are predominantly treated on
CNS injuries as the most common cause of injury death, an outpatient basis, comprising 25% of all injury-related ED
Epidemiology 27

Injury and Traumatic Brain Injury (TBI)

Death rates, by age group United States, 2006

200 Estimated average percentage of annual TBI
Injury death rate by external cause in the United States, 20022006
TBI death rate
Per 100,000 population



35.2% Struck by/
50 Falls Against











Age group (years) 17.3% Other
Nearly one third of all injury deaths involve TBI. Vehicle-traffic

FIGURE 2-7 Traumatic brain injury death rates in comparison

to overall injury death rates stratified by ageUnited States,
2006. (From Centers for Disease Control and Prevention, Atlanta,
FIGURE 2-8 Estimated average percentage of annual traumatic
brain injury by external causeUnited States, 20022006. (From
Centers for Disease Control and Prevention, Atlanta, Georgia.)
visits.28 Nearly 80% are treated and released. However, these
ED statistics may actually be an underestimate, as many mild
head injuries may be treated at urgent care centers and private
physician offices and therefore not counted in the statistics. areas, whereas homicide rates are several times higher in central
Estimates of the total incidence of head injury vary widely and cities compared to rural and suburban communities (Fig. 2-10).
range between 152 and 367 per 100,000 population.29 Injury death rates also vary by region of the country. Death
Although the majority of head injuries are classified as mild, rates for unintentional injury tend to be highest in the west and
conservative estimates suggest that between 70,000 and south, whereas suicide rates are highest in the west and homi-
90,000 people survive a significant head injury that often cide rates highest in the south. However, there is a substantial
results in long-term disability.30 Head injuries incurred as a state-by-state and even county-by-county variation. To date,
result of recreational activities are also not uncommon.3133 local data relating to nonfatal injuries are not uniformly
Approximately 300,000 such injuries occur annually. The esti-
mated average proportion of annual TBI stratified by external
cause is noted in Fig. 2-8.
Total of all burden, by body region
Spinal cord injuries account for a relatively small propor- 35%
tion of all nonfatal injuries accounting for an estimated 30% Medical costs
10,00015,000 hospitalizations per year.34 Once again, motor 25% Productivity losses
Total costs
vehicles are the major cause of these types of injuries with 20%
3060% being a result of traffic incidents. Falls follow closely 15%
accounting for an additional 2030%. Approximately 510% 10%
of all spinal cord injuries are due to diving. The total burden 5%
of injury stratified by body region is depicted in Fig. 2-9. 0%
I k I n o m m c e
TB nec SC lum Tors xtre xtre spe -wid
/ o n
DISTRIBUTION OF INJURIES ad lc re r e r/u tem
he ra pe owe the s
th e rt
The overall incidence and patterns of injury vary between FIGURE 2-9 Total of all injury burden stratified by body region.
urban and rural populations and across different regions of the (From Centers for Disease Control and Prevention, National Center
country.3,8 Unintentional injury death rates are highest in rural for Health Statistics, Atlanta, Georgia.)
28 Trauma Overview

Injury death rates by level of urbanization,

2003 2004
Large Large Medium Small

Deaths per 100,000 population

50 central fringe metro metro
metro metro

40 Micropolitan Noncore
(nonmetro) (nonmetro)


FIGURE 2-10 Injury death rates
stratified by degree of urbanization. 10
(From Centers for Disease Control and
Prevention, National Center for Health
Statistics, Atlanta, Georgia. Injuries in 0
Unintentional Suicide Homicide
the United States: 2007 Chartbook,
Figure 11.) Intent

available to examine trends by rurality or geographic region. care, mental health, alcohol and other drugs, as well as others.
The observed differences related to geographic location and Due to their number and multiplicity, adequate control for any
population density may be a function of a number of con- or all is difficult at best. Hence, forethought and caution should
founding factors such as access to care, economic, or educa- be exercised in making generalizations regarding some epide-
tional climate, to name a few. When these factors are controlled miological findings.
for, these geographic disparities can be less prominent, or Although on the surface there may appear to be certain
nonexistent. associations between race and injuries, particularly violent inju-
ries, controlling for socioeconomic status, there is little dispar-
ity between races as perpetrators or victims of violence. For
CONFOUNDERS OF INJURY example, homicide rates have been shown to vary significantly
by economic status (Fig. 2-11). Homicide rates for black males
of age 1524 show urban rates to be 96/100,000 population
There are a number of confounding factors that may influence and in nonurban areas only 41/100,000.
results and, more critically, the interpretation and conclusions Therefore, data that are stratified by race and Hispanic
drawn from epidemiological analyses of injury. These include origin must be interpreted carefully. First, the number of
race, ethnicity, culture, socioeconomic status, access to health people in the population that is used as the denominator in the

Deaths per 100,000 population

Black White



< $3,000 $3,000- $4,000- $5,000- $6,000-
FIGURE 2-11 Violence-related deaths
stratified by per capital income and race. Per capita income of area
Epidemiology 29

calculation of the death rate generally comes from U.S. Census the rate for all ages combined. White males age 1524 are at
Bureau estimates and the characteristics of those who died particular risk. For black males in that same age group, traffic-
used in the numerator generally stems from either the funeral related injury death rank second as a cause of death behind
director or the medical examiner. As a result, to the extent that firearm-related injuries. The elderly, age 75 and older, are also

race and Hispanic origin are reported inconsistently by the at relatively high risk for dying from motor vehicle incident-
different data sources generating the numerator and denomi- related injury.
nator, rates may be biased. Second, bias in estimates by race Males are more than twice as likely as females to die from
and ethnicity also can result from undercounting of specific motor vehicle crashes. Males under the age of 45 are also more
populations in the census, thereby potentially producing an likely to be hospitalized as a result of motor vehicle-related
overestimation of death rates. injuries, although the gender differential is not as great as for
Differences in health status by race and Hispanic origin also fatalities. Males and females age 45 and older, in contrast, are
are known to exist and may be explained by factors including equally likely to be hospitalized.
socioeconomic status, health practices, psychosocial stress and Determinants of injury occurrence and severity in a motor
resources, environmental exposures, discrimination, and access vehicle-related incident relate to speed of impact, vehicle crash
to health care.35 As these factors are not routinely collected or worthiness and the use of safety devices and restraints including
controlled for, analysis of injury mortality and morbidity by safety belts, air bags, and helmets. When used, safety belts have
race and ethnicity may lead to incorrect inferences. With spe- been shown to reduce fatalities to front-seat occupants by 45%
cific regard to data on violence, estimates may be misinter- and the risk of moderate-to-critical injury by 50%. Currently,
preted because attention may have been directed to the victim safety belt usage rates in the United States range from 68 to
rather than to the perpetrator, for whom sufficient data are not 98% with a national average of 84% in 2009.41 The additional
routinely collected. The National Violent Death Reporting presence of an air bag in belted drivers provides increased
System (NVDRS)36,37 may improve this particular problem by protection resulting in an estimated 51% reduction in fatality
attempting to acquire data, when possible, on the perpetrator rate.
as well as the victim. Despite some success in reducing the role of alcohol in
Although this chapter emphasizes the concept of injury motor vehicle injuries, it remains a major factor in fatal crashes
being a disease entity in and of itself, data suggest that for a among adolescents and young adults. Approximately 50% of all
significant number of trauma patients, injuries may be an traffic fatalities including the driver, occupant, bicyclist, or
unrecognized symptom of an underlying alcohol or other drug pedestrian have been found to have a blood alcohol concentra-
use problem. Therefore, it may be that injury is actually a tion (BAC) of 0.08 g/dL or greater. The proportion of fatally
comorbidity of the disease that is alcohol and substance use injured drivers with elevated BAC varies with age. For all age
disorder. Nearly 50% of injury deaths are alcohol related. groups, it has slowly declined over time but has remained
Traumatic injury accounts for roughly the same number of unchanged in recent years (Fig. 2-12).
alcohol-related deaths as cirrhosis, hepatitis, pancreatitis, and Also of note is distracted driving. Distracted driving is an
all other medical conditions associated with excessive alcohol increasingly recognized risk factor for traffic-related injuries
use combined. A multicenter study that included data on more and deaths, which may supersede impaired driving as a con-
than 4,000 patients admitted to six trauma centers demonstrated tributor to these injury incidents. The practice of distracted
that 40% had some level of alcohol in their blood upon admis- driving has become a dangerous epidemic on Americas road-
sion,38 when other drug use is included up to 60% of patients ways. In 2009 alone, nearly 5,500 people were killed and over
test positive for one or more intoxicants.3840 Therefore, it is 450,000 more were injured in distracted driving crashes. In
clear that alcohol and substance use must be considered in the that year, 16% of fetal crashes and 20% of crashes resulting in
epidemiology of injury as well as in the equation leading to non-fatal injuries involved reports of distracted driving.41 This
effective injury control. does not include injuries and deaths incurred by distracted
pedestrians and bicyclists.
Distracted driving is not limited to the high profile activity
of texting while driving but also includes other behaviors such
LEADING MECHANISMS OF MAJOR TRAUMA as eating, grooming, reading (including maps and directions),
or watching videos while driving. However, because text mes-
Traffic-related Injuries saging requires visual, manual, and cognitive attention from the
Traffic-related incidents involving motor vehicles are the driver, it is by far the most concerning and risky distraction. It
leading cause of injury death and rank second as a cause of has been reported that one is 23 times more likely to be
nonfatal injury in the United States. It is the leader of all causes involved in a crash while texting and driving.
of death in the 134 age group. There were 44,128 traffic- Legislation to ban texting while driving is currently in place
related deaths in 2007 and over 298,000 hospitalizations in or in process in many states and municipalities. At present,
2008 for these types of injuries. They also accounted for nearly nine states, the District of Columbia, and the US Virgin
5 million ED visits. Islands prohibit all drivers from using handheld cell phones
Adolescents and young adults are at the highest risk for both while driving. Thirty-five states and D.C. ban text messaging
fatal and nonfatal injuries due to motor vehicles. Their rates of for all drivers, with 12 of these laws being enacted in 2010
death, hospitalization, and ED visits are approximately twice alone.
30 Trauma Overview

Fatally injured drivers with BAC of 0.08 percent

or greater, 19822004

2130 years

31 years and over
1620 years


1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
FIGURE 2-12 Fatally Injured Drivers with Blood Alcohol Level 0.08%United States, 19822004. (From Centers for Disease Control and
Prevention, National Center for Health Statistics, Atlanta, Georgia. Injuries in the United States: 2007 Chartbook, Figure 13.)

Firearm-related Injuries 29 billion (78%) were related to productivity losses. In analyz-

In 2007 there were 31,224 intentional and unintentional ing firearm homicides, the firearm used in well over 80% of
gun related deaths in the United States, which equates to cases, where firearm type was known, involved handguns. It is
approximately 86 deaths per day. The overwhelming majority estimated that firearms of some type are present in about 38%
of these deaths are intentional (98%) and related to violence, of all U.S. households and carried by one in 12 students.42,43
with only 2% being unintentional.5 Some studies suggest that those who live in homes that harbor
Firearm-related deaths rank second as a cause of injury death guns are more likely to die from homicide and suicide in the
over all ages in the United States being responsible for 17% of home than are residents of homes without firearms.44,45 There
all injury deaths. More than half (57%) of all firearm deaths is evidence to suggest that few firearm deaths in the home stem
were suicide and an additional 40% were homicides. from acts of self-protection. It is reported that half of those
Firearm-related injuries disproportionately affect males and murdered in the home knew their assailant. Less than 2% of
younger people. Approximately 87% involve males. In the homicides committed with a firearm are judged to be justifi-
1534 age group, firearm-related death rates for males are able, that is, in self-defense. In one survey, results revealed an
nearly seven times that for females. Firearm-related injuries average of just under 110,000 defensive uses of guns each year
are the leading cause of death in black males ages 1534. From compared to approximately 1.3 million crimes committed
a global and cultural standpoint, firearm-related mortality is with a firearm.46
eight times higher in the United States than other high-income With regard to suicide and guns, firearms are the primary
countries in the world. method of suicide in both males and females. Firearms are uti-
The majority of firearm-related deaths among males ages lized in well over 50% of successful suicide attempts. Suicides
1534 in the United States (67%) are homicides. Suicide are five times more likely to be committed in homes that harbor
accounts for an additional 33%. Suicide in the elderly is also a firearms. Ninety-two percent of suicide attempts utilizing fire-
significant problem with 3,895 firearm-related suicides among arms are successful in comparison to only 27% that employ
the elderly between ages 65 and 84 or greater. This represents poisons and 4% involving cutting or stabbing.
22% of all firearm-related injuries for both genders and all
ages. Over 90% of the suicides in the elderly population were Falls
among males. There were 23,443 fatal falls in 2007 and over 8.5 million
Data on nonfatal firearm-related injuries are not as complete; nonfatal injuries that were a result of falls. The overwhelming
however in 2008, there were 78,622 reported nonfatal injuries majority of these were unintentional. Falls represent approxi-
caused by firearms. The majority were again intentional; mately 13% of all injury deaths. Falls account for over one third
however, 17,215 were determined to be unintentional (22%).5 of all injury hospitalizations and one quarter of all injury-
Both fatal and nonfatal firearm injuries are estimated to related visits to the ED.5
account for approximately 9% of the 406 billion dollar overall The greatest occurrence rate is witnessed in the younger and
cost of injury in 2006, or nearly 37 billion dollars.10 Close to older age groups; however, the severity profile in the two groups
8 billion (22%) were related to direct medical costs and over is quite different. In children, falls are common but generally
Epidemiology 31

not severe or fatal. Falls are the leading cause of nonfatal inju- as comprehensive or robust as those on fatal injuries, significant
ries for all children ages 019. Approximately 8,000 children improvement has occurred in recent years relating to the scope
are treated daily in U.S. EDs for fall-related injury.47 This totals and quality of data collection. This has enhanced the under-
almost 2.8 million children each year. Less than 3% of these standing of the magnitude and significance of injury as a major

visits result in hospitalization. Approximately one half of all public health problem.
pediatric falls occur in the home and one quarter occur at Several of these databases provide information on several
school. Falls in children ages 04 years are most commonly types of work-related injuries with a number of others focusing
from furniture or stairs. In older children, falls are commonly on injuries and injury deaths related to other unintentional and
from standing and/or associated with recreational activities intentional injuries. Many are ongoing surveillance systems.
related to playground equipment, bicycling, or sports. This collective group of databases varies in scope and the extent
In adults of working age, most fatal falls are from buildings, to which they provide information on mechanism and intent,
ladders, and scaffolds. Falls on stairs increase in significance nature and severity, risk factors, health services use, costs, and
starting at age 45.3 Gender ratios for injury deaths in adults differ health outcomes. Some are population based and some are not.
by mechanism. ED visit rates for falls are consistently higher for Comprehensive data on fatalities are available from vital statis-
men up to the age of 44. From age 45 and older, this trend tics data, although these data do not provide detailed informa-
reverses and by age 65, ED visit rates and hospitalizations for tion about the extent and nature of injury sustained.
falls in women are nearly three times those in men. This finding Standardized data on nonfatal injuries treated in the ED,
is consistent with the increased fracture risk in women after including those treated and released, transferred, or hospitalized
menopause and, specifically, those with osteoporosis. are available from the National Electronic Injury Surveillance
In the elderly, falls are a significant cause of mortality and SystemAll Injury Program (NEISS-AIP).53 The NEISS-AIP
morbidity being the cause of death in 23% of injury deaths for is a collaborative effort between the National Center for Injury
those 65 and over and 32% of injury deaths in those 85 years Prevention and Control (NCIPC) and the U.S. Consumer
of age and older. The death rate from falls after age 85 is Products Safety Commission (CPSC). This database acquires
over three times that for people age 7584 years old. Falls information on over half a million injury-related ED visits to a
are also the most common cause of nonfatal injury in the nationally representative sample of 66 hospitals on an annual
elderly, accounting for nearly 60% of injury-related ED visits basis. The NEISS-AIR is the most comprehensive database on
and approximately 80% of injury-related hospitalizations for all nonfatal injuries presenting to hospitals with EDs that is
persons age 65 years and older. In the United States, one in five currently available. These data, together with injury mortality
people over the age of 65 will sustain a fall annually. Of these, data, can be accessed through WISQARS (Web-based Injury
about one quarter will be injured and another quarter will Statistics Query and Reporting System), which is an interactive
restrict their daily activities for fear of another fall. Fractures database system supported by the NCIPC.5
occur in approximately 5% of falls. Risk for hip fractures from Injuries that result in hospitalization can also be obtained
falls increases dramatically with age. The elderly over age 85 from both the National Hospital Discharge Survey (NHDS)
are 1015 times as likely to sustain hip fractures as people and the Healthcare Costs and Utilization Project (HCUP-3)54,55
age 6065.48,49 The economic impact of falls in the elderly is Although both these sources can provide detailed information
sizable and estimated to reach nearly 55 billion dollars regarding the nature and severity of injuries, treatment, and
in 2020.50 discharge disposition, they are limited in that codes for classi-
Major risk factors for falls among the elderly include those fying the mechanism and intent of the injury are not routinely
related to the host (advanced age, anticoagulant medications recorded. Although strategies exist for estimating distribution
history of previous falls, hypotension, psychoactive medica- by mechanism and intent given incomplete data, the lack of
tions, dementia, difficulties with postural stability and gait, uniform E-coding of hospital discharges as well as the exclusion
visual disturbances, cognitive and neurological deficits, or other of ED cases that are treated and released remains a significant
physical impairment) and environmental factors (loose rugs impediment to the optimal use of these databases for studying
and loose objects on the floor, ice and slippery surfaces, uneven the entire spectrum of injury epidemiology. Initiatives to rec-
flooring, poor lighting, unstable furniture, absent handrails on tify this situation, as mentioned earlier in this chapter, are
staircases) to name a few. The risk of falling increases linearly currently being undertaken.
with the number of risk factors present, and it has been An additional confounder in the reliability and accuracy of
suggested that falls and some other geriatric syndromes may these essentially administrative databases is the extent, prioriti-
share a set of predisposing factors. All of these factors are poten- zation, and accuracy of ICD coding. Also, it should be pointed
tially modifiable with combinations of environmental, rehabili- out that these are only population based from the standpoint of
tative, psychological, medical, and/or surgical interventions.51 the population of hospitalized patients. They do not capture all
deaths and will not ever include patients with minor injuries
not seeking treatment at hospitals.
Softer and perhaps more subjective data on nonfatal injuries
There are a plethora of data available nationally52 and locally to not resulting in hospital admission or death are available from
define and research injury epidemiology. A number of these the National Health Interview Survey (NHIS),56 The National
data sources have been used in the production of this chapter Ambulatory Care Survey (NAMCS), and the National Hospital
and are referenced. Although data on nonfatal injuries are not Ambulatory Medical Care Survey (NHAMCS).57 The NHIS
32 Trauma Overview

relies on self-reports of injury events, whereas both the NAMCS Two additional phases of trauma care where data have been
and the NHIS rely on data abstracted from injury-related visits lacking are the prehospital phase and the postacute care phase
to hospital EDs, hospital outpatient departments, and/or phy- or rehabilitation. The National Emergency Medical Services
sician offices. These databases do generally include E-codes. Information System (NEMSIS)65 is the national repository that

In addition to these sources of comprehensive data across all is being developed to store prehospital EMS data from every
types and severities of injury, several sources of national data state in the nation. Since the 1970s, the need for EMS informa-
exist that are specific to a particular mechanism or intent. tion systems and databases has been well established, and many
Examples include the Fatal Analysis Reporting System statewide data systems have been created. However, these data-
(FARS),58 the National Automotive Sampling SystemGeneral bases vary significantly in their ability to acquire patient and
Estimates System,59 and the Crash Injury Research and systems data and allow analysis at a local, state, and national
Engineering Network (CIREN).60 Also worthy of note are the level. Currently 26 states contribute to the NEMSIS database,
National Occupant Protection Use Survey (NOPUS), National which is being characterized as the National EMS Registry and
Fire Incident Reporting System (NFIRS), the National utilizing the NEMSIS data dictionary. The registry now
Traumatic Occupational Fatality Surveillance System and the includes over 10 million records for 20082010. An additional
Survey of Occupational Injuries and Illness for Occupational 12 states are close to implementing a statewide EMS data
Injuries, the National Crime Victimization Survey (NCVS) collection system that will allow for contribution this registry.
and the Uniform Crime Reporting System for Intentional There is an increasing impetus due to initiatives from profes-
Injuries (which excludes suicides and self-inflicted injuries),61 as sional organizations and regulatory agencies to have prehospital
well as the American Burn Association Burn Repository.62 run sheets and data systems be NEMSIS compliant, which will
These databases are particularly useful for monitoring injury facilitate submission of consistent and valid data to the national
rates specific to certain mechanisms and for identifying risk database.
factors associated with their occurrence. Information from the postacute phase of care is essential
Less developed are the data systems that deal with violence- to long-term clinical and financial outcome studies. The
related injuries overall and firearm-related injuries in particular. Uniform Data System for Medical Rehabilitation (UDSMR)66
NVDRS37 catalogues violent incidents and deaths, death rates, catalogs data from rehabilitation hospitals nationwide for use
and causes of injury mortality. However, data are only provided in evaluating the effectiveness and efficiency of their rehabilita-
from 16 states and are not nationally representative. There has tion programs. It provides the most comprehensive data avail-
also been some movement toward developing a data collection able on rehabilitation patients across many diagnostic
system similar to that developed for motor vehicle crashes, categories, including injuries. The database includes informa-
which would be an essential component to a nationwide effort tion on demographics, type of injury, length of stay, primary
at reducing the epidemic of violence currently being experi- payor, and postinjury rehabilitation circumstances such as
enced in this country.63 The development of a national violent employment status, living situation and Functional
injury statistics system64 has initially focused on evolving a Independence Measure (FIM), which is the most widely
national reporting system for firearm-related injuries; however, accepted functional assessment measure in use by the rehabili-
it has since expanded to include deaths from all homicides and tation community. The FIM is an 18-item ordinal scale used
suicides, regardless of weapon type. The ongoing efforts to with all diagnoses within a rehabilitation population.67 The
develop this reporting system have focused on collection of USDMR has been used in at least one long-term study of
current data for use in planning and evaluating policies aimed motor vehicle crash outcomes and costs.68
at reducing violent deaths. National data can be used for drawing attention to the
Of particular interest to trauma clinicians and clinical magnitude of the injury problem, for monitoring the impact
researchers are clinical databases. The most noteworthy of of federal legislation, and for examining variations in injury
these is NTDB.19 This database is the largest aggregation of rates by region of the country and by rural versus urban/sub-
U.S. trauma registry clinical data ever assembled. Since its urban environments. They can also be useful in aggregating
inception, nearly 4 million records have been amassed ema- sufficient numbers of cases of a particular type of injury to
nating from over 900 trauma centers of various levels. Despite analyze causal patterns and clinical or other outcomes on an
the robust nature of this database, it only contains data from individual or systems basis.69 Often, however, these national
trauma centers that have voluntarily contributed data. This data are not appropriate for the same or other purposes or for
introduces a notable element of sample bias. Additionally, developing and sustaining injury prevention programs at the
data completeness, accuracy, and validity, have been continu- state and local level. State and local data are more likely to
ous concerns, which have been increasingly ameliorated over reflect injury problems specific to the local area and therefore
time. As a partial solution to these issues, the American more useful in setting priorities and evaluating the impact
College of Surgeons Committee on Trauma, which adminis- of policies and programs in these more limited catchment
trates the NTDB, has instituted the National Sample Program areas. Additionally, local data are typically more persuasive
that specifically seeks more highly controlled data from a than are national data in advocating to establish a policy or to
nationally representative sample of 100 Level I and Level II achieve funding of injury control programs at the local level.
trauma centers in the United States. A number of research Some of the previously described national databases do provide
data sets containing highly scrutinized and reliable data have subsets of data at the state or even county level; however, many
also been created for use by researchers. do not.
Epidemiology 33

Availability, accuracy and completeness of local injury data present an enticing opportunity for facilitating both short- and
varies substantially by state and county. Vital statistics and long-term trauma research and evaluation, it should be noted
death certificate data are generally available for 100% of injury- that linkage for the sake of linkage and analysis for the sake of
related deaths. As previously discussed, however, these data are analysis serves no useful purpose. Appropriate data must be

limited in the information they provide about the nature and turned into relevant information, which is then used to answer
circumstances of the injury, cause of death, and risk factors pertinent questions about injury, epidemiology, treatment,
associated with the death. Medical examiner and coroner cost efficiency, and prevention. Many of these questions can be
reports can be a useful adjunct to death certificate data, but answered adequately, and perhaps more appropriately and
once again, the completeness and quality of these data vary accurately, by analyzing a single database rather than employ-
substantially from state to state. Autopsy rates are equally ing sophisticated schemes of data linkage that are often
variable and are generally biased toward being performed in complicated and costly.
cases of suspected homicide.
State and local data on trauma hospitalizations are generally
available from two principal sources, those being uniform
hospital discharge data including the UB-04 along with its In summary, injury imposes a heavy burden on society in terms
predecessor UB-9270 and hospital or system trauma registries. of both mortality and morbidity along with its sizable eco-
Hospital discharge data are predominantly administrative in nomic burden on the health care system and society. Largely
nature, whereas trauma registry data are primarily clinical. Both unrecognized is the fact that many fatal and nonfatal injuries
types of databases have limitations, which have been alluded to are preventable and controllable using specific strategies guided
previously. Trauma registries suffer from selection bias and gen- by the analysis of injury epidemiology. Hence there is no soci-
erally inconsistent inclusion criteria as well as highly variable etal level of tolerance, or perhaps intolerance, and fear of inci-
data integrity. In both types of databases, ICD coding is not dence as there is for HIV or West Nile virus and H1N1
uniform. Administrative databases in general are not useful in influenza. Yet, these diseases contribute much less to the burden
attempting to analyze clinical issues despite available methods of public health disease than do injuries.
to estimate injury severity using ICD codes.71 Both hospital Risks of injury death vary by age and gender. The majority
discharge databases and trauma registries do not include of injury deaths are unintentional, with elderly people at a
information on trauma deaths that occur at the scene, in particularly high risk of death from unintentional injuries.
transport, or in the ED nor do they routinely include patients Considering intentional injuries, overall, suicide greatly exceeds
treated and released. homicides, but rates again vary by age, gender, and urban or
Specifically, in comparison to hospital discharge data, rural residence. Mechanisms of injury death also vary be age.
trauma registries typically include more detailed information The risk of injury death on the job varies by occupation. From
regarding the cause, nature, and severity of the injury. Some a global perspective, the United States compares less than
trauma registries will also include data on deaths occurring in favorably with other countries in terms of fatal injury,
the ED. Trauma registries, for the most part, collect particularly those related to firearms (Fig 2-13).
information only on major trauma patients, generally The risks of hospitalization for injury vary by age and
excluding those patients who survive but remain in the hospi- gender with elderly women at particularly high risk. Teens and
tal less than 3 days. Again, this leads to sample bias of a small young adults have the highest rates of initial ED visits for
subset of all injured patients in a population. It is important injury with many of these injuries occurring around the
to reemphasize that caution should be exercised in using these home.
databases for describing the epidemiology of trauma as nei- In total, injury deaths declined slightly during the 1985
ther is population based. 2004 period with some variation by intent of injury. Injury
Uniform data on trauma patients treated and released from mortality trends vary considerably by mechanism of injury.
EDs, hospital clinics, and physicians offices are generally less Some causes are on the rise with others declining or remaining
accessible on a county or state level. Other data sources, often essentially unchanged. Injury morbidity rates have demon-
available at the state and local levels that can be useful in study- strated declining trends among all age groups except the elderly.
ing the epidemiology of injury, include routinely collected Although certain assumptions or profiling may arise from the
information from EMS, police, fire departments, poison association of injury and certain mechanisms thereof, a number
control centers and child protective surgery, among others. of confounding factors unrelated to racial origin have been
The utility of existing data at the state and local level can be outlined, which should dissuade broad generalizations that are
significantly enhanced by linking data across multiple data unfounded. Alcohol and other drugs continue to be intimately
sources. Single data sources are often limited in their content associated with all types and mechanisms of injury.
or scope of coverage, or both. Techniques have been developed In conclusion, although significant strides have been made
and are continually being improved to facilitate linkage of in reducing the rate at which injury occurs, trauma remains a
these databases to avoid the high costs of gathering new data.72 major public health issue. More efficient ways of treating
Several states have now linked hospital discharge data, vital injuries as they occur, or tertiary prevention, should and will
statistics, police crash reports, and prehospital run sheet data continue to be the major thrust of clinical care providers and
to examine patterns and outcomes of motor vehicle-related researchers. However, it is equally important that efforts to
crashes.73 Although these linkage strategies and methods develop appropriate programs and policies that will prevent
34 Trauma Overview

Firearm Motor Vehicle Traffic

United States
New Zealand

The Netherlands
0 5 10 15 20 25 30 35 40 45 50 55 60 65
65 60 55 50 45 40 35 30 25 20 15 10 5 0
Deaths per 100,000 population Deaths per 100,000 population

FIGURE 2-13 Firearm and motor vehicle traffic injury death rates, males 1534, 19921995 for selected countries. (Reproduced with
permission from Annest JL, Conn JM, James SP. Inventory of Federal Data Systems in the United States. Atlanta, GA: National Center for
Injury Prevention and Control; 1996.)

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Injury Prevention
Ronald V. Maier and Charles Mock

INTRODUCTION In the following chapter, the historical development of the

scientific approach to prevention is discussed and practical
Trauma has been termed the neglected disease of modern considerations for implementation of prevention efforts and for
society. It is also now the costliest medical problem, with assessment of their effectiveness are reviewed. The chapter will
trauma costs nearly doubling since the mid-1990s.1 Until discuss how these basic principles have been successfully
recently, injuries were considered to be due to accidents, applied to the prevention of both unintentional and intentional
or randomly occurring, unpredictable events. Injuries were thus injuries. Finally, the chapter will conclude with a discussion of
regarded in a fundamentally different manner from other surgeons roles in injury prevention programs.
diseases, which are viewed as having defined and preventable
causes. This viewpoint, on the part of the public, professionals,
and policy makers, induced a nihilistic attitude and severely SCIENTIFIC APPROACH
limited the development of injury prevention efforts. TO PREVENTION OF INJURIES
Trauma, as with any other disease, should be approached
from a scientific vantage point, with delineation of causative Historical Development
factors and with development of preventive strategies targeting of the Science of Injury Prevention
such factors. This scientific approach has been successful in Early attempts at injury prevention were largely based on the
decreasing the toll of mortality and morbidity from most premise that injured individuals had been careless or were
diseases. However, this same organized scientific approach has accident prone. Although this may be true in some circum-
only recently been applied to the prevention of injury.27 stances, the resulting injury prevention strategies, limited to
The importance of injury prevention efforts is pointed out generic admonitions to be careful, were greatly limited in their
by trauma mortality patterns. One-third to one-half of trauma scope and success.7,10 The current foundation for the scientific
deaths still occur in the field,8,9 before any possibility of approach to understanding the causation of injuries and to
treatment even by the most advanced trauma treatment system. developing rational prevention programs was laid by several
Such deaths can only be decreased by prevention efforts. In pioneers.
terms of severely injured persons who survive long enough to One of the earliest developments of the science of injury
be treated by prehospital personnel, very few preventable prevention was the work of Hugh DeHaven in the 1930s1940s.
deaths occur in a modern trauma system with a well-run DeHaven demonstrated that during an injury-producing event
emergency medical system and designated trauma centers. Even such as a crash or a fall, the body could withstand varying
among those who survive to reach the hospital, a significant amounts of kinetic energy depending on how that energy was
portion of in-hospital deaths are directly related to head injuries dissipated. He pointed out the possibility of disconnecting the
and occur despite optimal use of currently available therapy. linkage of accident and the resultant injury.11,12 He
Hence, injury prevention is critical to further significantly provided a biomechanical foundation for subsequent injury
reduce the toll of death caused by trauma. Moreover, prevention prevention work and introduced the concept of injury thresh-
efforts can also decrease the severity of injuries and thus the olds. His groundwork is credited with eventually leading to the
likelihood of disability that arises after trauma. introduction of automotive seatbelts.11,12
Injury Prevention 37

In the 1940s, John E. Gordon introduced the use of epide- A. Pre-Event Phase
miology to the evaluation of injury. He pointed out how, simi- 1. Prevent the creation of the hazard; prevent the
lar to any other disease, injuries occurred with recognizable development of the energy that would lead to a
patterns across time and populations. He also pointed out how, harmful transfer. For example, prevent manufacture of

as with other diseases, injuries were the result of the interaction certain poisons, fireworks, or handguns.
of the host, the agent of injury production, and the environ- 2. Reduce the amount of the hazard. For example, reduce
ment within which they interacted.13 speeds of vehicles.
The most notable of the early pioneers of injury prevention 3. Prevent the release of the hazard that already exists. For

was William Haddon, the first director of the National example, placing a trigger lock on a handgun.
Highway Traffic Safety Administration (NHTSA). Haddon
advanced these early works and developed a systematic B. Event Phase
approach to the evaluation and prevention of injuries. He 4. Modify the rate or spatial distribution of the release
based his approach upon the recognition that virtually all inju- of the hazard from its source. For example, seatbelts,
ries resulted from rapid and uncontrolled transfer of energy airbags.
to the human body. Furthermore, such energy transfers were 5. Separate in time or space the hazard being released
understandable and predictable, and hence preventable. from the people to be protected. For example,
Haddon expanded Gordons ideas on the interaction of the separation of vehicular traffic and pedestrian
three factors of host, agent, and environment into what ulti- walkways.
mately became known as Haddons Matrix (Table 3-1). In this 6. Separate the hazard from the people to be protected
model, each of the three factors influences the likelihood of by a mechanical barrier. For example, protective
injury during each of the three phases: pre-event, event, and helmets.
post-event. In the pre-event phase, each of the three factors 7. Modify the basic structure or quality of the hazard to
influences the likelihood of an injury-producing event, such as reduce the energy load per unit area. For example,
a crash, to occur. During the event phase, they influence the breakaway roadside poles, rounding sharp edges of a
probability that such an event will result in an injury and household table.
determine the severity of that injury. During the post-event 8. Make what is to be protected (both living and
phase, these same components determine what ultimate conse- nonliving) more resistant to damage from the hazard.
quences the injury will have. Table 3-1 gives examples of such For example, fire and earthquake resistant buildings,
interactions.14 prevention of osteoporosis.
Haddon provided a firm basis for the modern approach to
injury control. The principles summarized in his matrix have C. Post-Event Phase
also served as guidelines for the development of prevention 9. Detect and counter the damage already done by the
efforts. He went on to develop 10 strategies to dissociate poten- environmental hazard. For example, emergency
tially injury-producing energy from the host. Most current medical care.
strategies for prevention and control of injuries are conceptually 10. Stabilize, repair, and rehabilitate the damaged object.
derived from these 10 strategies. They are listed below with For example, acute care, reconstructive surgery,
examples. physical therapy.7,10,14

TABLE 3-1 Examples of the Interactions of Phases and Factors Within Haddons Matrix of Injury Etiology
PHASE Human/Host Vector/Vehicle Environment: Social and Physical
PRE-EVENT Driver intoxication Condition of brakes, tires Speed limits
Experience Accessibility of moving parts in Traffic regulations
machinery in factories Societal attitudes and laws on
Window bars at high elevations intoxicated driving
Highway design (road curvature,
intersections, road conditions)
EVENT Use of safety belts Airbags Highway design (guard rails,
Collapsible steering column breakaway poles)
Side impact protection Societal attitudes and laws
regarding seatbelt use
POST-EVENT Age Integrity of fuel system/ Trauma care systems
Physical conditioning fire proof gasoline tanks
38 Trauma Overview

Practical Considerations health practitioners, epidemiologists, psychologists, manufac-

in Injury Prevention Work turers, traffic safety and law enforcement officials, experts in
Almost all prevention efforts can be conceptually derived from biomechanics, educators, and individuals associated with the
media, advertising, and public relations. Health care profession-

Haddons 10 strategies. However, implementing such strategies

in the real world involves a variety of practical considerations. als might include those in primary care, such as pediatricians,
In general, interventions can be thought of as either being and those involved in acute trauma care. Finally, individual
active or passive on the part of the person being protected. members of the public might be involved.15,17
There is frequently the need to organize several groups with

Active interventions involve a behavior change and require

people to perform an act such as putting on a helmet, fastening diverse interests into a coalition focusing on one particular
a seatbelt, or using a trigger lock for a handgun. Passive inter- injury prevention goal. Such groups might include governmen-
ventions require no action on the part of those being protected tal agencies, such as the health department, schools, and trans-
and are built into the design of the agent or the environment, portation department. They might also include academic
such as airbags or separation of vehicle routes and pedestrian institutions, the media, community groups, private founda-
walkways. In general, passive interventions are considered more tions, corporations, and medical associations.1416 Coordination
reliable than active ones.14,15 However, even passive interven- of these diverse groups and interests is an important compo-
tions require an action on the part of some segment of society, nent of the overall prevention program and is often best per-
such as passage of legislation to require certain safety features in formed by having one organization act as a lead agency.7
automobiles. Programs are more likely to be successful when they have
The accomplishment of injury prevention strategies in specific objectives and focus on a few or even just one key inter-
society can be undertaken through three primary modalities: vention. In general, interventions that can be integrated into
(i) legislation and enforcement, (ii) education and behavior existing programs will be more sustainable than will be short-
change, and (iii) engineering and technology. These are often term, temporary programs. When a prevention program
referred to as the three Es. achieves ongoing support and commitment from the agency,
Enforcement and legislation can work at different govern- organization, or community in which it is based, it can be con-
mental levels. For example, national or federal level legislation sidered to be institutionalized.7 Such sustainability is especially
regulates safety features built into the design of motor vehicles. necessary for interventions based on education and behavior
States define what constitutes drunk driving and establish the change.
strictness with which such laws are enforced. Local govern- Funding for injury prevention is frequently a limiting factor,
ments establish safety-related building codes. as these programs are almost always nonprofit endeavors.
Education and behavior change were once the mainstay of However, much can be accomplished by utilizing available com-
injury prevention work. However, if used uncritically and with- munity resources. These can include volunteer labor, publicity
out evaluation, they usually have limited effect.16 Educational from the media in the form of free advertising space or special
efforts need to be delivered in a well-thought-out manner, uti- interest stories, and gifts in kind, such as donations of safety
lizing the techniques of social marketing, to succeed in actually devices from manufacturers. The greater the level of involve-
effecting behavior change. Moreover, educational work is often ment of the community, the greater the availability of such
most effective when coupled with other methods of injury pre- resources. Hence, a key component of many injury prevention
vention, such as informing the public of the risk of being programs is to elicit and sustain the interest of the community.
apprehended and prosecuted under new and more stringent A critical element of injury prevention programs, which is
anti-drunk driving laws. Also, to be most effective, a commit- frequently given inadequate attention, is evaluation of effective-
ted and ongoing program is required. ness. This requires two main activities: evaluation of both the
Engineering and technology address a variety of issues, such process and the outcome. Process evaluation can be regarded, in
as development of safer roadways, more effective safety features part, as quality assurance of the program. For example, are the
for automobiles, and automatic protection for manufacturing various items in a public information campaign progressing at
equipment. the scheduled rate? The main purpose of such evaluation is to
These three main modalities are frequently complementary. provide feedback for modification of the intervention.
For example, seatbelts are a technological development. Con- Most importantly, outcome assessment evaluates possible
vincing people to adopt the behavior of using them requires changes or impact in the incidence of injury. Ideally, outcomes
education and is reinforced through legislation. Convincing leg- would monitor the most severe consequences of injury, namely,
islators to pass seatbelt laws requires lobbying and education.7 fatalities and injuries producing disability. This may not always
In the later sections of this chapter, specific examples of use of be possible, given the limitations of size of the target population
these modalities are discussed. and the influence of other factors influencing injury rates. In
Certain common principles run through many successful these circumstances, measurement of proxy outcomes can be
injury prevention programs. These include a multidisciplinary suitable, if carefully chosen. These are outcomes that are more
approach, community involvement, and should involve ongo- frequent and hence more easily measurable, but that are less
ing evaluation of both the process and outcome of the program. important and represent less tangible benefit than the more
Depending on the targeted injury type, a program might important outcomes. However, they should reflect or initiate a
involve contributions from health care professionals, public change ultimately in the more serious outcomes. For example,
a program to promote bicycle helmet use would reasonably
Injury Prevention 39

start by measuring changes in the percentage of bicycle riders are usually straightforward. For example, an individuals right
wearing a helmet rather than changes in head injuries or deaths. to drink and then drive is easily deprived in favor of protecting
Such a program would be more likely to demonstrate changes in other members of society from the potential harm of such an
the proxy measure, helmet use, in a shorter period or in a action. Similarly, laws mandating use of restraint seats for chil-

smaller population, whereas serious head injuries and deaths are dren in automobiles may be viewed as an infringement on the
more likely to change only over longer periods. Using such rights of their parents to choose how they wish to treat their
measurable outcomes are critical to document the success of children. However, the vulnerable state of children and the
a program and hence to increase or sustain community buy-in precedent of protecting them from potentially harmful acts of

and support. their parents is well established and such laws, once passed,
Injury outcomes can be thought of as a hierarchy, with the have easily stood.
highest level being fatalities. These are the most desirable to The difficult issues in injury prevention arise with laws to
prevent, but the hardest in which to reliably evaluate changes, protect against injuries in which the potential victims are pri-
due to their relatively infrequent occurrence. The lower levels of marily harming themselves. One of the best examples of this is
the outcome hierarchy are the easiest in which to assess change, mandatory motorcycle helmet laws. Such laws have been
especially in small-scale projects. However, the lower levels have opposed by motorcycle groups, who feel that they are only risk-
the disadvantage of being less directly and less definitely associ- ing their own safety by riding without a helmet. Proponents of
ated with ultimate decreases in the more serious outcomes. The helmet laws have generally pointed to the societal costs of treat-
list below indicates this hierarchy from most desirable, but ment of severely head-injured motorcyclists as the rationale as
more difficult to assess, to less important, but more easily to why the issue affects society as a whole.18 Courts have con-
measured: sistently backed the latter view, as best summed up in the case
of Simon v Sargent in Massachusetts:
1. Injury fatalities
2. Injury admissions From the moment of the injury, society picks the person
3. Injury cases treated as outpatients up off the highway; delivers him to a municipal hospital
4. All injury cases and municipal doctors; provides him with unemploy-
5. Direct observation of behavior or the physical environment ment compensation, if after recovery, he cannot replace
6. Measures of self-reported behavior his lost job and, if the injury causes permanent disability,
7. Measures of knowledge, attitudes, beliefs, or intentions may assume the responsibility for his and his familys
continued subsistence. We do not understand the state of
Factors that influence the choice of outcome to measure mind that permits the plaintiff to think that only he
include size of project, size of population to be studied, specific himself is concerned.19
intervention planned, and funding available. Larger programs
should focus on more important and tangible outcomes such as Ethical issues related to injury prevention will continue to
injury fatalities and injury admissions. However, these are not evolve. Most activities in life require some degree of risk taking.
usually possible for smaller programs. Moreover, if smaller pro- Societal norms and legal standards as to what represents accept-
grams are implementing an intervention that has had proven able risk taking are continually shifting. As these values change
success in other areas or in similar circumstances, then changes and as injury prevention strategies evolve, which might call
in behavior or attitudes regarding this intervention may suffice upon legislation for mandatory compliance, new ethical issues
to prove success. will continue to arise.
Whichever outcome is chosen, it is important to build
outcome assessment into the design of the prevention program. Political Issues
In this way baseline measurements can be obtained, which will Even when scientifically proven and cost-effective, the accep-
subsequently enable comparisons before and after an intervention tance by society and government of safety measures to prevent
and comparisons of groups with and without an intervention. important causes of injury are often blocked by a variety of
Such outcome assessment is useful for identifying strategies political issues.3,20 In some cases, there is resistance to behavior
that have been successful and hence are worth promulgating on change on the part of a specific segment of society. For example,
a wider scale. Outcome assessment is also useful for identifying motorcycle helmet laws are frequently challenged by motorcy-
those strategies that are not working and hence should be cle groups. Besides ethical issues, the actual alternating legisla-
changed or discontinued. tive enactment and repeal of state motorcycle helmet laws have
been due to political pressures from motorcycle groups on one
Ethical Issues hand and safety advocates on the other.3
In circumstances where educational efforts seek to increase In other cases, however, safety measures have been specifi-
voluntary compliance with safety measures, ethical issues in cally blocked by the active efforts of special interests that would
injury prevention are minimal. Ethical issues usually arise with stand to loose financially. For example, one of the major
laws mandating compliance with safety practices. These issues advances in automotive safety in recent decades has been the
typically involve the balancing of an individuals personal rights enactment of the Federal Motor Vehicle Safety Standards
with the overall good of society. In circumstances where an (FMVSS). These have been estimated to have saved 10,000
individuals actions adversely affect others, the ethical questions 20,000 lives per year since their initial enactment in the
40 Trauma Overview

1960s.3,2123 Despite their effectiveness, efforts to promote such STRATEGIES TO PREVENT

safety advances are often hindered by lobbying from the UNINTENTIONAL INJURIES
automobile industry or opposition from anti-regulatory
minded members of the government.3,24 The remaining portions of this chapter will demonstrate how

Another example of political opposition involves efforts to Haddons principles of injury causation and his strategies for
legislate mandatory setting of hot water heater temperatures at prevention, as well as three main modalities for implementation
120125F. As will be described later, this is a tremendously (legislation, education, and technology), can be utilized in
effective strategy to prevent scald burns in young children. programs directed at specific types of both unintentional and

Initial work on such regulation was carried out at the state level. intentional injury.
Despite the obvious low-cost and significant benefits of such
laws, they were frequently opposed. As one particular example,
the legislative fight to pass a 120F water heater temperature Motor Vehicle and Transportation
bill in Wisconsin has been well documented.20 This bill was Several well-established groups have been working in motor
opposed by legislators who considered it to be anti-business. vehiclerelated safety, including NHTSA, the Centers for
Although a state level bill, it was lobbied against by national Disease Control and Prevention (CDC), state and local high-
interests, such as the Gas Appliance Manufacturers Association, way departments, as well as various injury prevention coali-
as representing too much government interference in their tions. Progress in road safety has been made along multiple
business. Such opposition was eventually overcome by lobbying avenues, as indicated by the examples given in Table 3-1. Some
from several groups, including the State Medical Association of those warranting special discussion are detailed below.
and the state chapter of the American Academy of Pediatrics
(AAP), and by a public letter writing campaign.
Unfortunately, many other examples are also common. Safety-related Vehicle Design
Among these is the opposition to efforts to promote respon- and Occupant Protection
sible alcohol advertising on the part of alcohol manufacturers Much has been accomplished to make motor vehicles safer.
and retailers.20 One of the more extreme examples is the vehe- This includes engineering features that make it less likely for a
ment opposition to efforts to any limit on availability of vehicle to crash. This is referred to as crash avoidance and takes
firearms by the National Rifle Association and its allies in the into account such features as brakes, headlights, triple brake-
gun manufacturing industry. Such groups have opposed even lights, and signals. Automotive safety also includes engineering
efforts such as closing the gun-show loophole, which has features that make occupant injury less likely in the event of a
allowed convicted criminals to continue to purchase guns. crash. This is referred to as crashworthiness and takes into
In addition to specific injury prevention issues, addressing account such features as collapsible steering columns, shatter
deeper issues in our society is pertinent in protecting the health proof glass, and improved side impact protection. These
of the public from injury-related death and disability. Virtually improvements have resulted from both improved car design on
every form of injury is more common in the lower socioeco- the part of the automobile manufacturers and regulations from
nomic strata of society. The inequities that produce this situa- NHTSA, in the form of FMVSS.
tion need to be confronted as well. This has been well stated by One of the greatest advances in automotive safety was the
Christoffel and Gallagher in their book, Injury Prevention and realization that a significant component of the injuries sus-
Public Health: Truly effective injury prevention interventions tained in crashes were due to ejections and to secondary
challenge the structural underpinnings of the status quo. collision of the occupant with the vehicle interior after the
Effective injury prevention means things like worker participa- vehicle had collided with another object. This understanding
tion in production decisions, community involvement in land led to the development of seatbelts to allow occupants to ride
use policy, equitable distribution of risk These are dangerous down the crash, dissipating their kinetic energy more slowly
ideas; they challenge unbridled free-market competition. Yet and in a controlled fashion.
they are necessary for long-term, meaningful advances in injury However, this accomplishment of engineering is an active
prevention.3 intervention, requiring the occupant to decide to put on the
These deep-seated political challenges indicate the need for belt each time they begin a new journey. Hence, convincing
those who wish to promote injury prevention to develop skills people to use seatbelts remains a major injury prevention
in advocacy and lobbying. This includes becoming proficient at challenge. Even though the addition of airbags has enhanced
efforts such as testifying before legislatures, pushing behind the safety and is a completely passive intervention, concomitant use
scenes as individuals or through organizations such as professional of seatbelts is required to optimize their benefit and avoid air-
societies, publicly countering unproven or nonevidence-based bag-related injuries. Efforts to increase belt usage include both
arguments used by safety opponents (such as motor cycle hel- education and legislation. Legislation includes mandatory
mets increase the risk of crashes), and by working to mobilize seatbelt laws. Although some form of such a law has been
public support for safety-related measures. Simultaneously, this passed in most states, only 27 states have laws allowing primary
challenge places the burden on the injury prevention community enforcement. Belt usage in the United States remains incom-
to develop scientific, evidence-based proposals that can plete, at 84% overall, including 88% in those states with pri-
withstand the appropriate public scrutiny before imposing mary enforcement and 77% in states with secondary
legislative constraints on selected components of society. enforcement of seatbelt laws.25
Injury Prevention 41

A particular subset of restraint use that warrants special As a consequence, the nation sustained a rise in motor
attention is that of infant and child car seats and booster seats. vehiclerelated deaths in the early and mid-1990s.25
These are necessitated by the fact that infants and children do
not fit into adult-size seatbelts and hence such seatbelts do not

provide adequate protection for these age groups. The need for Alcohol
infant car seats was recognized many years ago. These are required Another of the major risk factors for motor vehicle crashes is
by legislation in all states. These laws require infant/child alcohol-impaired driving. Risk of a crash increases dramatically
harness seats that are appropriate for children ages 04 years. with increasing blood alcohol concentration (BAC). The risk of

These have played a major part in decreasing occupant deaths a crash increases 5-fold at a BAC of 80 mg/dL; 7-fold at a BAC
for children ages 04 years from 682 deaths nationwide in of 100 mg/dL; and 25-fold at 150 mg/dL.7,35 On weekend
1994 to 261 deaths in 2006.26,27 nights, when a large percentage of severe crashes occur, 2% of
The need for booster seats for children ages 49 years (under all drivers are legally intoxicated. Drunk driving is associated
4 ft 9 in.) has been more recently recognized. The need for currently with 32% of all fatal crashes in the United States.36,37
these arises from the fact that adult seatbelts rarely fit children In light of these dramatic facts, anti-drunk driving efforts
of this age group. The shoulder belt portion typically lies over have been a cornerstone of road safety efforts in the United
the face, leading children to place it behind their backs. States and most other developed nations. These have employed
Likewise, the lap belt portion rides high, over the abdomen. both educational and legislative approaches.38 A great many
These factors have been associated with intra-abdominal and anti-drunk driving educational campaigns have been under-
spinal injuries, known as seatbelt syndrome.28 Such factors have taken by diverse groups such as NHTSA, state agencies, and
contributed to the minimal declines in occupant death rates for citizen groups such as Mothers Against Drunk Driving. Many
children of this age group. of these have targeted younger drivers, who are at especially
Booster seats raise the child into a position where the high risk for drunk driving.7
shoulder belt fits more properly over the chest and shoulder In terms of legislation, all states have adopted per se laws, in
and where the lap belt is properly positioned low, across the which any driver with an alcohol level above a specified level is
pelvis. Booster seats reduce severe injuries to child occu- considered impaired, regardless of any witnessed driving infrac-
pants.29 The recognition of the importance of booster seats tions. This legal limit has now been decreased to 80 mg/dL in
has led an increasing number of states to pass booster seat all states. Likewise, many states have moved toward zero
laws. tolerance laws for underage drivers.25
However, legislation must be linked to enforcement because
Helmets any law is only as good as its enforcement. Drunk-driving laws
are enforced to extremely varying degrees in different jurisdic-
Occupant protection is obviously difficult to engineer for
tions. Random sobriety checkpoints and administrative license
motorcycles and bicycles due to the exposed position of the
suspension are just two methods to increase enforcement
riders. However, head injuries are the primary cause of death
effectiveness and should strongly be considered.7
and prolonged disability for crashes involving both types of
Another avenue to pursue in the fight against drunk driving
vehicles.5,6 Helmets have been shown to decrease the probabil-
is identification of injured, alcohol-impaired drivers following
ity of a head injury during crashes, to decrease the severity of
hospital admission. There is a documented high rate of recidi-
head injuries when they occur, and to decrease the probability
vism among intoxicated trauma patients in general, and not
of death in both bicycle and motorcycle crashes.3034 As with
only among drunk drivers. Hence, identification and appropriate
seatbelts, helmets are an active intervention and the challenge
treatment of injured persons with alcohol abuse problems is a
has been to get riders to wear them. Programs to accomplish
means toward decreasing the level of alcohol-related injury
this have involved both education and legislation. The two case
from all causes.5,6,39,40
studies at the end of this section of the chapter detail examples
Blood alcohol screening on admission, accompanied by brief
of each approach.
questioning, such as the Short Michigan Alcohol Screening Test,
Michigan Alcohol Screening Test, or CAGE, can detect patients
Speed Limits at a high risk for alcohol-related injury recidivism. The CAGE
In the precrash, environmental segment of Haddons questionnaire consists of four basic questions: Have you every
Matrix, two factors that stand out are roadway design and tried to Cut down on your drinking? Are you Annoyed when
traffic regulations, including speed limits. Safety aspects of people complain about your drinking? Do you ever feel Guilty
roadway design have been greatly advanced by such fea- about your drinking? Do you ever drink Eye-Openers?5,6,39,40
tures as greater use of limited access highways, which have Referring these patients for counseling or even engaging in
eliminated the risk of head-on collisions and decreased very brief interventions by trained professionals in the hospital
intersection-related conflicts. One of the most important is a potentially effective way of getting these patients to
safety-related traffic regulations has been the speed limit. decrease their alcohol intake. In a prospective, randomized,
The nationwide 55 MPH speed limit contributed signifi- controlled trial of screening and brief intervention (SBI)
cantly to lowering the motor vehicle crash fatality rate. The among admitted trauma patients, it was found that patients
move toward higher speed limits can be considered a soci- who had undergone this brief counseling demonstrated a long-
etal sacrifice to directly appease personal freedom demands. term (1 year) decrease in their alcohol intake. This group
42 Trauma Overview

reduced their alcohol intake by more than 20 drinks per week rated as fair, marginal, or poor, indicating that much work
compared to only 7 per week in patients not undergoing such still needs to be done.42
brief counseling. In addition, there was a 43% reduction in
new injuries in treated individual compared to controls.41 Brief

interventions generally entail one or more counseling sessions, Distracted Driving

adding up to less than 1 hour. These have been shown to be The rapidly growing use of cellphones has brought the subject
effective in the context of acute injury hospitalization for all of distracted driving to the forefront of road safety. Distracted
except the most severely impaired patients. The reader is driving is one of several forms of driver inattention and can be

directed to the cited references for more details on brief defined as occurring when a drivers attention is diverted away
intervention counseling methods.3941 from driving by a secondary task that requires focusing on an
The effectiveness and importance of alcohol SBI has recently object, event, or person not related to the driving task.44
led the American College of Surgeons Committee on Trauma Various forms of distraction include conversations with
(ACSCOT) to add a requirement that SBI programs must be passengers, eating, smoking, reaching for objects inside the
present to its list of requirements for trauma center verification vehicle, manipulating controls, and cellphone use.44
for Level I and II trauma centers. CMS has recognized the Such distracted driving, in general, is a significant contribu-
merit of intervention programs and created a specific billing tor to crash causation. NHTSA estimates that 10.5% of crash-
code to enable reimbursement. involved drivers were distracted at the time of their crash
involvement44 and that, in 2008, there were 5,870 deaths in
crashes in which at least one form of driver distraction was
Graduated Drivers Licensing Systems reported on the police crash report.45 Given the difficulties in
A particularly high-risk group for crashes is new adolescent knowing whether distraction was occurring or contributing to
(1617-year-old) drivers. Rates of crashes and crash-related a crash, these figures are likely underestimates.
death are higher than for older drivers due to having less Use of cellphones while driving has been shown in driving
experience and skill coupled with more risk-taking behavior. simulator studies to result in driving performance degradation,
Drivers ages 1620 have an annual rate of involvement in fatal slowed response times (including braking), and reduced aware-
crashes of 44/100,000 licensed drivers, compared with ness of other traffic.44,46 Studies have consistently shown an
24/100,000 for the general public.25 increase of approximately 4-fold (i.e., 400% increase) in risk of
One particularly effective method to decrease the crash rate a crash compared to baseline.44,46,47 This increased risk becomes
in this age group has been graduated driver licensing (GDL). especially problematic, given the widespread and growing use
Details vary from state to state and between countries; how- of cellphones, both in the USA and globally. Observational
ever, several common features include (1) new adolescent studies show 16% of drivers using cellphones at any given
drivers first obtain a learners permit that allows them to drive time while driving.46
only while supervised by a licensed adult; (2) a provisional Furthermore, use of hands-free units does not appear to
license is next obtained that allows new adolescent drivers to eliminate the risk. Some studies indicating no change in risk
drive unsupervised only under restricted conditions, such as and others decreased risk, but not to baseline. This is likely
only during certain times of day (usually not late at night), because drivers are still at risk due to the diversion of attention
and with restrictions on the numbers and ages of passengers away from driving caused by the conversation itself.44,46,47
(e.g., with only limited numbers of other adolescents). In an attempt to confront this problem, several states have
Progression from one stage to the next and to a full license can adopted laws prohibiting use of cellphones while driving. As of
only occur after specified minimum time periods and is con- 2010, 7 states had bans on handheld cellphones, 21 states had
tingent upon the absence of traffic violations or at-fault bans on text messaging while driving, and 24 had bans on teen
crashes.42 drivers use of cellphones.48 In general, these laws lead to 50%
GDL programs have been shown to be effective in decreasing reductions in cellphone use after they become effective.
rates of crashes and crash-related death among new adolescent However, long-term effectiveness appears weaker.46 For exam-
drivers. For example, after institution of a GDL system for ple, a law in New York state in 2001 (the first such law in the
16-year-old drivers in North Carolina, rates of fatal crashes USA) resulted in a decrease in the percentage of drivers using
involving 16-year-old drivers declined by 57%, from 5 to handheld mobile phones from 2.3% before the law to 1.1%
2/10,000 population per year.43 one month after the law became effective, at which time there
As of 2010, all states and several other countries have had been considerable publicity and enforcement. However,
adopted GDL. However, only 35 such states have achieved a after 1 year the percentage of drivers using handheld mobile
rating of good according to the scale developed by the phones had risen back to 2.1%.46,49 Thus, as with many other
Insurance Institute for Highway Safety, which takes into road safety and injury prevention laws, there is a need for ongo-
account the toughness of the restrictions and the length of the ing social marketing and law enforcement for the safety effect
period after the 16th birthday for which these restrictions of the law to be realized. Furthermore, there are no data at this
apply. Factors in this rating include the hour at which night- time confirming that such laws have an effect in lowering rates
time restrictions apply, the number of adolescent passengers of crashes or injuries.46
that are allowed, and the age at which a full license may be There is considerable need for research on this topic.
obtained, among other criteria. The other states have been Priorities include better definition of the extent of the problem,
Injury Prevention 43

especially the contribution of cellphone use and other types of cigarette-related fires, has been worked on by (a) educating
distracted driving to the number of crashes and crash deaths. people about the dangers of smoking in bed and (b) laws that
There is especially a need to understand the effect of require mattresses to be made with less flammable materials.7
interventions, such as laws and methods for their enforcement, Unfortunately, the most effective measure, manufacture of

as well as new, potential, technological solutions such as meth- self-extinguishing cigarettes, has been effectively blocked by
ods to block mobile use while driving similar to the use of the industry, even though the technology exists.20
interlocks to prevent alcohol-impaired driving or speed gover-
nors to automatically limit vehicle speed. There is also a need Scalds

to approach the use of cellphones within the broader context of
Young children, ages 04 years, account for half of scald injuries.51
other sources of driver distraction.46
The leading cause is hot water, especially hot tap water used for
bathing. A typical scenario is a child being bathed and the faucet
Residential Safety: Burns being turned on too hot, either unintentionally by a child playing
Improved residential safety encompasses poisoning, suffoca- with the knobs or by an adult not realizing how hot the water is.
tion, drowning, falls, and burns. In the United States, burns Thus, a major prevention focus is lowering the temperature
are the fourth leading cause of injury-related mortality. in hot water heaters. Hot water heaters can heat water as high as
There are three major causes of death and injury due to burns. 160F (71C), which can produce a first-degree burn in 1 second
House fires account for 75% of burn deaths, but only 4% of of exposure, and more severe burns with longer periods of
burn admissions, due to their high case fatality rate. Many exposure. However, temperatures of 125F (52C) require three
of these deaths from fires are actually due to smoke inhala- or more minutes of exposure to produce burns. Hence, essentially
tion.5,6,50 Scalds from hot liquids and burns from clothing igni- all scald burns due to tap water can be prevented by keeping
tion each account for only about 3% of burn deaths, but these the temperature in hot water heaters to 125F or less.7,51
mechanisms account for a large percentage of burn admissions Reduction in thermostat settings is the engineering aspect.
(scalds29%; clothing10%).51 Hence, burn prevention To achieve this, injury prevention groups have been educat-
efforts have been oriented toward these three most common ing parents of the dangers of high temperatures for hot water
causes. heaters and the importance of lowering the thermostat on
the heater. Liquid crystal thermometers have been made spe-
House Fires cifically for the purpose of checking the temperature at the
faucet. As regards legislation, many states have introduced
Most house fire deaths occur because of entrapment in burning
laws that require manufacturers to preset their hot water
buildings. In many cases, people do not know their building is
heaters at 120125F (4952C). These scald prevention
on fire until it is too late to escape or to call the fire department.
efforts have been very effective. Between the 1960s and the
Many injuries and deaths could be prevented if people knew
1980s, scald-related deaths have decreased by over half for all
earlier that a fire had started and had time to escape. Therefore,
age groups and by 75% for children.7,51
a key component to injury prevention for house fires is the early
warning system provided by smoke detectors.
Smoke detectors are an extremely effective injury prevention Clothing Ignition
tool. They have been found to lower the potential for death in The second leading cause of burn-related admissions is ignition
86% of fires.7 This is an example of the use of engineering of clothing. This may happen from contact with stoves, electri-
in injury prevention. However, the tool is of no value if people cal heating units (space heaters), cigarettes, matches, or other
do not use it. Use of smoke detectors has been promulgated by sources. The two major groups in whom these occur are young
both education and legislation. Educational campaigns have children, who do not realize the dangers, and the elderly, in
been run on a regular basis by local fire departments and whom reaction time is slowed.
nonprofit groups, such as the Northwest Burn Foundation in One of the most notable examples of burn prevention
Seattle. These activities educate people about the importance of efforts is in this field. Most of the clothing ignition burns to
having a smoke detector in their home and the need to change children occurred from sleepwear, which was formerly made of
the batteries every 612 months. In addition, most states have easily flammable fabrics. In the 1970s, the Childrens Sleepwear
laws that require placement of smoke detectors in all new build- Standard law required childrens sleepwear to be made of less
ings. These measures have been extremely effective. The flammable materials and required that any new sleepwear prod-
percentage of homes having smoke detectors rose from 5% in ucts pass a flame test before being allowed in the market. These
1970 to 67% in 1982. Primarily based on increased use of measures have resulted in a dramatic decrease in childhood
smoke detectors, fire-related deaths in the United States clothing related burns to the point where burns related strictly
decreased by 20% between the 1970s and the 1980s.7,51 to clothing ignition are very rare. However, a major problem
Other efforts to prevent deaths due to house fires have remains in clothing ignition burns among the elderly, which
attempted to attack root causes.52 Most house fires arise from currently account for over 75% of clothing ignition burns.
(1) faulty heating equipment, especially in lower-income Likewise, clothing industry lobbyists have had some recent suc-
housing, and (2) ignition of mattresses or upholstered furni- cess in loosening some of the sleepwear standards for children,
ture from cigarettes. The first has been addressed primarily thus indicating that vigilance and continued advocacy are
through legislation regarding housing codes. The second, required even after safety-related laws are passed.7,51
44 Trauma Overview

Two Contrasting Case Studies: The program focused on elementary school-aged children as
Helmet Promotion these were felt to be most amenable to changes in behavior.
These two case studies address a similar issue, the use of protec- Increasing parental awareness was primarily undertaken via the
mass media. Air time was donated as a gift in kind from local

tive helmets: in one case for bicycle riders and in the other for
motorcycle riders. Both affect the crash phase and human radio and television stations for public service announcements
factor of Haddons Matrix (i.e., decreasing the likelihood of about bicycle helmets. The media provided reports by the Level
injury once an injury-producing event has occurred). In addi- I trauma center at Harborview Medical Center to publicize, as
human interest stories, head injuries to unhelmeted children

tion, both involve the same concepts of Haddons 10 principles

of prevention, namely, separation of the hazard from the people bicyclists. Families of bicycle crash victims were asked if their
to be protected by a mechanical barrier. This particular strategy childs case could be publicized on behalf of the helmet
has been shown to decrease the severity of head injuries in campaign. Compliance was usually high with these requests.
victims of both bicycle and motorcycle crashes.3034 From an The pediatricians and surgeons caring for these children played
implementation viewpoint, use of helmets for bicyclists and a key role in identifying their cases for publicity and also acted
motorcyclists is an active intervention, requiring the rider to as spokespersons for helmets in the subsequent news stories.
put on a helmet, voluntarily and repetitively, each time he or The trauma registry at Harborview Medical Center provided
she performs the act of riding. The challenge in both circum- up to date statistics on bicycle trauma, which were popular with
stances has been to increase compliance with this behavior. reporters and news broadcasters.
However, due to selective social circumstances and pressures in In addition to the direct mass media approach, articles on
the populations to be protected, very different modalities of bicycle helmets appeared in the newsletters of the Washington
implementation have been required. State PTA and the Boy Scouts. Similar articles, directed at
health care providers, also appeared in the newsletters of the
Washington State Medical Association and the state chapter of
the AAP. Such items stressed the importance of injury preven-
The Seattle Bicycle Helmet Campaign tion counseling in general and, in particular, about bicycle
The Seattle bicycle helmet campaign has been considered a helmets, in primary care practices involving children. Through
model program in health promotion and injury prevention. It the state medical association, informational pamphlets were
utilized a multidimensional approach, emphasizing a broad- provided to physicians to distribute to their patients.
based community coalition building and focusing on young At the start of the campaign, helmets were primarily sold at
elementary school-aged children. The initial step consisted of specialty bicycle shops catering to adults and retailed for
a background survey of schoolchildren and their parents, $4060. Few stores that sold childrens bicycles also sold hel-
undertaken to assess the current knowledge, attitudes, and mets. A partnership was developed between the helmet coali-
practices regarding bicycle helmets. Over 1,000 elementary tion and Mountain Safety Research, a Seattle-based helmet
school-aged children and their parents were surveyed. Only manufacturer. This company mass produced and marketed
12% of children who had bicycles reported that they used helmets for children under a different label for $2025. In
helmets when they rode. Among the large majority of children exchange, retailers of bicycles who were involved with the
who did not use helmets, three main barriers to helmet use coalition, agreed to attach hang tags on childrens bicycles
were identified. (1) Parents were largely unaware of the danger they sold to promote helmets. Large chain stores that sold
of head injuries to bicycle riders and were also unaware of the childrens bicycles were convinced to also provide helmets at
effectiveness of helmets in preventing such injuries. (2) The reduced costs. The retail outlets likewise received public
price of helmets at the time was $4060 and was considered commendation and hence publicity from the state chapter of
too high. (3) Children were reluctant to wear helmets as most the AAP. In addition, helmets were made available through the
other children did not do so and hence wearing a helmet PTA. Other cost-lowering activities included distribution of
would result in them being viewed as nerds.53,54 These discount coupons through physicians offices, schools, and
barriers subsequently became the main targets of the bicycle youth and community groups. Other helmet manufacturers
helmet campaign. eventually became involved in the campaign.
After this background survey, the Harborview Injury To promote helmet use among school-aged children, bicycle
Prevention and Research Center (HIPRC) elicited the support safety programs were conducted in Seattle public elementary
and involvement of a number of organizations in forming a schools. These included posters, assemblies, and endorsements
coalition to promote helmet use. This coalition relied on use of by local sports figures. Outside of school, bicycle rodeos and
volunteer labor and gifts in kind. Members of this coalition rallies were put on in city parks and other public sites, hosted
included the Cascade Bicycle Club, local and state health by radio stations, and the Cascade Bicycle Club. At these
departments, the Washington State Medical Association, the bicycling events, rewards were given to children wearing
Parent Teachers Association (PTA), local television and radio helmets, including coupons for free French fries and free tickets
stations, local sports figures, manufacturers of bicycle helmets, to Seattle Mariner baseball games.5456
and Group Health Cooperative, the states largest health main- This campaign has been held annually since 1986 with most
tenance organization. The HIPRC acted as the lead agency intensive activities from April to September each year.5456 The
in the program and coordinated the activities of the other direct monetary costs of the program were primarily for
coalition members.5456 printing and mailing. The only full-time personnel was a health
Injury Prevention 45

educator for years two and three of the campaign. A public mortality rate for admitted bicyclists also decreased from 7% in
relations specialist was employed on a part-time basis for the 19861990 to 3% in 19911993.57
most intensive periods of the campaign, during the riding
season. Otherwise, the bulk of activities of the campaign were

provided for by in-kind donations of services.55 Washington State Motorcycle Helmet Law
A key element in the program was assessment, both of the In contrast to the bicycle helmet campaign, efforts to improve
process of the campaign and of its outcome. Process factors that use of helmets by motorcyclists in Washington State have
were followed included (i) number of discount coupons distrib- emphasized legislation. Mandatory motorcycle helmet laws

uted and percentage redeemed; and (ii) number of helmets sold. have been the subject of nationwide debate. During the 1960s
During the first 2 years of the campaign, 109,450 discount and 1970s many states enacted such legislation, primarily due
coupons were distributed, of which 4.7% were redeemed, a to the threat of the withholding of federal highway funds.
figure that is deemed very high by standards of product promo- In 1976, Congress withdrew the U.S. Department of
tion. Discount coupons distributed at the bicycle rodeos and Transportations authority to withhold highway funds based on
fairs were especially productive, with an 8.7% redemption rate. individual states helmet laws. Many states, including
Seattle area bicycle helmet sales also rose dramatically during Washington, repealed their mandatory motorcycle helmet laws,
the early years of the campaign, from 1500 in 1986 to 20,000 primarily due to lobbying by motorcyclists groups. Increases in
in 1988.55 motorcycle related deaths and severe head injuries were noted
In terms of assessment of outcome, death or major neuro- nationwide.7,18
logical disability related to bicycle crashes would be the most In Washington State, attempts were made to reinstitute a
important to decrease. Given the proven efficacy of helmets at motorcycle helmet law during the 1980s. Such efforts were
preventing severe head injuries and death in bicycle crashes it defeated twice in the legislature. A third and final lobbying
was felt that a change in helmet use behavior would be a reason- effort by proponents of the helmet law utilized not only
able surrogate measure of the programs effectiveness.5456 information on the terrible human consequences of preventable
Observations on randomly chosen bicyclists were carried out motorcycle-related head trauma but also data on the financial
throughout the Seattle area, utilizing a formal epidemiological cost of these injuries. These data showed that not only does
sampling strategy. To fully assess the effectiveness of the helmet helmet use decrease the incidence of severe head injury by more
campaign, such observations were carried out before the initia- than 50% but also that the average cost ($15,592) of an
tion of the public information campaign. Moreover, as a con- admission for motorcycle-related trauma was increased
trol for general societal trends in helmet use, similar observations dramatically by the presence of a severe head injury ($46,936),
were carried out simultaneously in Portland, Oregon, a city with even more costs accruing for subsequent rehabilitative and
without a helmet promotion campaign at the time.54,56 These custodial care of those with these severe head injuries.58 Of
observations were carried out on 8,860 Seattle area bicycle rid- special interest to the state legislature was the fact that 63% of
ers from 1987 to 1993. During the first 2 years of the program, the costs of treatment for motorcycle-related injuries were
the percentage of helmeted riders rose from 5% in 1987 to borne by general public funds, primarily state Medicaid.59 In
16% in 1988, during which time the helmet use rates in part, because of these data showing the stake of taxpayers and
Portland remained below 3%54 Helmet use rates in Seattle the state budget in the motorcycle helmet debate, the
continued to rise to 62% in 1993.57 Washington State Legislature passed a law the following year
This helmet promotion campaign has continued for the past requiring helmets for all motorcycle drivers and passengers,
15 years, becoming partially institutionalized in that effective June 7, 1990. Follow-up of the results of the reinstitu-
pamphlets and other educational materials are available on a tion of the motorcycle helmet law has re-established the efficacy
regular basis from the state medical association; helmets are of this law. Among victims of motorcycle crashes admitted to
now a routine item for sale at stores that sell childrens bicycles; the states Level I trauma center, the proportion of those
free helmets are available for all children on public assistance sustaining severe (AIS 4 or 5) head injuries declined from 20%
through the state welfare office; and many pediatricians and before enactment of the helmet law to 9% afterward. The
family practitioners routinely work injury prevention and mortality rate declined from 10% to 6%.57
bicycle helmet promotion into their counseling of families. In These case studies point out several important principles
turn, over the years of the program, the programs success at about injury prevention efforts. First, they show the need for
decreasing the more serious sequelae of bicycle crashes has multidisciplinary collaboration and point out the important
materialized. In a study of the population enrolled in the states role that surgeons and other clinicians caring for injured
largest health maintenance organization, Group Health patients can play in both education and advocacy work.
Cooperative, it was found that from 1987 to 1992, medically Second, they show the importance of considering the political
treated (admitted or emergency room) bicycle-related head and cultural environment in which the prevention effort is
injuries decreased by 72% among 5- to 9-year-olds and by 78% occurring. Parents were more than ready to listen to messages
among 10- to 14-year-olds.56 Likewise, at the states only Level about the safety of their children, when those messages were
I trauma center, at Harborview Medical Center, among patients properly delivered. Although many motorcyclists were utilizing
admitted for bicycle crashes, the proportion of patients with helmets without a mandatory law, those who were not using
severe head injuries (Abbreviated Injury Scale [AIS] for head of helmets have been unlikely to appreciably respond to educational
4 or 5) declined from 29% in 1986 to 11% in 1993. The efforts, hence the need for legislation.23 Advocacy for passage of
46 Trauma Overview

this legislation was aided by publicizing information on the advocacy for passage of mandatory seatbelt laws with provi-
public costs of motorcycle trauma at a time when fiscal conser- sions for primary enforcement in all states; further promotion
vatism was a priority. Third, these efforts each focused on one of helmets for motorcyclists and bicyclists; and increased occu-
key injury prevention strategy, rather than a wide array of pational safety especially in the highest risk professions of min-

activities, such as promotion of safe riding habits by riders ing, construction, logging, and transportation.
of both types of vehicles. Although such efforts might be useful
and should be promoted, intensive efforts, as in the helmet
campaigns, are more likely to succeed when focused on a simple

message.55 Fourth, outcome assessment was a key component,

especially of the bicycle campaign. Outcomes that were feasible Organized injury prevention efforts do not have as long a
to measure and that would reliably indicate the success of the history for intentional injuries as it does for unintentional
campaign were chosen (e.g., change in behavior of wearing injuries. Prevention of intentional injuries has traditionally
helmets). Assessment of this outcome was built into the design been the realm of the criminal justice system, with health care
of the campaign, both in before-and-after comparisons and in professionals and injury prevention personnel being relative
comparisons with a control community. Finally, both efforts newcomers. However, the same basic principles of injury etiol-
were accomplished largely with a minimum of funding and in ogy apply. Likewise, prevention work can be based on the
the case of the bicycle campaign with a generous input of development of strategies to identify and decrease risk factors.
volunteer labor. These strategies can use the same modalities of engineering,
education, and enforcement to accomplish change in society.
Some of the prevention efforts that have been utilized
Nationwide Effectiveness of Prevention against some of the more common forms of intentional injury
Efforts Aimed at Unintentional Injury will be reviewed briefly. Fatal intentional injury is commonly
Other examples of successful prevention programs aimed at categorized as either homicide or suicide. However, it is impor-
unintentional injuries abound, so do examples of the comple- tant to remember that homicide is a final common pathway for
mentary use of the three primary injury prevention modalities. several types of violent behavior, each of which produces many
These have been applied particularly well to traffic-related more nonfatal injuries. These include domestic violence, child
trauma. On a nationwide scale, this is especially well seen with abuse, elder abuse, and assaultive behavior in general. Prevention
promotion of restraints. The technological advancements, first strategies for each of these are fairly different and examples will
of seatbelts and then the development of child safety seats and be considered separately.
airbags have been complemented by promotion and education
and by advocacy for legislation. Increased awareness of the
importance of seatbelts has enabled passage of mandatory safety Assaultive Behavior
seats for children under 4 years old in all states and of A minority of interpersonal violence occurs between strangers.
mandatory seatbelt laws for all occupants in many states.7,25 The majority occurs between people who know each other and
The field of traffic-related injury prevention has also been occurs in the course of interpersonal relationships, which have
advanced by other means, including vehicle design, highway evolved into conflicts. Hence, a focus for violence prevention
design, lower speed limits, increased minimum legal drinking has been to promote nonviolent conflict resolution. The
age, and increased public awareness about and increased teaching and promotion of conflict resolution skills has been
enforcement of laws against driving while intoxicated. Similar undertaken within two broad categories of programs: school
advancements have been recorded in other types of uninten- based and community based.7,6164
tional injuries such as occupational injuries, residential injuries,
and burn prevention. School-based Programs
These advances in prevention, coupled with advances in These usually involve an educational curricula aimed at chang-
trauma treatment, have reduced the death rate for uninten- ing students attitudes toward violence and teaching adaptive
tional injuries to some of the lowest rates recorded since interpersonal skills for nonviolent conflict resolution. Several
statistics were first collected in the early part of the past standardized curricula are available, oriented for a variety of
century.51 The accomplishments have been especially notable in grades, from primary through high school. These curricula have
the last two decades. During the 1980s and 1990s, the rate of been shown to change students attitudes toward violence and
death due to unintentional injury declined by 19%, from 42.8 to decrease interpersonal aggression in the short term. However,
deaths/100,000/year (1981) to 34.9/100,000/year (2000). their long-term effectiveness at decreasing assaultive behavior is
Obviously, there is still much to do. In fact, there has been not known.7
some erosion of gains in the past few years, with rates increasing An example of one such curriculum is Second Step: A
from the nadir of 34.9 deaths/100,000/year in 2000 to Violence Prevention Curriculum, Grades 13. The curriculum
39.8/100,000/year in 2006.26,60 consists of 30, half-hour lessons. Each lesson involves the pre-
Priorities for future work in the prevention of unintentional sentation of a social scenario, with an accompanying photo-
injuries include decreasing public acceptance of driving while graph. This scenario forms the basis for discussion and role
intoxicated, especially among younger drivers; increasing use playing by the students. Teachers who participate are usually
of seatbelts both through educational efforts and through given a 2-day training session. The lessons are arranged in three
Injury Prevention 47

groups: (1) empathy training, (2) impulse control, and partner violence. The vast majority of such abuse involves a
(3) anger management. man injuring his female partner.
In a study to evaluate the effectiveness of this curriculum, This is often regarded as a separate entity because of the
12 elementary schools in King County, Washington State, were interpersonal dynamics involved and the associated prevention

randomized to have the curriculum taught or to be a control. implications. Domestic violence usually is a chronic, repetitive
Observers rated specific childrens interactions with other chil- phenomenon. It is usually associated with psychological abuse
dren and with teachers using a standardized social science and verbal intimidation. It is usually characterized by a man
behavior coding system. These observers were blinded as to who seeks to dominate his partner both physically and

whether or not a given school or specific children had received emotionally and by a woman who is afraid to leave the relation-
the curriculum. There was a decrease in physical aggression and ship because of psychological and/or financial dependency. The
an increase in neutral/prosocial behavior in the group receiving more extreme forms of domestic violence, including homicide,
the curriculum compared with the control group. This was true are usually the endpoints of long abusive relationships.7,66,67 It
at both 2 weeks and at 6 months after the course was taught. is the identification of domestic violence at its earlier stages
These changes were significant at both time periods, but less upon which most preventive strategies are built.
pronounced at 6 months. The ultimate effect on violent behav- For years, the mainstay of domestic violence prevention has
ior in adolescence and adulthood remains unknown.63 been the criminal justice system. This has included both active
interventions, such as restraining orders against abusive men,
Community-based Programs and deterrence by threat of punishment. None of the other
These programs focus on decreasing youth violence outside of newer interventions are likely to work unless such a system is
the school environment. This has the advantage of reaching functional. However, as traditionally used, the criminal justice
older adolescents and dropouts. Some community-based system is underutilized primarily because many women
programs utilize conflict resolution education, similar to are afraid to step forward and file complaints.
school-based programs. Such education is delivered by public Hence, other modalities have been deemed necessary. These
education campaigns and via neighborhood health centers. In have included the use of hot lines, counseling services, and
some cases, high-risk youths, such as those seen in emergency shelters for battered women. Another component of prevention
rooms for assaultive injuries, are identified and referred for has included early identification of battered women through
violence prevention counseling.65 the health care system. This has included identification in the
Some community-based programs are parts of more general setting of both emergency departments and primary care
youth development programs, featuring mentoring, as well as practices. Although many battered women may not volunteer
recreational and cultural activities. These include some tradi- information as to a history of battering, many are willing to
tional approaches that have been active for years, such as the divulge the information when asked. Hence, questioning about
Boys Club. Such programs seek to decrease violent behavior as domestic violence is critical for screening and identification.
part of decreasing overall delinquency and drug dependency. Both the American Medical Association and the American
An example of a successful community-based program is the College of Emergency Physicians strongly recommend routine
Harlem Hospital Injury Prevention Program (HHIPP). This screening for domestic violence.6669 Specific programs aimed at
program, founded in 1988, sought to decrease childhood inju- domestic violence have included programs to improve training
ries from all causes, including violence. The program used a of health care workers (including doctors, nurses, and recep-
broad multidimensional approach, including educational tionists) in such screening for domestic violence. This includes
programs on health and safety; increased environmental safety techniques for eliciting confidential information from victims,
in parks and playgrounds; and increased availability of super- for establishing severity and risk, and for presenting options for
vised recreational activities for children and adolescents. The safety and counseling. Such programs have been documented
program was community based, with the HHIPP acting as the to improve screening and case identification of abused
lead agency in building a coalition, which included neighbor- women.7,66,67,70
hood organizations and agencies of the local and state In addition, further work is needed to identify the most
government.61,62 effective interventions, once a woman at risk for repeated
The results of these activities were evaluated using the domestic violence has been identified. The same rigor that has
Northern Manhattan Injury Surveillance System. The inci- been applied to outcome assessments for unintentional injury
dence of all injuries targeted by the HHIPP decreased by 44% needs to be applied for intentional injury. This implies a fur-
after the institution of the program. Violent injuries decreased thering of scientific inquiry into domestic violence and other
by 50%, in comparison to control communities, where such forms of intentional injury. As one example of such evaluation,
violent injuries increased by 93% during the study period.61,62 Holt et al. demonstrated that year-long restraining orders were
more likely to lead to a decrease in subsequent acts of violence
against women than short-term orders.71
Domestic Violence
Although a large proportion of all violent acts involve persons
living in the same household, a specific subset of such violence Suicide
warrants special attention. This is violence involving spouses or High-risk groups for suicide include adolescents and young
other intimate partners and hence is often know as intimate adults in all races, but especially Native Americans. Unlike
48 Trauma Overview

other forms of intentional injury however, one of the highest way to commit suicide may not lead to choosing another
risk groups is older white men.51 A common problem with alternative, but rather to a decision not to complete the act.7,78
suicide prevention efforts is the relative lack of evaluation of One of the best examples of the effects of decreasing the
their effectiveness. In part, this has been due to a difficulty in availability of the means of suicide was in England. Prior to the

monitoring suicides due to underreporting. Also, the sporadic 1960s, half of the persons committing suicide in England used
nature of actual suicides mandates very large sample sizes in cooking gas to asphyxiate themselves. At the time, cooking gas
order to assess effectiveness. Thus, a variety of different preven- was coal-based and consisted of 1020% carbon monoxide.
tion strategies have been utilized. During the 1960s and 1970s, this was replaced by natural gas,

both for safety and for economic reasons. The overall suicide
rate in Britain decreased by 35% in the years after the gas
Identification and Treatment of supply had changed.79,80 This example has obvious implications
Individuals at High Risk of Suicide for the United States, where the majority of suicides are
Such identification has most often been done within the health committed with firearms.
care system, especially in emergency departments and primary
care practices. Patients who present to an emergency depart-
ment having just made an unsuccessful suicide attempt are The Roles of Alcohol and Firearms
obviously one high-risk group to identify. Identifying patients As can be seen, there are a variety of interventions to decrease
with depression or other warning signs of impending suicide specific types of intentional injury, based on the human, psy-
within the context of a primary care practice, however, is much chological, and interpersonal factors at play. However, there are
more difficult.72 several common risk factors for all forms of intentional injury.
In addition to a history of prior suicide attempt, studies These are the high frequency of involvement of alcohol and
have shown several risk factors for future attempts, including firearms. Between 3060% of all homicides involve alcohol on
alcohol or substance abuse and mental illness, especially affec- the part of at least either the assailant or victim.7 Alcohol
tive disorders.73 However, none of these factors is sufficiently involvement in suicides also appears frequent, although the
sensitive or specific to be a good screening test in and of itself. exact percentages are more difficult to identify. Similarly, fire-
Special efforts to upgrade the training of primary care provid- arms are used in 60% of suicides and 70% of homicides.57,51
ers to improve recognition of these risk factors and to increase Strategies to decrease the availability or impact of alcohol in
their familiarity with treatment for these disorders has shown society are also ways to decrease alcohols involvement in inten-
some promise in improving the detection and treatment of tional injuries. Such strategies include institution of a 21-year-
high-risk individuals.7477 old drinking age, higher alcohol excise taxes, and increased
availability of alcohol rehabilitation services. Hospital- and
Education Programs trauma center-based counseling interventions aimed at patients
Aimed at General Public who present with any type of alcohol-related injury are another
strategy to consider, as discussed in the section on uninten-
These have most notably been utilized in school-based set-
tional injury.3941
tings. The goals of such programs are to educate teachers,
Likewise, strategies to decrease the availability or impact
students, and parents about warning signs of impending
of firearms are ways to decrease intentional injuries in gen-
suicide attempts and to provide them with information about
eral. However, probably no other aspect of injury prevention
available resources for help.7,78
engenders a greater debate than this issue. Firearms are more
common in American society than in almost any other devel-
Crisis Intervention Services oped country. The United States has higher rates of firearm-
Accessible self-referral resources for suicidal persons have related injury than any other developed country that is not at
included hot lines and personal counseling. In addition to the war. Attempts to decrease the availability of firearms have
services they directly provide, these also function as an entry met with sustained, emotional resistance from Americans
point into the mental health system. Such crisis intervention who consider unrestricted ownership of firearms a constitu-
services have been the most frequently utilized suicide preven- tionally guaranteed right.
tion strategies. However, their impact on lowering the suicide However, it is important to recognize that communities
incidence rate has not been well demonstrated.7,78 with differing gun laws causing resultant differences in the
prevalence of gun ownership also demonstrate decreases in
homicide rates in those communities with more restrictive gun
Reducing the Availability control laws.81 Data on the effects of the institution of more
of the Means of Suicide restrictive gun ownership laws in a given area over time are less
Reducing access to the means of suicide can be considered on clear cut. However, the weight of the evidence does indicate a
both an individual and a societal level. It might seem that net reduction in firearm-related deaths from such laws.5,6,82,83
someone who wishes to commit suicide would find alternative The CDC recommends a greater use of restrictive licensing
means. However, most cases of suicide involve complex psycho- for firearms, especially for handguns. Such gun control laws
logical processes in which both ambivalence and spontaneity restrict possession of handguns to those with a clearly demon-
play major roles. Elimination of a convenient and acceptable strated need. The CDC also recommends greater enforcement
Injury Prevention 49

of existing firearms laws, such as requiring waiting periods and that the health sector brings by its focus on changing
background checks for those wishing to purchase guns.7 In the behavioral, social, and environmental factors that give rise
addition, another matter requiring attention is closing the to violence. Health also brings its focus on prevention, its
current gun-show sales loophole. scientific outlook, and its potential to coordinate multidisci-

Other preventive measures directed at firearms include plinary approaches.
educational programs to teach safe gun handling, as a way In similar fashion, the Global Burden of Surgical Disease
primarily to decrease unintentional firearm injuries. However, working group has been formed, consisting of surgeons,
similar to other generic nonfocused educational programs, anesthesiologists, public health specialists, and others from

the efficacy of such programs is not well demonstrated. the United States and from many other countries. This group
Moreover, unintentional injuries account for only a small has worked closely with the American College of Surgeons
proportion of all firearm-related injuries.7 Finally, there has and WHO. It is working to get increased global attention to
been increased emphasis lately on safer storage of firearms. a spectrum of issues that involve surgical care, including
This includes keeping guns stored unloaded with ammuni- trauma, obstetrics, and emergency surgical conditions.
tion stored separately. Other alternatives include the use of Among other activities, the group is attempting to get better
trigger locks and locked gun boxes. These devices allow a estimates of the toll of surgical conditions especially within
loaded gun to be kept more immediately available for those the Global Burden of Disease study, and to promote increased
who feel the need to have such weapons rapidly available for attention to planning for surgical care within the worlds
self-protection. All these techniques are felt to be ways to ministries of health.91
decrease not only unintentional firearms injuries, but also This increased attention to global injury control has gradu-
both assaultive and suicidal use of firearms.8486 In addition ally resulted in increasing political commitment. In 2009, the
to social marketing efforts to promote use of these devices, First Global Ministerial Conference on Road Safety was held.
mandated trigger locks on all guns sales is a currently pro- This was attended by ministers of health and/or transporta-
posed approach. tion and other senior officials from 150 countries, who com-
mitted their countries to greater attention to road safety. This
was followed shortly thereafter, in March 2010, by the United
Nations General Assembly declaring 20112020 as the
Decade of Action for Road Safety. Through this Decade of
This chapter primarily addresses the circumstances of North Action, country governments worldwide committed to action
America and other high-income countries. However, the in such areas as developing and enforcing legislation on key
vast majority of injury-related deaths occur in low- and risk factors, including speed reduction, reducing drunk-driv-
middle-income countries (LMICs). This is because this is ing, and increasing the use of seatbelts, child restraints, and
where the majority of people live; injury rates are higher; there motorcycle helmets. Efforts will also be undertaken to improve
have been limited application of organized injury prevention trauma care, upgrade road and vehicle safety standards, pro-
efforts; and trauma care systems are less than optimally mote road safety education and enhance road safety manage-
developed. Moreover, injury rates are declining in most high- ment generally.92 Of course, it is still up to injury control
income countries, but rising, sometimes rapidly, in most advocates to actively lobby their governments to see that these
LMICs.87,88 commitments become reality.
Many of the general injury prevention principles discussed There has also been increasing commitment to injury
in the current chapter are applicable under any circumstances. control by funders. For example, the U.S. National Institutes of
However, some of the specific applications need to vary to fit Health established the Fogarty International Collaborative
the circumstances of most of the world. This is due to varying Trauma and Injury Research Training Program. This funds
injury mechanisms, resource restrictions, and cultural differ- collaborative training programs linking U.S. universities with
ences. There is a need to develop local injury prevention partners in developing countries for the purpose of increasing
expertise and locally applicable strategies. the capacity of developing country institutions to conduct
After years of neglect by international agencies, injury research on injury prevention and trauma care. Similarly,
control has been gradually receiving justifiable increases in several private foundations have begun funding injury control
attention worldwide. One of the groups spearheading these issues. For example, the Bloomberg Philanthropies has recently
efforts has been the World Health Organization (WHO). Two funded a consortium of partners, headed by WHO, to improve
recent landmark publications by the WHO have addressed road safety in 10 developing countries that currently account
two of the biggest injury problems, road traffic injury and for half of all road traffic deaths globally.93 Nonetheless, overall
violence. The World Report on Road Traffic Injury Prevention funding for injury prevention remains inadequate compared to
has helped raise awareness about the problem and to promote the extent of the problem and major bilateral donors, such as
practical policy solutions for countries at varying economic USAID, have not yet established programs that encompass
levels worldwide.89 The World Report on Violence and Health injury prevention.
has emphasized the role that the health sector can have in vio- Readers interested in learning more about the application
lence prevention, in addition to sectors, such as criminal of injury prevention programs in LMICs are encouraged to
justice, that have traditionally been the foundation of violence read these and other related2,88,93,94 publications, as well as the
prevention.90 This report points out the complementary role WHO website ( prevention/en/).
50 Trauma Overview


1. Identify a significant, eminently preventable, injury problem and a potential, eminently feasible, intervention.
Problem should be a significant health problem, in terms of mortality or morbidity.

Focus on injuries that are severe or common, or both.

An effective intervention should exist, especially one which is being suboptimally utilized in a given environment.
Gather information on the extent of the problem and the effectiveness of possible interventions.
Be able to communicate this information in terms understandable to the public, politicians, and other

2. Identify and elicit the support of potential partners.
Create a coalition of those with similar interests and goals.
This coalition could include clinicians, public health practitioners, government, members of the lay public,
insurance companies and other industry representatives, and others.
Having one of these partners function as a lead agency is helpful to coordinate and stimulate the actions
of the other partners.
3. Identify barriers to the use of the intervention. Such barriers could include:
The knowledge and attitudes of the public.
Available interventions may need to be modified or presented differently to certain high-risk groups.
Lack of political will.
Opposition by special interest groups.
4. Develop and implement a plan to address these barriers.
Such a plan could involve a wide variety of actions and goals, such as, among other items:
A public information campaign to change a dangerous behavior.
A change in a law or the enforcement/application of a law.
Change in the availability or characteristics of a product.
Change in a hazardous environment.
Surgeons and other clinicians can play key roles in all of the above, through actions, such as, among others:
Bearing witness to the human toll of injury, so as to increase public and political will for changes.
Advocacy for changes with local, state, and national government.
Institute changes in injury prevention practice in their own institutions, such as with instituting alcohol
interventions in hospitals.
Injury prevention related counseling and advice for patients and their families.
Successful programs usually involve:
Multidisciplinary approach.
Community involvement.
Ongoing evaluation.
Need to mobilize resources:
Volunteer labor.
Publicity/free advertising/human interest stories.
More resources usually available with increased community interest and involvement.
Other aspects of successful programs.
Specific tasks assigned to specific partners.
Set reasonable, meaningful, yet achievable goals.
Regular meetings and updates by coalition members.
5. Evaluate the outcome of this program.
Potential items to assess.
Change in a law or its enforcement.
Change in behavior, such as use of safety devices (e.g., smoke detectors, helmets).
Decreases in rates of death or severe injury.
Be prepared to change plans, if needed, based on feedback from outcome assessment.
6. Prevent the erosion of success.
Most successful injury prevention campaigns are those that eventually become institutionalized and
thus a regular part of the function of government or other groups.
Guard against successful programs being rolled back by opposing interest groups or apathy by the public.
Injury Prevention 51

CONCLUSION: THE SURGEONS society and to provide answers to questions about violence pre-
ROLE IN INJURY PREVENTION vention strategies (
Injury prevention efforts do work. Such efforts have had For surgeons and other clinicians wishing to get involved in

considerable success in lowering the toll of injury-related death injury prevention, many of the references cited in this chapter
and disability. These successes have been most notable in unin- offer useful practical information. We especially recommend
tentional injury, especially due to road safety. Organized injury Injury Prevention: Meeting the Challenge, published by the
prevention work is also being increasingly applied to inten- CDC,7 Injury Prevention and Public Health by Christoffel and

tional injury. Obviously, much more remains to be done. This Gallagher,3 and the Handbook of Injury and Violence Prevention
is especially true in light of recent setbacks in highway safety, by Doll et al.4 Finally, the American Association for the Surgery
motorcycle helmet use, and flame retardant clothing for of Trauma and the American College of Surgeons both have
childrens sleepwear. In addition, the raising of speed limits in prevention sections on their websites ( and
most states resulted in an increase in the motor vehicle crash These sites pro-
death rate in the early 1990s with stagnation in the death rate vide useful, practical information on injury prevention and on
thereafter, until the most recent few years.25 important injury-related legislation, which is pending. They
The accomplishments and successes of injury prevention also have multiple links to other injury prevention resources,
programs rely on multidisciplinary input. Although many including a large number of local programs.
surgeons may not consider themselves as a usual part of injury A summary of the components of a successful injury preven-
prevention work, there is much they can contribute. In some tion program, with emphasis on a surgeons involvement, is
injury prevention programs, they have played a pivotal role. included in Box 3-1.
Their contributions can be on both individual and societal
levels. Surgeons, along with emergency physicians and prehos-
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Injury Prevention 53

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Trauma Systems, Triage, and Transport

Raul Coimbra, David B. Hoyt, and Vishal Bansal

DEFINITION OF TRAUMA SYSTEMS have estimated the total cost of injury in the United States to
be about $260 billion per year.8
A trauma system is an organized approach to acutely injured Because of the association of injury and personal behavior,
patients in a defined geographic area that provides full and trauma is often predictable and preventable.
optimal care and that is integrated with the local or regional The modern approach to trauma care is based on lessons
emergency medical service (EMS) system. learned during war conflicts. Advances in rapid transport, vol-
A system has to achieve cost efficiency through the integra- ume resuscitation, wound care management of complex inju-
tion of resources with local health and EMS system to provide ries, surgical critical care, early nutritional management, and
the full range of care (from prehospital to rehabilitation).13 deep venous thrombosis prophylaxis were all derived from the
Regionalization is an important aspect of trauma as a system military experience.
because it facilitates the efficient use of health care facilities The American College of Surgeons Committee on Trauma
within a defined geographic area and the rational use of equip- (ACSCOT) was created in 1949 and evolved from the
ment and resources. Trauma care within a trauma system is Committee on the Treatment of Fractures that was established
multidisciplinary and is provided along a continuum that in 1922. A specific trauma unit was opened in 1961 at the
includes all phases of care.26 University of Maryland. In 1966, the National Academy of
The major goal of a trauma system is to enhance the com- Sciences and the National Research Council published the
munity health. This can be achieved by identifying risk factors important white paper entitled Accidental Death and Disability:
in the community and creating solutions to decrease the inci- The Neglected Disease of Modern Society.9 The outgrowth of this
dence of injury, and by providing optimal care during the document was the development and propagation of systems of
acute as well as the late phase of injury including rehabilita- trauma care. This publication increased public awareness and
tion, with the objective to decrease overall injury-related mor- led to a federal agenda for trauma system development. Two
bidity and mortality and years of life lost. Disaster preparedness trauma centers were simultaneously formed in Chicago and San
is also an important function of trauma systems, and using an Francisco.
established trauma system network will facilitate the care of The Maryland Institute of Emergency Medicine became the
victims of natural disasters or terrorist attacks. The Model first completely organized, statewide, regionalized system in
Trauma System Planning and Evaluation Standard has recently 1973. Similar initiatives were taken in 1971 in Illinois,10 where
been completed by the U.S. Department of Health and the designation of trauma centers was established by state law,
Human Services.7 and in Virginia in 1981, where a statewide trauma system based
on volunteer participation and compliance with national stan-
THE NEED FOR TRAUMA SYSTEMSHISTORY dards as defined by the ACSCOT was established.
In 1973, the Emergency Medical Services Systems Act
The need for a trauma system seems obvious and intuitive. became law, providing guidelines and financial assistance for
However, trauma is not yet recognized as a disease process. the development of regional EMS systems. In addition, state
Many people still think of trauma as an accident. Trauma is an and local efforts were initiated by using prehospital care systems
epidemic that affects all age groups with devastating personal, to deliver patients to major hospitals where appropriate care
psychological, and economic consequences. Recent calculations could be provided. Prehospital provider programs were
Trauma Systems, Triage, and Transport 55

formalized, and training programs were established for para-

TABLE 4-1 Criteria for Statewide Trauma Care System
medics and emergency medical technicians (EMTs).
At that time, major teaching hospitals in large cities were, by Legal authority for designation
default, recognized as regional trauma centers. With strong Formal process for designation

academic leadership, these centers were able to develop region- Use American College of Surgeons standards
alization of systems of trauma care by setting examples. Use out-of-area survey teams
ACSCOT developed a task force to publish Optimal Number of trauma centers population or volume based
Hospital Resources for the Care of the Seriously Injured in 1976, Triage criteria allow direct transport to trauma center

establishing a standard for evaluation of care. This document Monitoring systems in place
was the first to set out specific criteria for the categorization of Full geographic coverage
hospitals as trauma centers. This document is periodically
revised and is recognized nationally and internationally as the Source: West JG, Williams MJ, Trunkey DD, Wolferth CC.
standard for hospitals aspiring to be trauma centers. The cur- Trauma systems: current statusfuture challenges. JAMA .
rent version entitled Resources for Optimal Care of the Injured 1988;259:3597.
Patient was published in 2006.4 It establishes criteria for pre-
hospital and trauma care personnel and the importance of
ongoing quality assessment. In addition, ACSCOT developed
the Advanced Trauma Life Support (ATLS) course in 1980, initiatives from this legislation were noteworthy: (1) planning
which has contributed to the uniformity of initial care and the grants for statewide trauma system development were provided
development of a common language for all care providers. to states on a competitive basis and (2) the Model Trauma Care
In 1985, the National Research Council and the Institute of System Plan was published as a consensus document.15 The
Medicine published Injury in America: A Continuing Health Model Trauma Care System Plan established an apolitical
Care Problem. This document concluded that despite consider- framework for measuring progress in trauma system develop-
able funding used to develop trauma systems, little progress had ment and set the standard for the promulgation of systems of
been made toward reducing the burden of injury.11 This docu- trauma care. The program was again funded in fiscal year 2001
ment also reinforced the necessity of investments in epidemio- but lost funding in 2006. New legislation is being written to
logical research and injury prevention. Following the publication further this effort. The newest document for trauma system
of this document, the Centers for Disease Control and planning uses the public health care model of assessment, pol-
Prevention (CDC) was chosen as the site for an injury research icy development, and evaluation of the outcome. With appro-
center, to coordinate efforts at the national level in injury con- priate federal funding, this approach will be very successful.7
trol, injury prevention, and all other aspects of trauma care.
In 1987, the ACSCOT instituted the Verification/ TRAUMA SYSTEM DEVELOPMENT
Consultation Program, which provided further resources and
incentive for trauma system development and trauma centers The criteria for a statewide EMS and trauma systems have been
designation. More recently, the ACSCOT published a docu- determined and are identified in Tables 4-1 and 4-2. The first
ment entitled Consultation for Trauma Systems with the objec- step is to establish legal authority for the development of a
tive of providing guidelines for trauma system evaluation and system. This usually requires legislation at a state or local level
enhancement.12 In 1987, the American College of Emergency that provides public agency authority. The next step in the
Physicians (ACEP) published Guidelines for Trauma Care development of a trauma system is to determine the need of
Systems.13 This document focused on the continuum of trauma
care, and identified essential criteria for trauma care systems.
In 1988, the National Highway Safety Administration TABLE 4-2 Emergency Medical Service System
(NTHSA) established the Statewide EMS Technical Assessment Components
Program and the Development of Trauma Systems Course, both Regulation and policy
important tools to assess the effectiveness of trauma system com- Resource management
ponents as well as for system development. NHTSA also devel- Human resources and training
oped standards for quality EMS, including trauma care. The Transportation
standard required that the trauma care system be fully integrated Facilities
into the states EMS system and have specific legislation Communications
(Table 4-1). The trauma care component must include desig- Trauma systems
nated trauma centers, transfer and triage guidelines, trauma regis- Public information and education
tries, and initiatives in public education and injury prevention. Medical direction
In 1990, the Trauma Systems Planning and Development Evaluation
Act created the Division of Trauma and EMS (DTEMS) within
the Health Resources and Services Administration (HRSA) to Source: Development of Trauma Systems (DOT).
improve EMS and trauma care. Unfortunately, the program Washington, DC: National Highway Traffic Safety
was not funded between 1995 and 2000 in many states that Administration; 1988.
were in the process of developing trauma systems. Two
56 Trauma Overview

systems, and about 20% have no trauma system at all. The

Legal Authority
necessary elements of a trauma system are: access to care, pre-
hospital care, hospital care, and rehabilitation, in addition to
prevention, disaster medical planning, patient education,

Inclusive research, and rational financial planning. Prehospital commu-

Trauma Needs nications, transport system, trained personnel, and qualified
System Assessment
trauma care personnel for all phases of care are of utmost
importance for a systems success (Fig. 4-1).

External peer review generally is used to verify specific hos-

pitals capabilities and its ability to deliver the appropriate level
Trauma Center of care. The verification process can be accomplished through
Designation the ACSCOT or by inviting experts in the field of trauma as
FIGURE 4-1 Regional trauma system development must progress outside reviewers. Finally, quality assessment and quality
in a sequential fashion; a comprehensive needs assessment is improvement is a vital component of the system, as it provides
a pivotal early step. (Reproduced with permission from Moore directions for improvement as well as constant evaluation of the
EE. Trauma systems, trauma centers, and trauma surgeons: systems performance and needs.
opportunity in managed competition. J Trauma. 1995;39:1.) The Model Trauma Care System Plan introduced the con-
cept of the inclusive system15 (Fig. 4-2). Based on this model,
trauma centers were identified by their ability to provide
such a system. In general, this has been done in communities definitive care to the most critically injured. Approximately
by reviewing the outcome of trauma cases in the region. 15% of all trauma patients will benefit from the resources of a
Traditionally, such reviews have focused on preventable deaths. Level I or II trauma center. Therefore, it is appropriately
The surgeons role is critical in both leadership and commit- expected in an inclusive system to encourage participation and
ment to establish a better standard of care. to enhance capabilities of the smaller hospitals.
The designated agency in combination with local trauma Surgical leadership is of fundamental importance in the
surgeons and other medical personnel develops criteria for the development of trauma systems. Trauma systems cannot
trauma system, determines which facilities will be designated develop without the commitment of the surgeons of a hospital
trauma centers, and establishes a trauma registry, a fundamental or community.
component of a quality assurance program4,1417 (Fig. 4-1).


The most significant improvement in the care of injured Death following trauma occurs in a trimodel distribution.
patients in the United States has occurred through the develop- Effective trauma programs must also focus on injury preven-
ment of trauma systems. However, recent data show that only tion, since more than half of the deaths occur within minutes
60% of states in the United States have statewide trauma of injury, and will never be addressed by acute care.

FIGURE 4-2 Diagram showing the growth of the trauma care system to become inclusive. Note that the number of injured patients is
inversely proportional to the severity of their injuries.
Trauma Systems, Triage, and Transport 57

Because trauma is not considered an important public is responsible for the design and implementation of field treat-
health problem by the general population, efforts to increase ment guidelines, their timely revision, and their quality control.
awareness of the public as well as to instruct the public about Medical direction can be off-line in the form of protocols for
how the system operates and how to access the system are training, triage, treatment, transport, and technical skill opera-

important and mandatory. A recent Harris Poll conducted by tions or online, given directly to the field provider.
the Anemia Trauma Society showed that most citizens value the
importance of a trauma system with the same importance as
fire and police services. Trauma system must also focus on

injury prevention based on data relevant to injuries and what The word triage derives from the French word meaning to
interventions will likely reduce their occurrence. Identification sort. When applied in a medical context, triage involves the
of risk factors and high-risk groups, development of strategies initial evaluation of a casualty and the determination of the
to alter personal behavior through education or legislation, and priority and level of medical care necessary for the victim. The
other preventive measures have the greatest impact on trauma purpose of triage is to be selective, so that limited medical
in the community, and, over time, will have the greatest effect resources are allocated to patients who will receive the most
on nonfatalities.1820 benefit. Proper triage should ensure that the seriously injured
patient be taken to a facility capable of treating these types of
injuriesa trauma center. Patients with lesser severity of inju-
ries may be transported to other appropriate medical facilities
Because the system cannot function optimally without quali- for care.
fied personnel, a quality system provides quality education to Each medical facility has its own unique set of medical
its providers. This includes all personnel along the trauma care resources. As such, triage principles may vary from one locale
continuum: physicians, nurses, EMTs, and others who impact to another depending on the resource availability. Likewise,
the patient and/or the patients family. established triage principles may be modified to handle multi-
ple casualty incident or mass casualties. Then, a different set of
triage criteria may be employed that will attempt to provide
medical care to the greatest number of patients. In this scenario,
Trauma care prior to hospital arrival has a direct effect on survival. some critically injured patients may not receive definitive care
The system must ensure prompt access and dispatch of qualified as this may consume an unfair share of resources. The goal of
personnel, appropriate care at the scene, and safe and rapid trans- triage and acute medical care is to provide the greatest good to
port of the patient to the closest, most appropriate facility. the greatest numbers.
The primary focus is on education of paramedical personnel From a historical perspective, war has been the catalyst for
to provide initial resuscitation, triage, and treatment of trauma developing and refining the concept of medical triage.
patients. Effective prehospital care requires coordination Dominique Jean Larrey, Napoleons chief surgeon, was one of
between various public safety agencies and hospitals to maxi- the first to prioritize the needs of the wounded on a mass scale.
mize efficiency, minimize duplication of services, and provide He believed it is necessary to always begin with the most
care at a reasonable cost. dangerously injured, without regard to rank or distinction. He
evacuated both friend and foe on the battlefield and rendered
medical care to both. He refined his techniques for evacuation
and determining medical priorities for injured patients over the
A reliable communications system is essential for providing opti- 18 years and 60 battles while being a member of the French
mal trauma care. Although many urban centers have used modern army.
electronic technology to establish emergency systems, most rural During World War I, the English developed the casualty
communities have not. A communications system must include clearing station, where the injured were separated based on the
universal access to emergency telephone numbers (e.g., 911), extent of their injuries. Those with relatively minor injuries
trained dispatch personnel who can efficiently match EMS exper- received first aid, while those with more serious injuries under-
tise with the patients needs, and the capability of EMS personnel went initial resuscitative measures prior to definitive care. As
at the trauma incident to communicate with prehospital dispatch, medical and surgical care of battlefield injuries expanded, a
the trauma hospital, and other units. system of triage and tiered levels (echelons) of medical care was
Access also requires that all users know how to enter the sys- designed. Echelons of medical care and triage of single, multi-
tem. This can be achieved through public safety and information ple, and mass casualties remain the paradigm for military com-
and school educational programs designed to educate health care bat medical care.
providers and the public about emergency medical access. There are five echelons (or levels) of care in the present
military medicine. The first line of medical care is that which is
provided by fellow soldiers. Principles of airway management,
cessation of bleeding, and basic support are offered by fellow
Medical direction provides the operational matrix for care pro- soldiers. Organized medical care begins with a medic or corps-
vided in the field. It grants freedom of action and limitations to man who participates in echelon 1 care. They are assigned to
EMTs who must rescue injured patients. The medical director functional military units and serve as the initial medical
58 Trauma Overview

evaluation and care of the injured patient. Echelon 2 is a bat- facility, information concerning the patients injuries and
talion aid station or a surgical company. Resuscitation and basic physiologic state should be transmitted to the receiving facility
lifesaving surgical procedures may be performed at these sta- if possible. This will give the receiving physician an opportunity
tions. Echelon 3 is a Mobile Army Surgical Hospital (MASH) to gather the appropriate personnel and equipment to treat the

or Fleet Surgical Hospital. Advanced surgical and medical diag- incoming casualty. A concise prehospital radio report will
nostic and therapeutic capabilities are available at these facili- enable the receiving medical personnel to anticipate emergent
ties. An Echelon 4 facility is larger and has enhanced medical equipment and personnel needs. In some instances, a direct
capacity. Examples include a hospital ship (USNS Mercy or operative resuscitation may be indicated to stabilize the patient.21

Comfort) or an out-of-country medical facility (Landstuhl In other cases, emergent airway control may be the primary
Region Medical Center [Army], Germany). An Echelon 5 facil- concern. The few minutes of preparation, prior to the patients
ity is a large tertiary and rehabilitative medical facility and is arrival, may be the difference in patient survival.
located within the home country (Naval Medical Center San The other goal is to define the major trauma victim. While
Diego). Each increasing echelon has a more comprehensive this term may be easy to conceptualize, it is very difficult to
medical and surgical capacity. As patients are identified on the quantify. A precise definition is important so that triage, treat-
battlefield, they are triaged and transferred to the next higher ment, and outcomes can be compared. Prompt recognition of
echelon for care. During the Vietnam War, air medical trans- those patients who are in immediate risk of life (e.g., loss of
port enabled the triage of a seriously injured soldier from the airway or hemorrhagic shock) or loss of a limb (ischemia) or
battlefield directly to an MASH unit. The time to definitive will need immediate operative or lifesaving interventions is
surgical care was less than 2 hours compared to 6 hours during paramount. These patients are in need of definitive care in an
World War II. expedient fashion where delays in care may result in excess
The lessons learned from the triage and treatment of combat morbidity or mortality.
casualties were slow to translate into civilian use. Injured The Injury Severity Score (ISS) provides the means for a
patients, regardless of the severity of injury, were simply taken trauma system to retrospectively identify major trauma victims
to the nearest hospital for treatment. Neither a triage system with an ISS of greater than 15 being a commonly accepted
nor an organized approach to injury existed. The ATLS course level.22 Another definition of major trauma is provided by the
was created in the late 1970s and with it the concept of requi- Major Trauma Outcome Study (MTOS), which defines the
site skills and facilities to treat injured patients emerged. trauma patient as all patients who died due to their injuries or
were admitted to the hospital.23 The threshold that defines the
major trauma victim within a trauma system is based not only
on the resources of a particular trauma center but also on the
The purpose of triage is to match the patient with the optimal inability of the nondesignated hospitals to consistently provide
resources necessary to adequately and efficiently manage his or appropriate care for an injury exceeding the threshold. This
her injuries. It is a dynamic process of patient evaluation and may vary from system to system.
reevaluation until the patient receives definitive care. The chal- After a traumatic event, the effectiveness of a triage system
lenge of a triage system lies in correctly identifying which should be analyzed based on expected performance standards.
patient has injuries in need of a designated trauma center. Data monitoring and quality assessment tools should be
Studies have demonstrated better outcomes in major trauma applied after a disaster or after any one patient who has been
victims who have been treated at hospitals that have a commit- treated so that system or operator errors can be identified and
ment for this specialized care.16 Of all trauma patients, only corrected. Each multiple casualty event presents unique prob-
715% have injuries that require the facilities of a dedicated lems to a triage system. Constant reevaluation and refinement
trauma center. are cornerstones for improved performance.
The ideal triage system would direct patients with serious One of the accepted performance markers to an effective
injuries to the most appropriately staffed hospital while trans- triage system is found in the determination of the undertriage
porting those with less serious injuries to all other hospitals and overtriage rates. Undertriage is defined as a triage decision
within the geographic area. Due to the complexities of patient that classifies a patient as not needing a higher level of care (e.g.,
evaluation and injury determination, the perfect triage system trauma center), when in fact they do. This is false-negative tri-
is yet to be developed. age classification.44 Undertriage is a medical problem that may
The primary goal of an effective triage system is to identify result in an adverse patient outcome. The receiving medical
which casualties are seriously injured and in need of immediate facility may not be adequate to diagnose and treat the trauma
surgical or medical care. This requires a rapid evaluation of the victim.
patient and a decision about the level of emergency care that Defining an acceptable level of undertriage is dependent on
will be needed for the patient. Once this is determined, they are how one defines the patient requiring trauma center care. One
matched and transported to the appropriate medical facility. method is to identify all the potentially preventable causes.
The triage physician often has limited resources, information, Using this method, a target undertriage rate would be 1% or
and time to make this important decision. While many triage less. Using a broader definition, undertriage would also result
methods can be used, they often rely on physiologic, anatomic, in patients being sent to institutions without the capability to
and mechanism of injury information to assist in the triage render appropriate care. In this instance, an undertriage rate of
decision. Once the patient has been routed to a treatment 510% is accepted.
Trauma Systems, Triage, and Transport 59

Another method is to determine how many major trauma to make a disposition decision without further evaluation. In a
patients were incorrectly transported to a nontrauma center. If mass casualty event, rapid triage may be performed with a quick
an ISS of greater than 16 or more is used to define the major visual exam of the patient. Anatomic criteria that suggest triage
trauma patient, undertriaged patients would be those patients to a trauma center may include, but are not limited to: penetrat-

(ISS 16) who were taken to a nontrauma center hospital. ing injury to the head, neck, torso, or proximal extremity; two
Using this method, an acceptable undertriage rate can be as or more proximal long-bone fractures; pelvic fracture; flail chest;
high as 5%. amputation proximal to the wrist or ankle; limb paralysis; or
Overtriage is a decision that incorrectly classifies a patient as greater than 10% total body surface area burn or inhalation

needing a trauma center, although retrospective analysis sug- injury. Each regionalized trauma system must decide what con-
gests that such care was not justified. It has been said to result stitutes significant anatomic injury as a triage criterion.
in overutilization of finite material, that is, financial and human Anatomic injury may be challenging to predict reliably
resources.24 based on physical examination in the field. Fracture of long
bones, amputations, and skin and soft tissue injuries may
appear devastating in the field but are rarely life threatening and
COMPONENTS OF TRIAGE TOOLS may distract the field examiner as well as the patient from more
AND DECISION MAKING subtle and serious injuries.
Trauma triage decisions are usually made within a limited time Significant blunt chest and abdominal injuries can have little
frame and are based on information that can be difficult to external evidence of internal injury and initial physical exami-
obtain. These decisions are based on evidence gathered in the nation lacks diagnostic accuracy.26,27 Other significant injuries
field that estimates the potential for severe injury. Physiologic missed on initial examination include spine28 and certain types
and anatomic criteria, mechanism of injury, and comorbid fac- of pelvic injuries. A pelvic bony injury can be diagnosed on
tors are used in the triage decision-making process. Unfortunately, physical examination in the awake, cooperative patient; how-
all these criteria have limitations that affect their validity in ever, a significant number of trauma victims have altered men-
certain situations. The judgment of experienced EMS person- tal status due to head injury or ingestion of drugs or alcohol.
nel is also a key factor in triage. The distinction between blunt and penetrating injury is an
important triage distinction. Oftentimes there may be little
external trauma to the patient. However, recognition of the
PHYSIOLOGIC CRITERIA penetrating wounds correlated with the likelihood of internal
injury is needed to effectively triage these patients. Penetrating
Physiologic data are felt to represent a snapshot into the well- injuries to trunk and proximal extremities are of concern
being of an injured patient. Physiologic criteria include mea- because of their proximity to vital structures; however, it is
surements of basic life-sustaining functions such as heart rate, nearly impossible to know the direction or depth of penetration
blood pressure, respiratory rate and effort, level of conscious- while in the field. Finally, the triage officer must expeditiously
ness, and temperature. The advantage of physiologic data is that evaluate patients and not perform time-consuming physical
they are readily assessable in the field with a simple physical examinations in the field that only slow down the triage pro-
examination. These data can be ranked into a numerical format, cess. Complex patients may be better served by urgent trans-
which allows them to be quantified, and used in various trauma port to a trauma center.
scoring systems such as the Revised Trauma Score (RTS). The
larger the deviation from normal, the more likely there is a
severe injury. In this way, physiologic data may correlate to MECHANISM OF INJURY
severity of injury and may predict serious injury or death. Evaluation is more than the simple determination of how a
Patients who have sustained a mortal injury tend to have the trauma injury occurred. To the trained eye, it can give informa-
greatest deviation in their vital signs.25 The problem is that their tion on the type, amount, and direction of force or energy
ability to detect physiologic derangement is time dependent. A applied to the body. Prehospital personnel, who view the effects
single set of physiologic signs is only a snapshot to the patients of the forces that were applied during the injurious event, can
state. Patients who have sustained significant injury may not estimate the amount of energy involved. This, in turn, helps
manifest physiologic changes immediately after the event and, predict the likelihood of injury. Mechanisms of injury felt to
as a result, are at risk for undertriage. A significant injury may have a high potential for major trauma include falls of more than
take some time to manifest life-threatening hemorrhage or ten- 15 ft; motor vehicle accidents with a fatality at the scene, pas-
sion pneumothorax. This is especially true of young, otherwise senger ejection, prolonged extrication (20 minutes), or major
healthy adults who have significant physiologic compensation intrusion of the passenger compartment; pedestrians struck by a
mechanisms that may mask the true extent of the injury. motor vehicle; motorcycle accidents of more than 20 mph; or
any penetrating injuries to the head, neck, torso, or proximal
extremities. When used as a triage criterion by itself, mechanism
of injury results in the high overtriage rate. However, when
The anatomic location and external appearance of the injury aid combined with other triage components, such as physiologic
in the immediate field triage decisions. This visual picture of the indices and anatomic injury, mechanism of injury improves the
injured patient may be sufficient for an experienced triage officer sensitivity and specificity of the triage process.29,30
60 Trauma Overview

AGE, COMORBID DISEASE, AND TABLE 4-3 Commonly Used Trauma Triage Criteria
Physiologic and anatomic criteria
Age has been shown to impact the outcome of trauma victims Glasgow Coma Scale of 13 or less

and should be taken into consideration when triaging a patient. Systolic blood pressure of 90 or less
Elderly trauma victims, using a variety of definitions (i.e., Respiratory rate of 10/min or less, or greater than 29/min
55 years old, 65 years old, etc.), have been shown to have Sustained pulse rate of 120/min or more
increased morbidity and mortality compared to younger Head trauma with altered state of consciousness,

trauma victims. When compared to young patients, the elderly hemiplegia, or uneven pupils
are at risk for undertriage, because a similar amount of force Penetrating injuries of the head, neck, torso, and
may cause a greater magnitude of injury.31 extremities proximal to the elbow or knee
The effect of age on morbidity and mortality is not as clear Chest trauma with respiratory distress or signs of shock
in the pediatric population.32 There are significant differences
Pelvic fractures
in physiology and anatomy in the pediatric population that
Amputations above the wrist or ankle
require specialized equipment, facilities, and personnel.
Certainly, the optimal treatment involves identifying the Limb paralysis
unique resources needed to care for the injured child and hav- Two or more proximal long-bone fractures
ing those available when needed. These differences are signifi- Combination of trauma with burns
cant enough that specialized triage criteria have been developed Mechanism of injury and high-energy impact
for the pediatric population.33 Fall of 20 ft or more
Chronic diseases have also been shown to have a significant Patient struck by a vehicle moving 20 mph or more
impact on morbidity and mortality in the trauma victim inde- Patient ejected from a vehicle
pendent of age and injury severity.34 Acute conditions such as Vehicle rollover with the patient unrestrained
ethanol or cocaine intoxication or systemic anticoagulation High-speed crash (initial speed of 40 mph) with 20 in
may also impact morbidity and mortality. Comorbidities such of major front-end deformity, 12 in or more deformity
as cardiopulmonary, hepatic, renal disease, diabetes mellitus, into the passenger compartment
malignancy, or neurologic disorders have been found to have Patient was a survivor of a MVA where a death occurred
increased mortality rates compared to their disease-free coun- in the same vehicle
terparts. The problem is that many times the associated medical Other criteria
condition of the patient cannot be ascertained in the prehospi- Age of less than 5 years old, or over 55 years old
tal arena unless the patient has identification such as a medical History of cardiac disease, respiratory disease, insulin-
alert bracelet or a relative who can provide the necessary history dependent diabetes, cirrhosis, or morbid obesity
to the field personnel. Pregnancy
Environmental extremes can have serious consequences for Immunosuppressed patients
the trauma patient. Hypothermia is known to have adverse Patients with bleeding disorders, or patients on
physiologic effects, prolongs blood coagulation time, and con- anticoagulants
tributes to mortality.35 Prolonged heat exposure may lead to Burns of greater than 30% of body surface area in
dehydration. Burn injuries require accurate assessment for adults, or 15% body surface area in children
resuscitation and wound care, as well as evaluation for potential Burns of the head, hands, feet, or genital area
inhalation injury. When combined with associated trauma, Inhalation injuries
patient management can be complex36 (Table 4-3). Electrical burns
Burns associated with multiple trauma or severe medical

A working familiarity of clear, concise, and reliable triage guide-

lines is essential for effective triage. Experience and judgment of
EMS personnel are crucial to this mission. EMS personnel are other triage criteria, improves on the identification of major
in a unique position to directly assess the trauma scene, ascer- trauma victims. In a systematic review of Mulholland et al.
tain the mechanism of injury, determine the extent of the there was no conclusive evidence for or against paramedic judg-
patients injuries, and estimate the patients physiologic response. ment in the field.38 The one constant theme in triage at all
For example, a patient with a fractured femur due to a frontal, levels of medical personnel was the level of clinical experience.
high-speed motor vehicle collision will be evaluated and triaged Pointer et al.39 studied the compliance of paramedics to estab-
differently than will a patient with a femur fracture due to a lished triage rules. Paramedic triage was best when evaluating
low-speed collision. Paramedic triage is outlined in the prehos- triaging based on a patients injury patterns. Compliance was
pital trauma life support manual. intermediate when based on mechanism of injury and the low-
Several studies have shown that prehospital field personnel est for patients evaluated for physiologic triage criteria. They
judgment can be as good or better than the available triage scor- demonstrated a paramedic undertriage rate of 9.6%, which is
ing methods commonly in use37 and, when combined with relatively close to the acceptable 5% or less undertriage rate.
Trauma Systems, Triage, and Transport 61

CURRENT FIELD METHODS prehospital evaluation tool. A more recent study found that the
FOR FIELD TRIAGE SCORING motor component of the GCS is almost as good as the TS and
better than the ISS in predicting mortality. This suggests that
In order for a triage scoring method to be acceptable for use in the the motor component score could be used to identify patients

field, it must meet certain criteria. The components of the scoring who are likely to require urgent trauma center care.
scheme must be credible, meaning that they have some correlat-
ing relationship with the injuries being described. Because there is
no gold standard to test the accuracy of the scoring scheme, the Triage Index, Trauma Score,
Revised Trauma Score

results of the scoring scheme must be in general agreement with
other, currently accepted scoring methods.40 The Triage Index (TI) was described in 1981, and analyzed
The triage scoring method must correlate with outcome. The physiologic parameters of an injured patient. These variables were
scores that indicate more severe injury should identify the examined alone and in combination in an effort to make the TI
patients with worse outcomes. The better the correlation with more precise. One year later, Champion et al. modified the TI by
outcome, the lower the undertriage and overtriage rates within adding systolic blood pressure and respiratory effort in an effort
a trauma care system. Outcomes for major trauma victims are to be more discriminatory in patient severity identification. The
usually classified as death, need for urgent/emergent surgical resulting TS was designed to look at those physiologic parameters
intervention, length of intensive care unit (ICU) and/or hospital known to be associated with higher severity of injury if found to
stay, and major single-system or multisystem organ injuries. be abnormal.45 Central to this idea was the fact that the known
The scoring scheme must also have interobserver and intrao- leading causes of traumatic death were related to dysfunction of
bserver reliability, that is, it should be able to be consistently the cardiovascular, respiratory, and CNS. The authors recom-
applied between observers and by the same observer at another mended trauma center care for trauma victims with a TS of 12 or
point in time with the same results. Finally, the scoring scheme less. The TS was revised in 1989 because of concerns about accu-
must be practical and easily applied to trauma victims for a rate assessment of capillary refill and respiratory effort at night as
variety of mechanisms, by a variety of personnel without the well as potential underestimation of CNS injury.46 These compo-
need of specialized training or equipment. nents were deleted and the RTS consists of three parameters:
GCS, systolic blood pressure, and respiratory rate.


CRAMS was first proposed as a simplified method of field tri-
Trauma Index
age.47 These parameters are individually assessed and assigned a
The Trauma Index was one of the earliest triage scoring methods, value corresponding to normal, mildly abnormal, or markedly
first reported in 1971 by Kirkpatrick and Youmans.41 It included abnormal. With a range of 010, a score of 8 or less signifies
measures of five variables: blood pressure, respiratory status, major trauma, indicating that the patient should be taken to a
central nervous system (CNS) status, anatomic region, and type designated trauma center. Both retrospective and prospective
of injury. One study showed some correlation with injury studies have shown that the CRAMS method of triage is accu-
severity42; however, the Trauma Index never saw widespread use. rate in identifying major trauma victims with relatively high
A revision of the Trauma Index in 1990 reported undertriage and specificity and sensitivity and is easy to use.49
overtriage rates comparable to those of the Trauma Score (TS);
circulation, respiration, abdominal/thoracic, motor, and speech
(CRAMS); Prehospital Index (PHI); and mechanism of injury Prehospital Index
scales and correlated to the final ISS.43 The PHI consists of field measurements of blood pressure,
pulse, respiratory status, and level of consciousness, which were
determined to have the best correlation with mortality or the
Glasgow Coma Scale
need for surgery. A subsequent prospective multicenter valida-
When Teasdale and Jennett first introduced the Glasgow Coma tion study by the same authors showed that the PHI is accurate
Scale (GCS),44 it was intended as a description of the functional in predicting the need for lifesaving surgery within 4 hours and
status of the CNS, regardless of the type of insult to the brain, death within 72 hours following injury.50 Furthermore, the
and was never intended to be used as a prehospital assessment attachment of non-time-dependent variables such as age, body
tool. The three components of the score reflect different levels region injured, and mechanism of injury to the PHI improved
of brain function with eye opening corresponding to the brain- the predictive power to select those patients who were likely to
stem, motor response corresponding to CNS function, and need intensive care or a surgical procedure.
verbal response corresponding to CNS integration.
Because the degree of injury to the CNS is considered to be
a major determinant of outcome in trauma victims, many of Trauma Triage Rule
the field triage tools measure CNS function, including the The TTR proposed by Baxt et al. consists of measurements of
TS,45 the RTS,46 the CRAMS scale,47 and the Trauma Triage blood pressure, the GCS motor response, and the anatomic
Rule (TTR).48 Interpretation of GCS in the presence of an region and type of injury.48 Rather than comparing the scoring
intubated patient diminishes the ability to use the GCS as a method to traditional outcome measures to determine the
62 Trauma Overview

factors that constitute a major trauma victim, major trauma potential injury to a trauma victim. As shown earlier in the
was defined a priori as a systolic blood pressure of less than chapter, mechanism of injury, anatomic region and type of
85 mm Hg; a GCS motor component score of 5 or less; or injury, preexisting illnesses, and paramedic judgment are
penetrating trauma to the head, neck, or trunk. Retrospective important considerations in providing additional information

review revealed major trauma victim identification with a sen- in the field to help determine whether a patient requires trans-
sitivity and specificity of 92%. The TTR was concluded to port to a designated trauma center. Combination field triage
potentially reduce overtriage while maintaining an acceptable methods make use of this additional information by including
undertriage rate. However, it has not been adapted widely. it in the initial evaluation of the trauma victim.

Disaster Triage: Simple Triage American College of Surgeons

and Rapid Treatment (START) Field Triage System
In the event of a mass casualty or disaster, EMS personnel may The ACS Field Triage System is a more complete, advanced
utilize the START triage system initially developed to be used triage scoring scheme that is described in the Resources for
in earthquakes in California. The object of this system is to tri- Optimal Care of the Injured Patient. This decision scheme
age large numbers of patients rapidly. It is relatively simple and describes indications for transport of the trauma victim to a
can be used with limited training.51 The focus of START is to trauma center based on specific physiologic and anatomy of
evaluate four physiologic variables: the patients ability to injury variables. In addition, mechanism of injury and comor-
ambulate, respiratory function, systemic perfusion, and level of bid factors are evaluated and, if specific criteria are met, may
consciousness. It can be performed by lay and emergency per- also indicate transport to a trauma center. Finally, if there is
sonnel. Victims are usually divided into one of the four groups concern on the part of the prehospital medical personnel that
with color codes according to the timing of care delivery based the victim may have significant injuries, consideration is given
on the clinical evaluation as follows: (a) greenminor injuries to taking the patient to the designated trauma center. Fig. 4-3
(walking wounded); (b) redimmediate; (c) yellowdelayed; shows the triage decision scheme that is widely used through-
and (d) blackunsalvageable or deceased. out the country.
If the patient is able to walk, he or she is classified as a delayed
transport, but if not, ventilation is assessed. If the respiratory rate
is 30, the patient is an immediate transport. If the respiratory APPLICATION OF TRIAGE PRINCIPLES
rate is 30, perfusion is assessed. A capillary refill of 2 seconds FOR MULTIPLE PATIENT SCENARIOS
will mandate an immediate transport. If the capillary refill is
Triage principles may need to be modified to include triage of
2 seconds, the patients level of consciousness is assessed. If the
multiple patient and mass casualty situations.
patient cannot follow commands, he or she is immediately
transported; otherwise he or she is a delayed transport. The Fire
Department of New York used this system during the World Single Patient
Trade Center disaster. Unfortunately, due to the collapse of the Triaging a single trauma victim is relatively straightforward.
buildings and concern for the safety of the rescue workers, the The prehospital care provider assesses the patient according to
START system came to a complete halt.52 It resumed only when the defined triage criteria for that particular regionalized trauma
it was declared safe to approach ground zero. system. If the patient meets the criteria of a major trauma vic-
In some systems the START system is coupled with severity tim, he or she is transported to the nearest designated trauma
scores: in the immediate category the TS varies from 3 to 10, in center.
the urgent category the TS varies from 10 to 11, and in the
delayed (nonurgent) group the TS is 12.
The triage principles are the same for children and adults. Multiple Casualties
However, due to differences in physiology, response to insults, In the situation of multiple patients, such as seen with multiple
ability to talk and walk, and anatomic differences, disaster tri- cars involved in the same accident, the same essential principles
age in the pediatric age group is not straightforward. Assessment apply; however, decisions must be made in the field as to which
tools have been proposed to increase the accuracy of the process patients have priority. A state of multiple casualties occurs when
but were found to have major limitations. the numbers of patients and injury severity do not exceed the
The START system is important in the triage of severely hospital resources. Those patients who are identified as major
injured trauma patients because those requiring surgical care are trauma victims by field triage criteria have priority over those
transported by air or ground ambulances to trauma centers distant who appear less injured. All major trauma patients should be
enough from the incident where the number of victims is lower transported to a trauma center as long as the trauma center has
and the resources are still available to provide optimal care. adequate resources to manage all the patients effectively. This
type of situation can stress local resources, and possible diver-
sion of the less critically injured to another trauma center
Combination Methods should be considered. Monitoring transports with online com-
While most of the field triage criteria are based on physiologic puter assistance allows for contemporaneous determination if
criteria, there are other methods for assessing the severity of the one trauma center is overwhelmed.
Trauma Systems, Triage, and Transport 63


Measure vital signs and level of consciousness

Glasgow Coma Scale < 14 or
Step One Systolic blood pressure < 90 or
Respiratory rate < 10 or > 29 (< 20 in infant less than one year)



Take to a trauma center. Steps 1 and 2 triage attempts to identify the most seriously Assess anatomy of injury
injured patients in the field. These patients would preferentially be transported to the
highest level of care within the trauma system.

All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee
Flail chest
Step Two Two or more proximal long-bone fractures
Crush, degloved or mangled extremity
Amputation proximal to wrist and ankle
Pelvic fractures
Open or depressed skull fracture

Yes No

Take to a trauma center. Steps 1 and 2 triage attempts to identify the most seriously Assess mechanism of injury
injured patients in the field. These patients would preferentially be transported to the and evidence of high-energy
highest level of care within the trauma system. impact

Adults: > 20 feet (one story is equal to 10 feet)
Children: > 10 feet or two to three times the height of the child
High-risk auto crash
Step Three Intrusion: > 12 inches occupant site > 18 inches any site
Ejection (partial or complete) from automobile
Death in same passenger compartment
Vehicle telemetry data consistent with high risk of injury
Auto v pedestrian/bicyclist thrown, run over, or with significant (> 20 mph) impact
Motorcycle crash > 20 mph

Yes No

Transport to closest appropriate trauma center which, depending on the trauma Assess special patient or
system, need not be the highest level trauma center system considerations

Older Adults: Risk of injury death increases after age 55
Children: Should preferentially be triaged to pediatric-capable trauma centers
Step Four Anti-coagulation and bleeding disorders
Without other trauma mechanism: Triage to burn facility
With trauma mechanism: Triage to trauma center
Time sensitive extremity injury
End stage renal disease requiring dialysis
Pregnancy > 20 weeks
EMS provider judgment

Yes No

Contact medical control and consider transport to trauma center or a specific Transport according to protocol
resource hospital.

When in doubt, transport to a trauma center

FIGURE 4-3 Prehospital triage decision scheme recommended by the American College of Surgeons Committee on Trauma. (Reproduced
with permission from The American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient: 2006.
Chicago, IL: American College of Surgeons; 2006.)
64 Trauma Overview

Mass Casualties manage the battlefield situation. The Fire Service of the US
Triage in this situation is unique in that priorities are different Department of Forestry, in 1970, adapted command and con-
from those in the single- or multiple-victim scenarios. In the trol into an incident command structure. Within this frame-
work, a centralized group of disaster personnel works to

instance of mass casualties, the resources of the designated

trauma center, as well as the regional trauma system, are over- command and control all of resources at the disaster site.
whelmed. When resources are inadequate to meet the needs of Dynamic disaster scene information is processed at the incident
all the victims, priority shifts from providing care to those with command and decisions as to how best to engage the rescue
resources are implemented.

the most urgent need to providing care to those with the high-
est probability of survival. The incident command center structure is composed of
A severely injured patient, who would consume a large seven key groups. If the disaster is small in scope, a single per-
amount of medical resources, is now a lower triage priority. son may fill all seven areas. As the disaster increases in scope,
Despite the potential salvageability of this patient, the medical more personnel are required to fulfill these functions. The inci-
resources are focused on other patients who would benefit from dent commander is responsible for the entire rescue or recovery
advanced medical and surgical care. This method provides the operation. Under the direction of the incident commander are
greatest good for the greatest number of people. Field triage in the seven group commanders: operations, logistics, planning,
this situation is probably the most difficult to perform as one finance, safety, information, and liaison. Each of these section
has to make choices of quantity over quality with very limited commanders has well-defined areas of authority and responsi-
amounts of information. These issues are further complicated bility. Continuous on-scene information will be communicated
when dealing with children.53 to the command center. This will enable the incident command
The most experienced and best-trained personnel available center to plan and direct the rescue or recovery operation.
should make these field triage decisions. Physicians may be the Thus, limited resources and key personnel will be directed to
best qualified to make these triage decisions; however, if they produce the greatest benefit.
are the only receiving physicians available, direct patient care The disaster scene is typically divided into zones of opera-
should take precedence and triage decisions would fall to other tion. Ground zero is the inner hazard zone where the fire and
personnel. Patients are identified according to a triage code, rescue operations occur. EMS and other nonessential personnel
based on the severity of injuries and likelihood of survival, and are kept out of this area. Rescued victims are brought out of this
are treated accordingly. Occasionally, there may be an indica- area to the EMS staging area. This is the second zone, a primary
tion for a specialized surgical triage team with the capability to casualty receiving area, and it is here that EMS personnel per-
render acute lifesaving care of an injured trapped patient.54 In form triage and initial care for the patient. Disposition directly
some disaster scenarios moving the intensive care into a disaster to the hospital may occur or the patient may be sent to a distant
zone may be beneficial when evacuation of patients may be receiving area for care and ultimate triage and transport.
unrealistic due to logistical reasons. The distant casualty receiving areas provide for additional
In order to optimize patient care in these situations, it is safety in the environment. This downstream movement of
important for regionalized systems to periodically have mock injured patients prevents the primary triage sites from being
disaster drills. These drills allow for the proper training of all overrun. Transportation of the wounded from the primary
individuals who might be involved as well as the identification receiving site is reserved for the most seriously injured patients.
and correction of potential problems. With increasing terrorist Thus, a tiered triage approach is developed. A temporary
activity, specific triage algorithms have been developed for spe- morgue is also set up at a distant site.
cific scenarios such as biologic, chemical, radiologic, or blast Typically, groups of patients, the walking wounded, will
attacks.55 migrate toward the nearest medical treatment facility. This
process is called convergence. Medical facilities will often set up
a triage area in front of the emergency department to handle
Disaster Management these patients. Present-day medical teaching supports the treat-
Events surrounding the recent terrorist attacks of the Oklahoma ment of any patient who arrives at an institutions doorstep.
Federal Building, World Trade Center, and the Pentagon, and Perhaps thought should be given to transporting groups of
natural disasters such as Katrina, should crystallize the resolve of these patients to secondary medical facilities so that the closer
all medical personnel to become educated and proficient in hospitals do not become overburdened with an influx of
disaster management. The approach to disasters, whether natu- patients. The use of outpatient operating facilities is being con-
ral or man-made, requires a coordinated relief effort of EMS, sidered for this purpose.
hospital, fire, police, and public works personnel. This multior- The final operational zone of the disaster site is the outer
ganizational operation can function in a crisis environment only perimeter. Police permit only essential personnel access into the
if it is well directed and controlled. The ability to assess a disas- disaster site. Crowd and traffic control ensure the safety and
ter scene, call in appropriate personnel to provide damage con- security of the disaster scene as well as to provide emergency
trol, fire and rescue operations, and crowd control is dependent vehicles rapid transit to and from the site.
on an organization structure that permits dynamic information Disasters may be of a small scale such as an intrafacility fire
processing and decision making of vital scene information. or explosion and may remain only a local or regional problem.
The military uses the concept of command and control for As was seen at the World Trade Center, the magnitude of a local
its combat operations. Key personnel continually monitor and disaster was of such proportions that a national response was
Trauma Systems, Triage, and Transport 65

needed to address the rescue and recovery efforts. The standard so, what selection criteria are the most appropriate? Do trans-
appeal for this today is to activate the National Disaster Medical port times modify the definition of a major trauma victim, and
System. does this influence outcome? Finally, do present field triage
Interestingly, in some of the more recent natural disasters, criteria provide adequate rates of undertriage and overtriage?

there have been approximately 1015% of the survivors who Each of these questions will be addressed individually.
were seriously injured. The remaining people either were dead
or had mild to moderate trauma. It becomes a pivotal task to
rapidly sort through the survivors and identify the level of care Major Trauma Patient

needed by each patient. In the World Trade Center, the New The definition of a major trauma patient is a person who has
York Fire Department and EMS utilized the START system. sustained potentially life- or limb-threatening injuries and is
The initial scene casualties were from the planes striking the based on retrospective analysis of the patients injuries. The
building. Fire and rescue personnel could not reach these major trauma definition is used primarily to monitor field triage
patients. With the collapse of the first tower, rescue operations criteria as well as calculate undertriage and overtriage rates within
were aborted and attempts to evacuate rescue personnel became a regional trauma system. Unfortunately, there is no absolute
paramount.52 Following the collapse, victims injured in the standard for the criteria that have been used when defining
street or from the surrounding buildings required medical treat- major trauma. The best that can be accomplished is to retrospec-
ment. As rescue operations resumed, injured rescue workers tively compare quantified injury severity data to mortality and
began to arrive at medical treatment facilities. Unfortunately, then use a predefined threshold as defining major trauma.
there were only five survivors of the Twin Tower collapse with The ISS is a measure of physical injury, based on adding up
over 3,000 fatalities, which included civilians and rescue the square of the three highest individual anatomic injury
personnel. scores (Abbreviated Injury Scale [AIS], range 16) calculated
The experience in Israel with terrorist attacks has demon- from all of the patients known injuries.22 When used to define
strated that rapid and accurate triage is critical to decrease or major trauma, an ISS of 15 or more has been the most fre-
minimize mortality. Therefore, it has been suggested that the quently utilized threshold. Using this definition, a trauma vic-
best triage officer, at least in bombings and shooting massacres, tim must have a single anatomic injury score of 4 or two AIS
which are the most common form of terrorist violence, is the 3 injuries in order to be categorized as sustaining major
trauma surgeon. This is important to guarantee that those in trauma. Because ISS has been shown to have a good correla-
real need of immediate surgical attention are seen and treated tion with mortality over a wide range of ages and different types
in a timely fashion without inundating the hospitals with of injuries, it has been the most frequently utilized method for
patients who can be treated at a later time. stratifying the injuries of patients for comparison with prehos-
Critical concepts have been learned from the Israeli experi- pital triage scores. However, it has several shortcomings when
ence. These include rapid and abbreviated care, unidirectional used as a determinant of major trauma with regard to analysis
flow of casualties, minimization of the use of diagnostic tests, of field triage criteria.
and relief of medical teams ever so often to maintain quality and Several studies have shown that preventable deaths can
effectiveness in care delivery. The concepts of damage control occur with a single AIS 3 injury.14,62 For example, a patient with
should be liberally applied in the operating room (OR) to free a closed head injury and an AIS of 3 is at a higher risk of death
up resources for the next wave of injured individuals.5659 than if the patient had a similar grade extremity injury. In a
In mass casualties, hospitals become overwhelmed very eas- retrospective autopsy analysis of all patients dying within
ily. Therefore, communication between hospitals is critical to 24 hours, Bansal et al. demonstrated that closed head injury
distribute the casualties in an evenly fashion. was the most common cause of death; however, there was a
Surgeons should be familiar with the basic principles of mass significant variation in ISS and therefore ISS alone could not be
casualty management. Trauma surgeons should be the leaders used as a predictor of early death.63 As a result, there is no con-
in this field, as trauma systems serve as a template for the triage, sensus on the numeric value of ISS that defines major trauma.
evacuation, and treatment of mass casualty victims. The Stewart et al. used an ISS of greater than 12 to define their
American College of Surgeons has emphasized on this critical study population when they reported on the improvement in
role for surgeons.60 outcomes of motor vehicle accident victims after trauma center
designation.64 Similarly, Petrie et al. also used an ISS of greater
than 12 when they reported on the improvement of outcomes
of patients who had trauma team activation when compared to
There is little argument that a regionalized trauma system those who did not.65 However, Morris et al. defined major
reduces the number of potentially preventable deaths due to trauma as a patient with an ISS of 20 or more when they
trauma.16,61 To do so, one must accurately select which trauma reported on the ability of the TS to prospectively identify
victim will benefit from the resources of a trauma center. The patients with life-threatening injuries.66 Additionally, Norwood
dilemma is 2-fold: (1) Which criteria should be used to define and Myers stratified their patient sample into two groups based
the major trauma victims? (2) How are these patients identi- on ISSs of 19 or less and 20 or morewhen they reported on
fied in the field? Other relevant questions include: Does selec- outcomes from a rural-based trauma center.67 Thus, comparing
tive triage of patients in terms of hospital resources at the time studies that define major trauma becomes very difficult due to
of hospital admission benefit the major trauma patient, and, if the differences in the ISS threshold.
66 Trauma Overview

A second problem with ISS is that it is based on injuries lowest to highest quartile, did not reveal any increase in mortal-
identified within specific anatomic regions and takes into ity. The authors concluded that even though decreased EMS
account only one injury per body region. Therefore, ISS may transport times may improve mortality for select patients, over-
not be a sensitive indicator of certain types of injuries. Several all this relationship across a wide field of injured victims does

studies have found that ISS is not as accurate in identifying the not seem to affect mortality. Therefore, utilization of the most
severity of the injury in penetrating or blunt trauma, in which appropriate transport mode for specific patients should maxi-
several organ systems may be injured within the same anatomic mally utilize health care resources and dollars.73
location. This has led to the development of specialized ana-

tomic injury scoring systems such as the Penetrating Abdominal

Trauma Index (PATI)68 and, ultimately, the Organ Injury Scale Field Triage Scores
(OIS)69 that may more accurately reflect the severity of the Triage scores that are based on physiologic data are accurate in
injury. A modification to the calculation of ISS scoring has doing so. The original first step field trauma triage criteria
been introduced as the New Injury Severity Score (NISS), were published by consensus from the ACSCOT that stratified
which is defined as the sum of the squares of the AIS scores of them by GCS 12, SBP 90 mm Hg, and RR 10 or 29.74
each of a patients three most severe AIS injuries regardless of The TS, CRAMS scale, RTS, and the PHI have good correla-
the body region in which they occur. This method has been tion with the ISS and are able to predict mortality with a sen-
found to be more predictive of survival, but may overestimate sitivity of at least 85%. However, no single field triage scoring
the severity of injury for lesser injury grades.70 In addition, scheme has been universally accepted as the gold standard. This
injury severity scoring may also be inaccurate, as the ISS fails to is due, in part, to the fact that there is no agreed-upon standard
differentiate between severity of injury and mismanagement of that defines major trauma that allows for comparison of the
injury and, as a result, assigns an increased injury severity to individual triage scoring systems. An evidence-based analysis is
lesser injuries of inappropriately managed patients. limited by this problem. As a result, each of the individual scor-
Transport times may need to be included in the definition ing systems has its advocates as well as critics.
of the major trauma patient when used for triage or interfacility When Gormican originally described the CRAMS scale,
transport purposes, particularly when they exceed 30 minutes. rather than using an ISS threshold to define major trauma, he
When time is added to lesser injuries before definitive care, defined it as the patient who died in the emergency department
ongoing bleeding, the magnitude of the resuscitation, and the or went directly to the OR.47 Minor trauma was defined as a
relative stability of the patient may increase the injury severity patient who was discharged home from the emergency depart-
of otherwise equivalent injuries. A number of studies have ment. Using a CRAMS score of 8 or less to signify major trauma,
shown that hemodynamic and respiratory dysfunction, as well he found a sensitivity of 92% and a specificity of 98% in identify-
as mortality, is increased with increasing transport times.71 As ing major trauma victims. Others examined the ability of the
such, when long transport times are a problem and complica- CRAMS scale to accurately identify patients who required admis-
tions due to long transport and inadequate resuscitation can be sion to the hospital or any operation for their injuries. Using this
anticipated, these patients should be considered for a higher definition for major trauma, they found that a CRAMS score of
level of care where critical care resources are more likely to be 8 or less failed to identify two out of three patients.
available. Patient transport modalities and point to trauma Champion et al., who constructed the TS by analyzing CNS,
center time of transport are unique to each region. Goldstein et al. cardiovascular, and respiratory data, a priori defined major
validated a transport decision process that utilized a modifica- trauma as a TS of 12 or less because it correlated with a decreased
tion of the PHI (the pretransport index) and documented the probability of survival.45 It has been shown that a TS of 12 or less
time and distance from a trauma center for these trauma trans- also failed to identify two out of three patients who required
fer patients in British Columbia. The pretransport index adds admission or an operation. Similar criticisms in the literature can
onto the two PHI variables: intubation and pneumothorax. be found for the PHI for its failure to accurately identify patients
Accurate recognition of the more seriously injured patients requiring emergency surgery, and the RTS for its low sensitivity
and the knowledge of the quickest modality to transport the in identifying patients requiring emergency treatment.75 The
patient to a trauma center resulted in a quicker time to defini- addition of the variables of age, body region injured, mechanism
tive time to care.72 Recently, an analysis by the Resuscitation of injury, comorbidity, and the PHI improved prediction of the
Outcomes Consortium (ROC) of the association between EMS PHI alone by 10% (sensitivity of 76% vs. 66%). Unfortunately,
intervals and in-hospital mortality following serious injury was the addition of the mechanism of injury to the PHI was almost
conducted. A total of 3,656 patients were prospectively col- as accurate as all of the major descriptors.
lected and a secondary retrospective analysis was performed It has been shown that the physiologic-based triage scores
studying mortality as a function of EMS transport time. All were unable to accurately identify survivors of major injuries,
patients were seriously injured with a mean systolic blood pres- each score having a sensitivity and specificity of less than 70%.
sure less than 90 mm Hg and a GCS less than or equal to 12. Holcomb et al. recently evaluated the utility of manual vital
Of those studied, 22.0% died after EMS transport to the hos- signs plus the GCS (motor and verbal scores) to predict the
pital and most within the same day. The overall mean EMS need for lifesaving interventions in nonclosed head injured
time was 36.3 minutes; however, when EMS time was delin- patients. In this group, patients with a weak radial arterial pulse
eated into 10-minute increments, there was no evidence of had an 11-fold increase in the need for a lifesaving intervention.
increased mortality. Similarly, total EMS times, grouped by A GCS verbal score of 23 in a nonclosed head injured patient
Trauma Systems, Triage, and Transport 67

had a 6-fold increase while a GCS motor score of 23 had a (GCS score 3, 412, and 1315) and the same analysis was
20-fold increase in the need for a lifesaving intervention. An performed, they found that each group had a different factor
additional conclusion was that the addition of automated vital that best predicted mortality. Systolic blood pressure was the
sign reporting, oxygen saturation monitors, or end-tidal CO2 strongest predictor of mortality in the GCS 3 group, ISS in the

monitors did not improve the predictive model of which GCS 412 group, and age in the GCS 1315 group.80
patients might need a lifesaving intervention.76 The ROC group Finally, the use of non-time-dependent data requires that
studied mortality and hospital length of stay in 6,259 adult the prehospital personnel have enough training and experience
trauma patients meeting ACSCOT first step physiologic tri- to recognize, interpret, and report them to the physician.

age criteria. Patients who died or had an LOS 2 days were Burstein et al. reviewed the prehospital EMS reports for specific
considered high risk, whereas survivors and LOS 2 days were ACS mechanism of injury triage criteria and found that it was
low risk. Total patient mortality in the high-risk category was underreported in standard EMS reporting documentation.
58.0%. Those patients were found to have a statistically sig- Reporting improved with the use of a structured data instru-
nificant increase in abnormal respiratory rate as well as ment that requested the presence or absence of the criteria.81 A
depressed GCS as sole criteria for triage. The authors further paramedics ability to recognize and report this type of criteria
evaluated the need for advanced airway management, outside may explain the discrepancy in studies reporting on the ability
of the ACSCOT criteria, and found that 31% of high-risk of paramedic judgment to correctly or incorrectly triage
patients compared to 5% of low-risk patients required advanced patients to a trauma center. The mechanism of injury does seem
airway interventions. The authors conclude that no specific to have a correlation with the need for a higher intensity of
physiologic parameter using present ACSCOT physiologic medical care or operation. In a study by Santaniello et al.,
criteria can be omitted, but perhaps airway intervention should nearly 50% of patients who met a mechanism of injury criteria
be added to further risk stratify high-risk trauma patients.74 needed an operative intervention.82
The incorporation of non-time-dependent data, such as
mechanism of injury, anatomic injury, and comorbid factors,
has been shown to make physiologic-based triage scores more In-Hospital Triage
sensitive in identifying the major trauma victim. However, Secondary, or in-hospital, triage complements field triage by
questions have also been raised as to whether this type of data stratifying the immediate needs of the trauma patient at the
identifies the major trauma patient. Its ability to do so appears time of admission. The emphasis of this retriage is to direct the
to be dependent on the context in which it is used. For exam- patient into the proper hospital area: urgent care, emergent
ple, Cooper et al. found that mechanism of injury had a posi- care, trauma bay, or the OR. During a multiple casualty event,
tive predictive value of only 6.9% when used to identify this in-hospital triage is essential to maximize hospital resource
patients with an ISS of 16 or greater. They concluded that it did allocation and patient flow.
not justify bypass of local hospitals when used as a sole criterion Tinkoff et al. reported on a two-tiered trauma response pro-
for triage to a trauma center.77 tocol.83 They used field triage criteria to identify patients
There are conflicting reports when analyzing non-time- requiring either a surgery-supervised trauma code or an emer-
dependent criteria as a determinant of outcome in trauma gency medicine-supervised trauma alert. Using this protocol,
patients. Smith and colleagues stratified patients into age over they found that accurate identification of the most seriously
65 and age under 65, and they found that preexisting condi- injured patients was achieved as demonstrated by the improved
tions did not significantly affect outcome. Age, however, was a ability to predict those patients who would require direct dis-
significant determinant of mortality. DeKeyser et al. compared position to the OR or ICU. Prehospital prediction models as
the mortality and functional outcomes of patients who were well as admission systemic inflammatory response syndrome
stratified into three groups based on age: age 3545, age 5564, (SIRS) scores may be useful to predict the need for ICU ser-
and age 65 and over. They found that there were no differences vices, and estimate length of stay and potential mortality of
between the three groups in terms of ISS, mortality rates, or seriously injured patients.
functional outcome.78 Van der Sluis et al. also evaluated differ- Hoyt et al. originally described predefined field criteria that
ences in mortality and long-term outcome between young and indicated OR resuscitation.21 Indications included cardiac arrest
elderly patients. They analyzed two groups of patients with an with one vital sign present, persistent hypotension despite field
ISS of 16 or greater: age 2029 and age 60 and over. They intravenous fluid, and uncontrolled external hemorrhage. They
reported that while there was a significant difference in terms of found that penetrating and blunt trauma patients who under-
early mortality, survivors of both groups were discharged in went operation in less than 20 minutes had a significantly greater
equal percentages and their functional outcome 2 years after probability of survival versus that predicted by MTOS data.
injury was essentially the same.79 A more recent analysis of their 10-year experience with OR
A possible explanation for these contradictory findings may resuscitation shows the survival advantage predominates in the
be that there are interactions between all the possible factors penetrating trauma victims.84 Rhodes et al. used a variety of
that have not been previously appreciated. Hill et al. analyzed triage criteria to indicate need for OR resuscitation: systolic
multiple factors as possible determinants of outcome in major blood pressure of 80 mm Hg or less, penetrating torso trauma,
trauma patients (ISS 15). They found that preresuscitation multiple long-bone fractures, major limb amputation, extensive
GCS was the overall strongest predictor of mortality. However, soft tissue wounds, severe maxillofacial hemorrhage, and
when the patients were stratified into different GCS categories witnessed arrest.85 The mean ISS and survival rate of all patients
68 Trauma Overview

meeting these criteria were 29.3% and 70.4%, respectively, two extra patient evaluations per trauma center per day, hardly
which were better than those predicted by TRISS methodology. a significant overburden to a trauma system.
Finally, Barlow et al. have advocated triage of pediatric patients At present, a combination of methods may provide the most
(age 16 and younger) directly to the OR based on mechanism accurate field assessment of the seriously injured trauma victim

of injury and have reported survival rates of 100% for patients and represents the current state of the art in identification of
admitted with stab wounds and 94% for patients admitted major trauma victims. A number of studies have shown that the
with gunshot wounds.86,87 sensitivity and specificity of physiologic-based triage scoring
Secondary triage has also been shown to benefit the hospital methods are improved by the addition of anatomic and/or

in terms of human and financial resources. DeKeyser et al. mechanistic injury data. The addition of the mechanism of
reported that the institution of a two-tiered, in-hospital trauma injury with the PHI did not improve the ability to identify seri-
response system, based on patient status at the time of admis- ously injured trauma patients. The structure of triage decisions
sion, reduced the cost of trauma care by more than $600,000 must be based on the individual trauma systems unique
over a 1-year period by reducing the utilization of personnel, resources and capabilities in both the prehospital and hospital
OR, laboratory work, and protective wear.88 Secondary triage phases of care and then employed such that patient morbidity
characteristics such as patient response to resuscitation mea- and mortality are minimized.
sures, newly diagnosed major injuries, or the presence of mark-
edly abnormal blood values (e.g., elevated lactate levels) portend
the need for enhanced medical resources and ICU care. Interhospital Transfer
Many trauma victims who live in rural communities do not have
immediate access to a designated trauma center or regional
Undertriage/Overtriage trauma system. These patients are generally taken to the local
The determination of the rates of undertriage and overtriage community hospital for their initial care. While most are ade-
based on the use of each of the current field triage scoring quately cared for by these facilities, there are a significant num-
methods would provide an answer to the main question of ber of patients who will require the services found only at a
which method best identifies the major trauma patient in the hospital dedicated to the overall care of the trauma patient.
field. The best method would have the lowest rates of both Previous studies have shown that these patients are at an
undertriage and overtriage. However, the variability over an increased risk of death. Some of the factors that have been impli-
equivalent definition of a major trauma patient makes this type cated in contributing to potentially avoidable mortality in this
of analysis subject to criticism. situation include failure to recognize the severity of the injury,
It is impossible to achieve perfect overtriage and undertriage lack of adequate resuscitative measures, and delay in or lack of
rates using current field triage methods. West and colleagues necessary treatment procedures for stabilization. It is imperative
found that the addition of non-time-dependent criteria to tra- that the initial treating physician should be able to recognize that
ditional physiologic triage criteria reduced the undertriage rate the trauma victim may have injuries that require diagnostic and/
from 21% to 4.4%, when undertriage is defined as non-CNS- or therapeutic modalities beyond the scope of the initial receiv-
related motor vehicle accident deaths occurring in non-trauma- ing hospital. If this situation is identified, then transfer of the
designated hospitals. However, depending on the definition of patient to a higher level of care is appropriate.
major trauma, overtriage ranged from 36% to 80%. Interhospital transfers should occur from one facility to
Other factors also appear to confound analysis of undertri- another that will provide the additional resources needed. This
age and overtriage. Studies have found that major trauma generally occurs from a Level III or IV hospital as part of a
patients (defined by ISS) were more likely to be undertriaged if regionalized trauma system. Patients may also need care from
they were elderly or had single-system injuries. Patients with specialized centers such as a burn center or a pediatric trauma
minor injuries were more likely to be overtriaged if they were center. However, one must recognize that the period of trans-
intoxicated, obese, or had an injury to the head or face. In real- port is one of potential instability for the patient, and the risks
ity, acceptable rates of undertriage and overtriage are dependent of transport must be balanced against the benefits of a higher
on how a trauma system defines major trauma and the type of level of care.
field triage criteria employed. Risk to the patient can be minimized with the use of proper
The San Diego Trauma System has reported overtriage rates equipment, personnel, and planning. The patient may need to
by comparing patients transported to those entered into the undergo a period of resuscitation and stabilization prior to trans-
trauma registry using MTOS criteria. Data regarding prevent- fer.89 Some patients may not stabilize and require more definitive
able deaths are also available because all nontrauma centers intervention prior to transfer. Communication with the trauma
have trauma deaths reviewed. Using this approach the data sug- center will assist in this determination as well as interventional
gest that combining physiologic and non-time-dependent crite- planning. A patient with an unstable intra-abdominal hemor-
ria leads to an overtriage rate of approximately 35% and an rhage may need a damage control surgery with abdominal pack-
undertriage rate of less than 1%. These rates have been found ing in order to be stable enough for transfer. The trauma surgeon
to be stable over time and would seem to be reasonable targets. could be in constant communication with the outlying surgeon
Looked at another way, this translates to about 30% unneces- to assist in the decision making for the operative procedure. This
sary transports, which calculates to 2,000 patients per year or concept is particularly important with distant interhospital trans-
about 6 patients per day. This amounts to no more than one to fers. In addition to the medical aspects of interhospital transfer,
Trauma Systems, Triage, and Transport 69

physicians must also comply with certain federal and local legal actual transfer. This should include patient identification, his-
regulations. Failure to do so has serious ramifications for the tory and physical examination findings, diagnostic and thera-
transferring hospital as well as the individual physician.90 peutic procedures performed and their results, and the initial
impression and a clear identification of the referring and receiv-

ing physicians. This information then allows the trauma sur-
Criteria for Interhospital Transfer geon at the receiving hospital to suggest possible diagnostic or
Identification of a trauma victim who may benefit from transfer therapeutic maneuvers that may be required prior to transfer,
to a designated trauma center is based on specific criteria. A such as intubation, insertion of a nasogastric tube, Foley cathe-

number of factors must be examined when making this deci- ter, or thoracostomy tube. It also allows for mobilization of
sion, including patient status and recognition of possible inju- resources, such as an ICU bed or OR, at the receiving hospital
ries and/or comorbid factors as well as the personnel and in anticipation of possible injuries. The physicians involved
equipment resources necessary for optimal patient care. should also discuss the mode of transportation, accompanying
Criteria for transfer are often not followed because of finan- personnel, and equipment that may be needed for optimal
cial conflicts or failure to appreciate the long-term complexities transfer. Discussion should also include who will assume medi-
of certain injuries.91 This may be best addressed in a trauma cal control of the patient during transport. Full documentation,
system through a legislative process that defines which patients including a summary of care from the referring hospital and
should be transferred to which level of care. The Colorado State copies of all studies, should accompany the patient to the receiv-
Board of Health has published Rules and Regulations pertaining to ing hospital.
the Statewide Trauma System in which criteria for interhospital
transfer have been defined.92 Patient criteria are based primarily
on physiologic and anatomic injury data (aortic tears, liver inju- Transport Modality
ries requiring intraoperative packing, bilateral pulmonary contu- The objective is to get the trauma victim to the receiving hospi-
sions requiring nonconventional ventilation, etc.), and on the tal as quickly and safely as possible. However, the mode of
level of care (Level II, III, IV) that the patients facility is able to transportation is dependent on the availability of a particular
provide. If the patient meets the criteria for that specific health mode, distance, geography, weather, patient status, and the
care facility, then consultation with a Level I trauma surgeon and skills of the transport personnel and equipment that will likely
discussion of possibility for interhospital transfer is mandatory. be needed during transport. This should be discussed between
Interhospital transfer may be essential in multiple casualty the referring and receiving physicians with each transfer.
events whereby a single hospital is overburdened by casualties. Knowledge of transporting agencies in the area and their avail-
In this case the criteria for the transfer of patients change in ability should be ascertained as soon as the need for transport is
order to offload the primary hospital patient load. Good triage recognized.
principles need to apply so that those patients who would ben- The patient should have appropriate monitoring of physi-
efit the most would be transferred. These transfers may even ologic indices, including invasive monitoring, during the
occur between two equivalent level institutions in order to transport period. This may include monitoring of respiratory
facilitate the distribution of trauma victims. As was demon- rate, cardiac rhythm and blood pressure, intracranial pressure,
strated in the World Trade Center disaster, the walking and central venous or pulmonary artery pressure. If the patient
wounded inundated the closest medical facilities to ground is intubated, end-tidal CO2 should be monitored and the
zero. This condition has the potential to make it more difficult transport ventilator should have alarms to indicate disconnects
to identify and treat the most seriously injured patients from and high airway pressures. The other additional equipment
the mass of patients who arrive at the hospital. necessary for safe transport is that needed for effective ACLS/
ATLS interventions and has been outlined in a number of
Methods of Transfer
Transfer of the trauma victim must be organized in a way that Transport Team
minimizes the risk to the patient during the transfer process.
This includes establishing transfer protocols at the EMS and The patient should be accompanied by at least two people in
institutional levels prior to transport. It also includes the plan- addition to the vehicle operator, one of whom should have
ning that is necessary after the decision for transfer is made in requisite training in advanced airway management, intravenous
individual cases with respect to the type of equipment, mode of therapy, cardiac dysrhythmia recognition and treatment, and
transport, and personnel necessary to maximize patient safety. ATLS. If the transporting personnel do not have the necessary
training or skills, a nurse or physician should accompany the
patient during transport to ensure optimal care.
Transfer Agreement
Minor delays can have adverse consequences for the major
trauma victim; it is therefore necessary to expedite the transfer
process once its need is recognized. Transfer agreements are Reduction in the morbidity and mortality of trauma patients
established protocols between hospitals that ensure rapid and who require the resources of a trauma center depends on early
efficient passage of pertinent patient information prior to the identification of the severely injured, proper initial stabilization,
70 Trauma Overview

and safe interhospital transfer.93 There is evidence that patients geography, weather, and overall patient status. Because outcome
who sustain major trauma in a rural or small community set- is directly related to time to definitive care, the quickest mode
ting are at an increased risk for adverse outcomes. A high inci- of transport that ensures patient safety should be chosen.
dence of departure from well-defined standards in the initial Several options are available at many major trauma centers,

evaluation and management of major trauma victims in rural including traditional ground transport and helicopter and
community hospitals has been demonstrated. A report on the fixed-wing air transport. The data on transport modality may
care of fatally injured patients in a rural state found that 22% not directly correlate to interhospital transfer because much of
of fatally injured patients with non-CNS injuries reaching the them come from analyzing transports from the scene of the

emergency department alive had potentially survivable injuries. accident rather than from one hospital to another.
Errors in initial volume replacement, airway control, and recog- Baxt and Moody found that patients transported from the
nition of the need for surgical intervention were factors compli- scene of the accident by helicopter had a 52% reduction in
cating the care of these patients. mortality compared to those transported by ground.97 Similar
The adequacy of initial care of patients subsequently trans- results were found by Moylan et al. when they looked at factors
ferred to a trauma center with regard to neurologic, chest, improving survival in multisystem trauma patients who were
abdominal, and orthopedic injuries has also been studied. transported by air versus ground.98 There were no differences
Major departures from accepted standards of care, promoted in the prehospital times between these two sets of patients, and
by the ASCOT and the ACEP, in more than 70% of these the air-transported patients were more frequently intubated
cases were found. The care of patients initially treated at local and transfused blood, and had larger volumes of fluid given
community hospitals during initial management and subse- than the ground-transported patients.
quent transport to a referral trauma center was reviewed. The main benefit of air transport appears to be its use for
Quality of care was assessed based on ATLS guidelines. Life- long-distance transport. Several studies have shown that there is
threatening deficiencies occur in 5% and serious deficiencies an improved survival in patients who need higher level of care
in 80% of cases reviewed, including inadequate cervical spine when transported by air, and this benefit can be realized up to an
immobilization, inadequate intravenous access, and inade- 800-mile radius from the trauma center. This mode of transport
quate oxygen delivery. Veenema and Rodewald demonstrated may not be appropriate for short-distance transfer due to pro-
that, while initial triage and management of rural trauma vic- longed response time for interhospital transport. For local urban
tims at a Level III trauma center prior to Level I transfer pro- transport, helicopters offer no advantage over an organized
vide outcomes similar to MTOS data, there were still ground transportation system, and the increased cost for air
unexpected deaths.93 transport, especially that of helicopters, is probably not justified.
Timely transfer of major trauma victims to trauma centers Trauma triage and the interhospital transfer process have
improves patient care and subsequent outcome. Trauma centers many similarities. Both have the same goal: to minimize poten-
not only provide the resources for the early management of tially avoidable deaths. In order to accomplish this, both attempt
severely injured patients, but can also provide more extensive to accurately identify the trauma patient who will require the
support for the patient beyond the initial 24 hours. specialized skills and resources provided by a Level I or II trauma
There are few studies that have looked at specific criteria as center. Both utilize the same type of limited information early
markers for patients who would benefit from interhospital in the course of events in order to make that decision.
transfer. Lee et al. attempted to clarify specific anatomic criteria While certain types of obvious injuries warrant expeditious
that would indicate the need for interhospital transfer from transport of the trauma victim, it is best to look at all of the
Level III centers.94 They found that the presence of three or available information in terms of physiologic indices, mecha-
more rib fractures was a marker for potential serious injury, as nism of injury, comorbid factors, and known or suspected inju-
evidenced by significant differences in outcome when com- ries. This approach allows one to assess potential problems that
pared to patients with one or two rib fractures. A subsequent may be more appropriately handled at a major trauma center. If
population-based study confirmed that these patients have a there is any doubt, it is in the patients best interest to be taken
significantly higher mortality rate, higher ISS, and longer ICU to a facility providing the highest level of care available.
and overall hospital stay.95 Clark et al. reviewed their experience
with major hepatic trauma (Grade III or more) in patients
transferred from rural facilities. However, they did not delineate TRAUMA CENTER FACILITIES AND LEADERSHIP
specific transfer criteria.96 Similar studies have looked at mech- Hospital care of the injured patient requires commitments from
anistic and physiologic criteria as reasons for bypassing rural/ specific facilities to provide administrative support, medical
local community hospitals or determining the need for a spe- staff, nursing staff, and other support personnel. The trauma
cific transport modality. center integrates the trauma care system by providing local or
regional leadership. Trauma centers are categorized by level, as
The question of whether air or ground transport is more appro- Level I Trauma Center
priate for the transfer of the trauma victim is dependent on a The Level I trauma center is a tertiary care hospital usually serv-
number of factors. This includes the distance to be traveled, ing large inner-city communities that demonstrates a leadership
Trauma Systems, Triage, and Transport 71

role in system development, optimal trauma care, quality bums, spinal cord injuries, and hand (replantation) trauma.
improvement, education, and research. It serves as a regional Where present, these facilities provide a valuable resource to the
resource for the provision of the most sophisticated trauma care, community and should be included in the design of the system.
from resuscitation to rehabilitation and managing large num-

bers of severely injured patients to immediate 24-hour avail-
ability of an attending trauma surgeon. Level I trauma centers REHABILITATION
address public education and prevention issues on a regional Rehabilitation is as important as prehospital and hospital care.
basis and provide continuing education for all levels of trauma It is often the longest and most difficult phase of the trauma

care providers. They lead research efforts to advance care. care continuum for both patient and family. Only 1 of 10
trauma patients in the United States has access to adequate
Level II Trauma Center rehabilitation programs, although it is critically important to
reintegrating the patient into society. Rehabilitation can be
The Level II trauma center also provides definitive care to the
provided in a designated area within the trauma center or by
injured and may be the principal hospital in the community or
agreement with a freestanding rehabilitation center.
may work together with a Level I trauma center, in an attempt
to optimize resources and clinical expertise necessary to provide
optimal care for the injured victim. Its approach to trauma is SYSTEM EVALUATION
generally not as comprehensive as the Level I facility. The
attending trauma surgeons availability is equivalent and he or A trauma system has to monitor its own performance over time
she must participate early in the care of the patient. Graduate and determine areas where improvement is needed. To achieve
education and research are not required. this goal, reliable data collection and analysis through a state-
wide or systemwide trauma registry is necessary. Information
from each phase of care is important and must be linked with
Level III Trauma Center every other phase. Compatibility between data collection dur-
A Level III trauma center generally serves a community that ing different phases of care is important to accurately determine
lacks Level I or II facilities. Maximum commitment is required the effects of certain interventions on long-term outcome. The
to assess, resuscitate, and, when necessary, provide definitive practical use of a system evaluation instrument is to identify
operative therapy. For the major trauma patient, the principal where the system falls short operationally and allow for
role of the Level III center is to stabilize the injured patient and improvements in system design. This feedback mechanism
effect safe transfer to a higher level of care when capabilities for must be part of the system plan for evaluation.
definitive care are exceeded. Transfer agreements and protocols The implementation of trauma care systems coupled with
are essential in a Level III trauma center. Education program trauma registry databases, injury severity indices, and measur-
for health care personnel may be part of a Level III centers role, able outcome indicators has led to improved validity for inves-
as the hospital may be the only designated trauma center in the tigations across the entire spectrum of injury control research.
community. The system also has to be evaluated by the American College of
Surgeons Committee on Trauma Verification Review Committee
or by inviting experts as outside reviewers in addition to inter-
Level IV Trauma Center nal review.
A Level IV trauma center is usually a hospital located in a rural
area. Level IV trauma centers are expected to provide the initial
evaluation and care to acutely injured patients. Transfer agree- TRAUMA SYSTEM QUALITY IMPROVEMENT (QI)
ments and protocols must be in place, since most of these hospi-
The systemwide QI programs most important role is to moni-
tals have no definitive surgical capabilities on a regular basis.
tor the quality of trauma care from incident to rehabilitation
and create solutions to correct identified problems. The pur-
Acute Care Facilities within the System pose of quality improvement is to provide care in a planned
Many general hospitals exist within a trauma care system but sequence, measure compliance with defined standards of care,
are not officially designated as trauma centers. Circumstances and reduce variability and cost while maintaining quality. A
often exist in which less severely injured patients reach these comprehensive downloadable guide to this process is detailed
hospitals and appropriate care is provided. The system should on the American College of Surgeons Web site.
provide for interfacility transfer of patients if a major trauma It allows health care providers to monitor several aspects of
patient is mistriaged and registry entry for injured patients medical care using explicit guidelines to identify problems that
managed at nondesignated facilities. have a negative impact on patient outcome. This is accomplished
by establishing standards of trauma care and a mechanism to
monitor the trauma care provided (surveillance), usually with
Specialty Trauma Centers audit filters designed to identify outliers.
Regional specialty facilities concentrate expertise in a specific Errors occur due to the complexity of trauma care and
discipline and serve as a valuable resource for patients with criti- because of the involvement of multiple providers. It is of
cal specialty-oriented injuries. Examples include pediatric trauma, fundamental importance to make a distinction between process
72 Trauma Overview

complexity and human errors when developing a quality STANDARDIZED DEFINITION OF

improvement program in trauma.99102 ERRORS AND PREVENTABLE DEATH
A peer process must be established to review QA/QI prob-
lems.103 The process must be accurately documented, correc- The development of trauma systems led to a significant reduc-

tive action instituted and applied uniformly across the system, tion in the number of preventable deaths after injury. A pre-
and the results reassessed. These principles apply to system- ventable death rate of less than 12% is now widely accepted as
wide QA/QI as well as to the process within the hospital. ideal in a trauma system. However, a small number of patients
Corrective action is taken through changes in existing policies continue to die, or eventually, to develop complications that

or protocols, through education targeted at the problem, or by could otherwise be avoided or prevented. These errors occur in
restriction of privileges. different phases of trauma care (resuscitative, operative, and
A successful trauma system monitors the performance of the critical care phases), and are named provider related, as a group.
EMS agency and prehospital operations, individual trauma These include events that lead to delays or errors in technique,
hospitals, and care in nondesignated hospitals. judgment, treatment, or communication. A delay in diagnosis
The prehospital audit process should include timeliness of is defined as an injury-related diagnosis made greater than
arrival, timeliness of transport, application of prehospital pro- 24 hours after admission resulting in minimum morbidity. An
cedures and treatments, and outcomes. To develop this part of error in diagnosis is an injury missed because of misinterpreta-
the quality improvement process, extensive involvement by the tion or inadequacy of physical examination or diagnostic proce-
regional authority, the regional medical director, the provider dures. An error in judgment is defined as a therapeutic decision
agencies, and the trauma hospitals is required. or diagnostic modality employed contrary to available data. An
Standards of care are defined in relation to the availability of error in technique occurs during the performance of a diagnos-
resources and personnel, timeliness of physician response, diag- tic or therapeutic procedure.102
nosis, and therapy. These standards have been defined by the According to the ACSCOT Resources for Optimal Care of the
ACS and published in the Resources for Optimal Care of the Injured Patient: 2006 document, an event is defined as nonpre-
Injured Patient.4 Guidelines or protocols are then developed ventable when it is a sequela of a procedure, disease, or injury
and audit filters are established to monitor the guidelines. Audit for which reasonable and appropriate preventable steps had
filters are useful tools to provide continuous monitoring of been observed and taken. Potentially preventable is an event or
established practices. Standard audit filters and complications complication that is a sequela of a procedure, disease, or injury
that need to be monitored have been established by the that has the potential to be prevented or substantially amelio-
ACSCOT and include timeliness of care, appropriateness of rated. A preventable event or complication is an expected or
care, and death review. Tracking of complications and illnesses unexpected sequela of a procedure, disease, or injury that could
allows trends to be monitored over time. Death reviews should have been prevented or substantially ameliorated.4
be conducted in an attempt to determine preventability. With regard to mortality, the same definitions apply.
Guidelines reduce variability, and, consequently, fewer errors Nonpreventable deaths are defined as fatal injuries despite opti-
are made. mal care, evaluated and managed appropriately accordingly to
The process of quality improvement requires accurate docu- standard guidelines (ATLS), and with a probability of survival,
mentation and this is achieved by using the trauma registry. estimated by using the TRISS methodology, of less than 25%.
The trauma registry provides objective data to support continu- A potentially preventable death is defined as an injury or com-
ous quality improvement. The registry should be designed to bination of injuries considered very severe but survivable under
collect and calculate response times, admission diagnoses, diag- optimal conditions. Generally these are unstable patients at the
nostic and therapeutic procedures, discharge diagnoses, compli- scene who respond minimally to treatment. Evaluation and
cations, costs, and functional recovery. management are generally appropriate and suspected care, how-
The trauma coordinator is of utmost importance in making ever, directly or indirectly is implicated in patient demise. The
the quality improvement process effective. This person assures calculated probability of survival varies from 25% to 50%.
timely recognition of problems, use of the registry to document A preventable death usually includes an injury or combina-
problems, and that problems are resolved. Cases identified as tion of injuries considered survivable. Patients in this category
noncompliant with established standards of care are reviewed at are generally stable, or if unstable, respond adequately to treat-
the hospital level and by a trauma medical audit committee ment. The evaluation or treatment is suspected in any way, and
overseeing the trauma system.103 the calculated probability of survival is greater than 50%.
Peer review identifies the problem, the results are docu- The causes of preventable deaths in trauma centers are differ-
mented and determination of problem recurrence is made, ent than those occurring at nontrauma hospitals. In nontrauma
trends are identified, and a decision is made if more specific hospitals, preventable deaths occur because the severity or mul-
action for problem resolution is required. tiplicity of injuries is not fully appreciated, leading to delays in
Actions may include simple education of the staff or revision diagnosis, lack of adequate monitoring, and delays to definitive
of the guidelines, or eventually development of new guidelines, therapy. In trauma hospitals, the causes of preventable death
hiring additional staff, or even removing a staff member. The include errors in judgment or errors in technique. In trauma
monitoring process should continue after action was taken to centers the diagnostic modalities used are normally adequate,
determine its effectiveness. Quality improvement processes in and delays in diagnosis or treatment are uncommon and have
trauma are a multidisciplinary task. minimal impact on outcome.
Trauma Systems, Triage, and Transport 73

These definitions are useful to monitor trauma systems per- or in the same trauma center at different periods. The MTOS23
formance and to compare different trauma systems. Once pre- has been used as the national reference, although several of its
ventable death rate reaches a plateau after trauma system limitations have been recognized, compromising the reliability
implementation, system performance should focus on tracking of the comparison with data from other systems or centers

provider-related complications. This approach has been proved (Table 4-4). The advantages of registry-based studies include a
adequate to identify problems and to implement solutions. detailed description of injury severity and physiologic data.
Population-based studies use information obtained from
death certificates, hospital discharge claim data, or fatal acci-

dent reporting system (FARS) on all injured patients in a
Different study designs have been used to evaluate trauma sys- region. These methodologies of data collection and analysis are
tem effectiveness. The most common scientific approaches important to evaluate changes in outcome before and after, or
include panel review preventable death studies, trauma registry at different time periods following the implementation of
performance comparisons, and population-based studies. Panel trauma systems in a defined region. Limited information on
review studies are conducted by a panel of experts in the field physiologic data, injury severity, and treatment is available.104
of trauma who review trauma-related deaths in an attempt to The limitations of the most commonly used databases in pop-
determine preventability. Well-defined criteria and standard- ulation-based studies are described in Table 4-4.
ized definitions regarding preventability have been used, but The data on trauma system effectiveness published in the
significant methodological problems (Table 4-4) can lead to literature are difficult to interpret due to great variability in study
inconsistencies in the results and interpretation of the design, type of analysis, and definition of outcome variables. In
data.16,103 an attempt to review the existing evidence on the effectiveness of
Registry studies are frequently used to compare data from a trauma systems, the Oregon Health Sciences University with
trauma center or a trauma system with a national reference support from the NTHSA and the National Center for Injury
norm available, between trauma centers within the same system, Prevention and Control of the CDC organized the Academic
Symposium to evaluate Evidence regarding the Efficacy of Trauma
Systems, also known as the Skamania Symposium.105
TABLE 4-4 Limitations of Current Trauma System Trauma care providers, policy makers, administrators, and
Evaluation Studies researchers reviewed and discussed the available literature in an
Panel studies attempt to determine the impact of trauma systems on quality
Inconsistent definition of preventability of patient care. The available literature on trauma system effec-
Case mix of the population tiveness does not contain class I (prospective randomized con-
Size, composition, and expertise of the panel trolled trials) or class II studies (well-designed, prospective or
Process and criteria to determine preventability retrospective controlled cohort studies, or case-controlled stud-
Inconsistent report of prehospital and autopsy data ies). There are several class III (panel studies, case series, or reg-
istry based) studies that were reviewed and discussed during the
Registry-based studies symposium. According to Mann et al. reviewing the published
Missing or incomplete data sets literature in preparation for the Skamania Symposium, it is
Coding inconsistencies and errors appropriate to conclude that the implementation of trauma
Inconsistent report of autopsy data systems decreases hospital mortality of severely injured patients.106
MTOS limitations Independently of the used methodology (panel review, registry
Outdated data set based, or population based), and despite the above-mentioned
Data are not population based limitations of each study design, a decrease in mortality of
Mostly blunt trauma 1520% has been shown with the implementation of trauma
Differences in trauma centers level of care systems. The participants of the symposium also concluded that
Inconsistencies in trauma registry inclusion criteria not only mortality but also functional outcomes, financial out-
Lack of data on comorbid factors comes, patient satisfaction, and cost-effectiveness should be
Lack of data on long-term follow-up evaluated in future prospective, well-controlled studies.
Population-based studies Outcomes data are difficult to interpret due to differences in
Mechanism of injury, physiologic, and anatomic data study design. One recent area of interest has been in comparing
usually not available outcomes in inclusive and exclusive systems. As mentioned
Autopsies not performed consistently in all trauma deaths previously, in an inclusive system, care is provided to all injured
Limited number of secondary diagnoses in claims data patients and involves all acute care facilities, whereas in exclu-
Autopsy findings not always included in claims data sive systems specialized trauma care is provided only in high-
Hospital discharge data are inaccurate in transfers and level trauma centers that deliver definitive care. In inclusive
deaths in the emergency department systems, patients may be transferred to a higher level of care
Inconsistencies in obtaining AIS scores (trauma center) after initial stabilization based on the availabil-
Outcome measure is in-hospital mortality. No long-term ity of resources and expertise in the initial treating facility. Two
or functional outcomes data available problems arise: (a) delay in transfer and (b) dilution of trauma
centers experience. Utter et al. have recently investigated
74 Trauma Overview

whether mortality is lower in inclusive systems compared to

TABLE 4-5 Current Problems of Trauma Systems
exclusive systems. They concluded that severely injured patients
are more likely to survive in states with the most inclusive Urban
trauma system, independent of the triage system in place. A Financial

possible explanation to these findings includes better initial care Uncompensated care
in referring hospitals.107 A more recent study confirms a mortal- Closure of trauma centers
ity reduction of 25% in patients under the age of 55.61 Source of funding for indigent care
Overdesignations of trauma center

Sparse population
Despite the experience acquired on trauma system develop- Long distances
ment in the United States during the last three decades, trauma Difficult patient access
systems still face multiple problems and challenges. The finan- Weather conditions
cial aspect, linked to the problem of uncompensated care, has Delays in notification
led to the closure of several trauma centers and the collapse of Treatment delays due to interfacility transfer needs
some trauma systems. Alternative and stable sources for fund- Lack of medical oversight
ing indigent care have to be part of an agenda for legislative Pediatric
action in support of trauma systems. This is particularly impor- Integral part of the system
tant given recent published reports showing that the risk of Education
death is significantly lower in trauma centers than nontrauma Elderly
centers. In an important study, MacKenzie et al. compared rates Increased costs
of both in-hospital and 1-year mortality in trauma victims Increased morbidity and mortality
treated in trauma centers versus nontrauma centers. After risk Prevention
and case mix adjustment, trauma centers had an in-house mor- Lack of federal/state funding needs to be addressed in
tality of 7.6%, significantly less than nontrauma centers where order to increase the number of states engaged in
mortality was 9.5%. After 1 year, trauma center mortality was developing statewide or regional trauma systems in
10.4% compared to 13.8% in nontrauma centers.61 Funds for the United States
prevention strategies should also be provided, targeting particu- Funding required:
larly the pediatric and the elderly population. Table 4-5 lists National level: national trauma system development
the actual problems faced by regionalized trauma systems as State/local level: to finance the EMS system
documented through an SWOT analysis conducted by the Research/prevention/avoidance of duplication
Health Resources and Service Administration in 2003.
One effort that has been developed recently is the Consultations
for Trauma Systems document and accompanying process devel-
oped by the ACSCOT.12 It follows previous efforts to develop outcomes, reduces costs, improves efficiency, facilitates trans-
trauma systems and the original Model Trauma System Care fers, and enhances education and research.3,5,109
Plan.108 The consultation provides two unique services: (1) an Despite the realization that trauma systems reduce morbid-
exceptional and experienced team enables examination and a ity and mortality, there remain several barriers to full imple-
knowledgeable perspective to optimize hospital and community mentation. A trauma system agenda for the future has been
trauma resources and (2) the consultant team brings the credibil- recently written and endorsed as a template for going forward.
ity of the ACSCOT to hospitals developing a trauma center. A Critical elements are defined in Table 4-6. It is imagined that
more recent effort has led to the Model Trauma System Planning trauma systems when fully implemented will enhance commu-
and Evaluation Program developed in collaboration with the nity health through an organized system of injury prevention,
HRSA of the U.S. Department of Health and Human Services.7 acute care, and rehabilitation that is fully integrated into the
This is the most comprehensive tool available to help develop public health system of a community. In addition to addressing
regional trauma systems. the daily demands of trauma, it will form the basis for disaster
As important is the issue related to the ideal number of preparedness and possess the distinct ability to identify risk fac-
trauma centers needed in an organized system. Many states tors and early interventions to prevent injuries in a community
with organized trauma systems, as well as many counties with while integrating a delivery of optimal resources for patients
developed trauma systems, have not performed a needs assess- who ultimately need acute trauma care.
ment prior to the implementation of the system. Similar to The availability of federal dollars to assist in the develop-
other fields of surgery and medicine, data suggest that the ment of trauma systems will be essential. At the same time, a
patient volume correlates with outcomes. Severely injured developing consensus to build trauma systems that do not cover
patients should be treated at high-volume trauma centers designated trauma centers yet meet the needs of all components
within a community, and the number of Level I trauma centers of the trauma patient will be equally critical. The biggest
should be based on a needs assessment. Limiting the number of challenge in the future will be the implementation of what we
trauma centers and concentrating the experience of managing already know how to do. Developing the political and public
severely injured patients in Level I trauma centers improves will to do so remains the challenge before us.
Trauma Systems, Triage, and Transport 75

21. Hoyt DB, Shackford SR, McGill T, et al. The impact of in-house
TABLE 4-6 Critical Targets for Future Trauma System surgeons and operating room resuscitation on outcome of traumatic
Development injuries. Arch Surg. 1989;124:906.
22. Baker SP, ONeill B. The injury severity score: an update. J Trauma.
Regionalization of trauma care 1976;16:882.

23. Champion HR, Copes WS, Sacco WJ, et al. The major trauma outcome
Development of disaster preparedness study: establishing national norms for trauma care. J Trauma. 1990;
Identification of trauma as a disease process 30:1356.
Recognition of the continuum of care required 24. Hoff WS, Tinkoff GH, Lucke JF, Lehr S. Impact of minimal injuries on
a level I trauma center. J Trauma. 1992;33:408.
Recognition that trauma requires a multidisciplinary 25. Guzzo JL, Bochicchio GV, Napolitano LM, et al. Predictions of outcomes

approach in trauma: anatomic or physiologic parameters? J Am Coll Surg.
Improving cost-effectiveness 2005;201:891.
26. Mackersie RC, Tiwary AD, Shackford SR, et al. Intra-abdominal injury
Coordination of resources, services, and special following blunt trauma. Identifying the high-risk patient using objective
populations risk factors. Arch Surg. 1989;124:809.
Reimbursement, funding, and legislation 27. Rizoli SB, Boulanger BR, McLellan BA, et al. Injuries missed during
initial assessment of blunt trauma patients. Accid Anal Prev.
28. Frankel HL, Rozycki GS, Ochsner MG, et al. Indications for obtaining
surveillance thoracic and lumbar spine radiographs. J Trauma. 1994;
29. Lowe DK, Oh GR, Neely KW, et al. Evaluation of injury mechanism as
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Injury Severity Scoring

and Outcomes Research
Robert D. Becher, J. Wayne Meredith, and Patrick D. Kilgo

INTRODUCTION factors that can influence the outcome. This is called risk
adjustment, or case mix adjustment, and is essential for
Traumatic accidents have long been classified in terms of their proper outcomes analysis.
severity. The worlds oldest known surgical document, the In trauma outcomes research, trauma ISSs are the essential
Edwin Smith Surgical Papyrus (ca. 17th century BC), classified tools for stratified risk adjustment, thereby allowing accurate
48 traumatic injuries from ancient Egyptian battlefields and comparisons among disparate patient populations with varied
construction sites as successfully treatable, possibly curable, or degrees of risk. The goal is to compare populations with similar
untreatable.1 Such predictions about patient outcomes, and degrees of traumatic injury so that other risk factors (time to
attempts to quantify the severity of traumatic accidents, are treatment, mechanism, injury prevention equipment, etc.) may
today the realm of injury severity scores (ISSs). be properly isolated to examine their relationship to particular
Trauma injury severity scoring quantifies the risk of an outcomes. Risk adjustment might be as simple as defining
outcome following trauma. Injury scoring provides a single classes of a variable to stratify risk groups or as complicated as
metric based on elements of clinical acumen and statistical using a risk adjustor in a multivariable regression model.3
theory to describe aspects of the patient condition after a trau- This chapter provides a background into injury severity
matic incident. The primary outcome of interest is usually scoring and outcomes research, reviewed in three sections. The
survival, though the outcome can be whatever one wants to first section, Injury Coding, discusses the two major schemes
measure: hospital or ICU length of stay (LOS), a vital sign such used to classify traumatic injury in the United States, the
as blood pressure, performance of a procedure, or any other Abbreviated Injury Scale (AIS) and the International
endpoint of interest. Classification of Diseases (ICD). The second section, Injury
Clinically, these scores assist in the prehospital triage of Severity Scoring, highlights the major trauma scoring systems
trauma patients and can help to more accurately predict patient used for outcome prediction and risk adjustment. The final
outcomes to assist with clinical decision making, especially at section, Outcomes Research, discusses the increasingly impor-
the end of life. In the outcomes research setting, ISSs allow tant role of outcomes research in the field of trauma, the
valid comparisons between disparate groups, which in turn can databases used for such research, and the basic approaches to
be translated into myriad applications: quality improvements in risk adjustment and statistical analysis.
patient care, advancements in trauma systems and health care
delivery, enhancements in injury prevention, valid benchmark-
ing and quality control report cards, and epidemiological
studies of trauma, among others. Accurate classification of a patients injuries, also known as
Outcomes research is defined as a method of creating injury coding, is fundamental to the validity and success
empirically verified information to better understand how of severity scoring. This is because ISSs are uniformly based
variables in the real-world setting (from injury to treatment) on two classification schemes: the AIS and the ICD
affect a wide range of outcome variables (from mortality to (Table 5-1).
satisfaction with care).2 Because outcomes are the product of The most advanced trauma-specific, anatomically based cod-
many influences, the outcomes researcher must isolate the ing lexicon is the AIS, which was first conceived as a system to
effects he or she wants to study from the effects of other noisy define the type and severity of injuries arising from motor vehicle
78 Trauma Overview

TABLE 5-1 Injury Coding/Classification Schemes: A Comparison

(Year First

Introduced; Year
Last Revised) Brief Description Primary Use Interpretation Benefits Limitations
AIS (1971; Trauma-specific, Classification For post-dot Continually Proprietary
2008) anatomically based of type and scores, any score updated, with system that

coding system with severity of 3 is serious; last update requires

two numerical injury based on any score of 6 in 2008; also specialized
components: (1) an tissue damage. is unsurvivable; found to be a training
injury descriptor pre-dot codes valid tool to for coding
(pre-dot) that is include nine predict survival and is time
unique to each injury anatomic regions: based on post- consuming;
and (2) a severity 1, head; 2, face; dot severity severity scores
score (post-dot) 3, neck; 4, thorax; score; can be are based on
graded from 1 (minor) 5, abdomen and treated as consensus
to 5 (critical injury); all pelvic contents; nominal data assessments
unsurvivable injuries 6, spine; 7, upper if only use and are
scored a 6; severity extremity; 8, pre-dot injury not totally
scores are consensus lower extremity; descriptors. objective.
assessments assigned 9, unspecified.
by a group of experts.
ICD-9-CM General, all-purpose Administrative Codes 800.0 to Codes often ICD taxonomy
(1893;2004) diagnosis classification purposes, 959.9 are trauma- used to has no specific
system/taxonomy for specifically specific; this define health severity
all health conditions/ billing includes roughly conditions in dimension
diseases; codes exist and event 2000 codes. large national included with
for over 10,000 reporting. databases the diagnoses
medical conditions; and therefore of a traumatic
each medical condition contribute to injury.
is assigned a specific research and
code. epidemiology.

AIS  Abbreviated Injury Score; ICD-9-CM  International Classification of Diseases, 9th Revision, Clinical Modification.

accidents.4 The last major revision to the AIS occurred in 2005,5 general, all-purpose diagnosis taxonomy for all health condi-
with a subsequent update in 2008.6 To calculate AIS scores, tions; it is over 110 years old and is currently in its 10th revision
medical records of traumatic incidents are transcribed into specific (ICD-10),7 though in the United States the 9th revision
codes that capture individual injuries. AIS is a proprietary classifi- (ICD-9)8 is most commonly used (though a conversion to
cation system, meaning it requires specialized training for coding using ICD-10 will be complete by the year 2013). Codes exist
personnel. Therefore, AIS is not captured at every hospital. for over 10,000 medical conditions, about 2,000 of which are
The actual AIS code consists of two numerical components. physical injuries (the block of ICD-9 codes from 800.0 to
The first component is a six-digit injury descriptor code 959.9 encompasses all traumatic injuries). ICD-9 codes are
(pre-dot), which is unique to each traumatic injury; pre-dots used by all hospitals in the United States, primarily to classify
classify the injury by region, type of anatomic structure, specific diagnoses for administrative purposes, such as billing and event
structure, and level. The second component is a severity score reporting.
(post-dot), graded from 1 (minor) to 5 (critical injury), For the trauma outcomes researcher, AIS codes are generally
with the caveat that all unsurvivable injuries are scored a 6 preferred over ICD-9 because of their greater specificity of
(Table 5-2); these severity scores, or AIS severity, are consen- injury description (the pre-dot classification). However, as dis-
sus-derived assessments assigned by a group of experts. Of note, cussed in the next section, valid severity scores can be formu-
AIS is used as both a classification scheme for injury coding (the lated from either system. Additionally, while the AIS
pre-dots) and a severity score (the post-dots; see next section). classification scheme attaches an ordinal 16 severity level to
The second method to classify traumatic injury is the ICD each injury, ICD-9 codes are only nominal classifications and
coding system. ICD is not trauma-specific, but rather is a therefore do not measure the severity of injury.
Injury Severity Scoring and Outcomes Research 79

Injuries in each region are given an AIS score and the highest
TABLE 5-2 AIS Components, Definition of 16
AIS scores in the 3 most severely injured regions are squared
AIS Severity Ordinal Description and summed to form the ISS. ISSs have a range from 1 (least
1 Minor injury severe) to 75 (unsurvivable); higher scores reflect higher likeli-

2 Moderate injury hood of mortality. Any patient with an AIS severity of 6 is
3 Serious injury automatically given an aggregate score of 75.
4 Severe injury ISS correlates well with mortality and remains the most
5 Critical injury widely used anatomical scoring system. However, ISS has many

6 Virtually unsurvivable injury limitations.10 ISS is often incorrectly treated as a continuous,
monotonic function of mortality, though it is none of these
AIS  Abbreviated Injury Score. (Fig. 5-1).11,12 There are only 44 distinct values of ISS, some of
which are possible in two different combinations of sums of
squares. Optimally, each combination would be treated nomi-
nally (as its own class) in terms of risk adjustment, but in prac-
INJURY SEVERITY SCORES tice this seldom occurs. Furthermore, ISS only considers one
ISSs quantify the risk of an outcome after trauma, for both injury in each of the body regions and thus ignores important
clinical and research purposes. The selection of which trauma injury information. Because of these shortcomings we continue
severity score to use should be based on a clear sense of what to believe ISS should be retired and replaced by one of the more
one wants to measure and why. The scores vary considerably, modern injury scores that are now available (see below).
from complexity of calculation to ease of use. The majority of The New Injury Severity Score (NISS) was formulated by
scores are based on either the trauma-specific AIS coding Osler et al. to address some of the ISS shortcomings, specifi-
classification or the more general ICD-9 taxonomy. However, cally its omission of multiple occurrences of serious injuries
trauma scoring systems are continuously being revised, tested, within the same body region.13 NISS is the sum of the squares
and compared to each other, and still today there is no of the three most severe AIS severities, regardless of body
consensus on a best injury scoring system. region (and keeping the convention that an AIS of 6 auto-
The trauma outcomes researcher needs to be familiar with matically results in a NISS of 75). This permutation offers a
the various scoring schemes (Table 5-3) in order to most accu- slight prediction advantage but has several of the same short-
rately risk adjust their patient population to best isolate the comings as ISS (Fig. 5-2).
effects of an independent predictor variable on a dependent The Anatomic Profile Score (APS), developed by Copes et
outcome variable. In general, four types of risk adjustments al., adjusted for body region differences and AIS severity.11
(equally called scores) are calculated to account for trauma Three modified components are weighted to form a single
severity: (1) Anatomic Injury Scores; (2) Physiological scalar based on anatomic location of all serious injuries (AIS
Derangement Scores; (3) Comorbidity Scores; and (4) A com- severity of 3). Although APS represents a logical approach to
bination of the three. Unlike other circumstantial factors (time anatomic scoring, it has failed to supplant ISS.
to treatment, quality of care, etc.), each of these scores is The International Classification of Diseases Injury Severity
intrinsic to the patient and are therefore important to understand Score (ICISS), created by Osler et al., took an empirical estima-
and quantify. tion approach to injury severity scoring with the formulation of
ICD-9 survival risk ratios (SRRs).14 An SRR is an ICD-9 code-
specific estimate of the survival probability associated with that
Anatomic Scoring Systems particular injury. For a set of patients, the SRR for a particular
Anatomic injury scores are the most developed types of risk injury code is the number of patients that survive that injury
adjustment following trauma. Many scores have been proposed divided by the number of patients who display the injury. The
in the literature, but this review will be limited to scores that ICISS score is the product of the SRRs corresponding to a
have gained practical acceptance. The majority of scoring algo- patients set of injuries, and ranges from 0 (unsurvivable) to 1
rithms are designed to predict mortality (Table 5-3) and are not (high likelihood of survival).
specifically validated on other outcomes, such as LOS or func- ICISS offers several advantages over other anatomic scores.
tional status, though moderate correlations may exist. First, because of its ICD-9 base coding lexicon, it can be used
The AIS is not only a method to classify injuries, as in any clinical setting, including smaller centers that typically
described earlier, it is also a validated method to score injury do not perform AIS coding. Second, unlike the consensus-
severity. The AIS severity designation (ordinal scale from 1 to 6; derived AIS severity scores, ICISS empirical approach means
Table 5-2) that accompanies each coded injury is the simplest that powerful statistical estimates of injury-specific survival can
form of a score. The maximum AIS (maxAIS), which is the be computed if enough representative patients are available for
largest AIS severity among all of a patients injuries, is highly study. Consequently, unlike ISS and NISS, ICISS is a smooth,
associated with mortality but ignores information provided if nonlinear, function of mortality (Fig. 5-3).
from other injuries. However, ICISS does have limitations. First, although it
In 1974, Baker et al. first posited a multiinjury score by resembles an overall probability, ICISS can only be considered
introducing the ISS.9 ISS divides the body into six regions: a scalar since most SRRs are contaminated by patients with
head or neck, face, abdominal, chest, extremities, and external. multiple injuries. Independent SRRs can be calculated from

Trauma Overview
TABLE 5-3 Injury Severity Scores: A Comparison by Type of Score
Name (Year Predicts Score Range/
First Introduced) What? How Calculated? Interpretation Benefits Limitations
Anatomic scoring systems
AIS (1971) Patient See Table 1 See Table 1 Initially developed to classify Cannot predict functional
survival severity of injury, but has impairment; proprietary
been validated to measure scoring system.
probability of death; used
for trauma center evaluation
and quality improvement.
ISS (1974) Patient Body divided into six anatomical regions: 44 distinct possible Most widely used trauma No physiologic predictors;
survival head/neck, face, chest, abdomen/pelvis, scores ranging from severity score; relates AIS to does not account for
extremities, skin/general; injuries in each 1 (least severe) to 75 patient outcomes. 1 injury in the same
region given an AIS score; the highest (unsurvivable); higher region, only the highest
AIS scores in the three most severely scores reflect higher score; scored on three
injured regions are squared and summed likelihood of mortality. regions only, not all six;
for ISS; any patient with an AIS severity requires specialized training.
of 6 is automatically given an aggregate
score of 75.
NISS (1997) Patient Sum of the squares of the three most 44 distinct possible Addresses the ISS omission Scored on three injuries
survival severe AIS severities, regardless of body scores ranging from of multiple occurrences of only; requires specialized
region; as with ISS, any patient with an 1 (least severe) to 75 serious injuries within one training; not widely used,
AIS severity of 6 is automatically given (unsurvivable); higher body region; slight prediction but should be.
an aggregate score of 75. scores reflect higher advantage over ISS and ICISS
likelihood of mortality. in predicting mortality.
APS (1990) Patient Three modified components (head/brain Range varies; higher Logical, analytical approach; Failed to supplant ISS as
survival and spinal cord injury; thorax and neck numbers have worse based on location and predominant severity
injury; all other serious injuries) are scored prognosis. severity of illness. scoring modality.
based on AIS and weighted to form a
single APS; only serious injuries included.
ICDMAP-90 Injury Translates ICD-9 discharge diagnosis ICD/AIS scores vary. Conservative estimates of Based on a computer
(1997) severity codes into AIS pre-dot codes, injury injury severity. software program;
descriptors, and severity scores, which in loss of certain injury
turn are translated into an ISS, NISS, and information in the translation
APS for the patient. between diagnosis systems;
out of date as not mapped
to ICD-9-CM, ICD-10-CM, or
most recent AIS.
ICISS (1996) Patient Computed directly from ICD-9 codes; Scores range from 0 One of the few severity Multiple databases can
survival conversion of a specific ICD-9 code into (unsurvivable) to 1 (high scores not based on AIS/ be used to calculate SRRs
a SRR for that code, with higher SRRs likelihood of survival). ISS; accounts for all injuries; (ICD-9-CM, NTDB, etc.), and
reflecting higher likelihood of survival; no specialized training thus SRRs are database-
the final ICISS score in the product of required; multiple studies specific; SRRs from different
each SSR for each injury the patient has. show it outperforms ISS; sources are not comparable;
some evidence that most SRRs are not independent of
severe SRR outperforms each other; no consensus yet
multiplicative SRR. on best practice; some argue
ICISS measures hospital
survival not injury survival.
TRAIS (2003) Patient Exact same calculation as ICISS except Scores range from 0 Behaves very similarly to Not widely adopted.
survival TRAIS uses AIS injury descriptor codes (unsurvivable) to 1 (high ICISS; out-predicts its AIS
to create SRRs; the TRAIS score is the likelihood of survival). counterparts ISS, NISS, and
product of AIS-derived SRRs for each APS; used in models to
injury the patient has. predict mortality.
OIS (1987) Not for Anatomic injury within an organ Designed to standardize the Enhances communication No predictive abilities; not
patient system graded on an ordinal scale, descriptive language of between trauma surgeons. widely adopted; not used
outcomes with Grade 1 being a minor injury and injury for 32 organ and for risk adjustment.
Grade 5 being tissue-destructive and body system regions.
likely fatal.
Physiological scoring systems
GCS (1976) Patient Aggregate score of motor activity (scale Range from 3 (no or Simple to use; quickly Hard to measure all
survival; of 16 points), verbal activity (15 minimal neurological calculated; well validated; components in some
brain points), and eye-opening (14 points); function) to 15 (normal or used by many other scoring patients (if sedated,

Injury Severity Scoring and Outcomes Research

function higher scores indicate more function. near-normal neurological systems; can use motor intubated, etc.); score
function). score alone. changes with time (not fixed
on admission).
RTS (1989) Patient Computed by logistic regression equation Range from 0 (severe Provides physiological Intubation and sedation
survival based on indexed values of GCS, systolic physiological derangement) assessment of patient; high prior to ED arrival alter
blood pressure, and respiratory rate on to 7.84 (no physiological association with mortality; accuracy; use limited by
presentation to ED. derangement). contributes to TRISS. missing data.
APACHE-II Patient Based on the worst 12 routine Range from 0 (very low risk ICU specific; superior to Very time consuming and
(1985) survival; physiological measurements (heart rate, of mortality) to 71 (very TRISS and ISS at predicting complex to calculate.
disease blood pressure, etc.) in the first 24 hours high risk of in-hospital mortality in TICU.
severity of ICU admission, as well as age and mortality); scores 15
chronic health conditions. considered moderate
moderate-to to-severe risk.



Trauma Overview
TABLE 5-3 Injury Severity Scores: A Comparison by Type of Score (Continued )
Name (Year Predicts Score Range/
First Introduced) What? How Calculated? Interpretation Benefits Limitations
Comorbidity scoring systems
Charlson Patient Score consists of 19 possible comorbid Range from 0 (low chance Simple to calculate; Charlson score is not
(1987) survival conditions, each allocated a weight of death) to 37 (high validated in medicine trauma-specific.
of 16 based on the relative risk of cumulative mortality patients; good indicator
1-year mortality; values are summed attributable to comorbid of disease burden;
to provide a total score. disease). adapted for use with
administrative databases
with ICD-9 codes.
TRISSCOM Patient Similar to TRISS with adjustments Scores range from 0 Reflects the aging Comorbidities are not
(2004) survival to age (dichotomized at 65 years (unsurvivable) to 1 (high population. weighted based on
old as opposed to 55 years old) and likelihood of survival). severity.
the addition of eight comorbidity
variables (recorded as a binary
yes/no variable).
Combination scoring systems
TRISS (1987) Patient Combines ISS, RTS (respiratory Scores range from 0 Useful for quality Requires multiple variables;
survival rate, systolic blood pressure, GCS), (unsurvivable) to 1 (high improvement initiatives; if one not captured you are
and age; regression coefficients likelihood of survival). separate probability unable to calculate TRISS.
derived from MTOS database; equations for blunt and
equations vary between blunt versus penetrating patients.
penetrating trauma.
ASCOT (1990) Patient Uses APS to define injury severity, with Range varies. Out-predicts TRISS for Complex calculation.
survival different regression coefficients for blunt penetrating trauma.
versus penetrating trauma.

AIS  Abbreviated Injury Score; APACHE-II  Acute Physiologic and Chronic Health Evaluation II; APS  Anatomic Profile Score; ASCOT  A Severity
Characterization of Trauma; Charlson  Charlson Comorbidity Index (CCI); ED  emergency department; ICDMAP-90  International Classification of Disease
map; ICISS  International Classification of Disease Injury Severity Score; ICU  Intensive Care Unit; ISS  Injury Severity Score; GCS  Glasgow Coma Score;
MCOT  Major Trauma Outcomes Study; NISS  New Injury Severity Score; NTDB  National Trauma Data Bank; OIS  AAST Organ Injury Scale; RTS  Revised
Trauma Score; SRR  Survival Risk Ratios; TRAIS  Trauma Registry Abbreviated Injury Score; TRISS  Trauma and Injury Severity Score; TRISSCOM  Trauma and Injury
Severity Score Comorbidity.
Injury Severity Scoring and Outcomes Research 83

90% 90%
80% 80%
70% 70%



50% 40%
40% 30%
30% 20%
20% 0%
10% 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

0 15 30 45 60 75
ISS FIGURE 5-3 ICISS versus actual mortality. ICISS, unlike ISS and
NISS, has a very smooth association with mortality, though it too
FIGURE 5-1 ISS versus actual mortality. This graph plots the
is nonlinear. In the places where ICISS mortality decreases from
mortality associated with each ISS value. Of note is the erratic
one value to the next, the decrease is very slight, never more
choppiness of the curve, indicating that ISS is not a monotonically
than about 7% and corrects itself quickly. Contrast these small
increasing function of mortality. It is characterized in places by
decreases with the decreases seen in ISS and NISS, which can be
steep decreases in mortality as ISS gets larger. Ideally, ISS would
as large as 20% from one value to the next and 30% in the span
be considered nominal and not ordinal.
of two values.

patients who only have an isolated injury, but these are not NISS, and the ICDMAP versions of ISS, NISS, and APS. A
available for all codes because many injuries rarely occur in surprising finding was that maxAIS performed better than its
isolation.15 Second, SRRs are database-specific and the degree multiinjury counterparts ISS and NISS. Based on this result,
to which they are applicable within disparate populations Kilgo et al. showed that the patients worst injury, regardless of
remains uncertain.16 the coding lexicon (ICD-9 or AIS) or the estimation approach
ICD-9 codes are nominal, meaning they are unordered, (AIS severity-consensus or empirical SRRs), was a better predic-
qualitative categories not ranked by severity. If one ignores the tor of mortality than multiinjury scores, though there remains
AIS severity score, AIS codes can also be treated nominally, no consensus on this.17 More recently, however, Harwood et al.
taking advantage of their specificity in injury classification. As found that NISS was better than the ISS and equivalent to the
such, AIS injury descriptor codes can be used to create SRRs, maxAIS in the prediction of mortality in blunt trauma
similar to the SRR calculated from ICD-9 codes for ICISS. patients.20
AIS-based SRRs are used for the TRAIS score (Trauma Registry Finally, in 1987, the American Association for the Surgery
Abbreviated Injury Score), which is the product of AIS-derived of Trauma (AAST) introduced the AAST Organ Injury Scale
SRRs. Kilgo et al. showed that ICISS and TRAIS behave very (OIS).21 The goal of the scale was not to predict outcomes, but
similarly in a large group of patients coded both ways (Fig. 5-4) to standardize the descriptive language of injuries to improve
and that TRAIS out-predicts its AIS counterparts ISS, NISS, communication between trauma surgeons and physicians. Like
and APS.17 AIS, the OIS provides an ordinal scale to each level of organ
Trauma clinicians, outcomes researchers, and hospital disfigurement, with Grade 1 injuries being relatively minor and
administrators may ask: which of these approaches is the best? Grade 5 injuries being destructive injuries that are thought to
There is no consensus, and many publications each year be fatal. These scales, originally developed by Moore et al. via a
continue to debate this question. series of journal articles, exist for 32 organ and body region
Several large studies, including Sacco et al. and Meredith systems.2227
et al., compared these anatomic scores in terms of their ability Although descriptions using this lexicon are common, the
to predict mortality.18,19 Both studies found that APS and ICISS scale has not been widely adopted into formal risk adjust-
better discriminate survivors from nonsurvivors than ISS, ment methods. The potential exists for these scales to make
an enduring impact on outcomes research. The validation of
OIS should be carried out with a large representative
90% database.
60% Physiological Scoring Systems

40% Physiological status is a powerful predictor of mortality. Clinical
30% markers, including respiratory rate (RR), systolic blood pressure
20% (SBP), base deficit, and others, are important prognosticators
of outcome and are routinely used in clinical management.
0 15 30 45 60 75 However, unlike anatomic injuries and preexisting comorbidi-
NISS ties, which are fixed at the time of hospital admission, physio-
FIGURE 5-2 NISS versus actual mortality. This graph plots the logical parameters are ever-changing, both spontaneously and
mortality associated with each NISS value. The NISS curve is also in response to therapy. This makes them difficult to utilize in
very nonmonotonic, even more so than ISS. risk adjustment. The solution, even though imperfect and with
84 Trauma Overview



FIGURE 5-4 TRAIS and ICISS by mortality rate. ICISS and TRAIS behave very similarly in terms of their association with mortality
(the vertical axis) despite being derived from two very different types of codes. This suggests that empirical approaches might obviate
the inherent structure of the coding systems.

some exceptions, is to use a snapshot of physiological status summed to produce the Glasgow Coma Score, or equally
at one point in time, usually immediately upon emergency the GCS. The GCS is labeled a measure of brain injury but in
department (ED) arrival. actuality it measures brain function. It ranges from 3 (completely
Perhaps the most widely employed physiological adjuster unresponsive) to 15 (completely responsive) and has been
is the Glasgow Coma Scale (GCS), first proposed first by shown to be highly associated with survival. Osler and
Teasdale and co-workers as a means to monitor postoperative co-workers used the National Trauma Data Bank (NTDB) to
craniotomy patients.28,29 The GCS was subsequently adopted show that the Glasgow Motor Component was almost as
by trauma surgeons as a measure of overall physiological powerful as the full GCS score and had better statistical
derangement. The scale has three componentsmotor properties in general.30 As such, the motor score alone could
(GCS-M), verbal (GCS-V), and eye (GCS-E)each with ordi- replace the full GCS score.
nal characterizations of severity (Table 5-4). The scales can be The Trauma Score, later updated to the Revised Trauma
Score (RTS), was designed by Champion et al. as an approach
to combining clinical and observational physiological data
into one score.31,32 Two forms of the RTS exist, one for triage
(Triage-RTS) and one for outcomes evaluation and risk
TABLE 5-4 Descriptors of GCS Components adjustment. Both are based on variable physiological break-
GCS Scaled points for GCS, SBP, and RR (Table 5-5). The Triage-RTS
Function Description Value score is calculated by summing the coded values for each of
Eye Spontaneous 4 the three variables; it has a minimum score of 0 and maximum
To voice 3 of 12.
To pain 2
None 1
Verbal responses Oriented 5 TABLE 5-5 Revised Trauma Score (RTS) Variable
Confused 4 Breakpoints
Inappropriate 3
Coded SBP
Incomprehensible 2
Value GCS (mm Hg) RR (breaths/min)
None 1
0 3 0 0
Motor response Obeys commands 6
1 4 to 5 1 to 49 1 to 5
Localizes pain 5
2 6 to 8 50 to 75 6 to 9
Withdraw (pain) 4
3 9 to 12 76 to 89 29
Flexion 3
4 13 to 15 89 10 to 29
Extension (pain) 2
None 1
GCS  Glasgow Coma Score; RR  respiratory rate;
GCS  Glasgow Coma Score. SBP  systolic blood pressure.
Injury Severity Scoring and Outcomes Research 85

The RTS equation for outcomes evaluation computes comorbidities recorded as a binary yes/no variable if any one of
indexed values of GCS, SBP, and RR (Table 5-5) by weighting the eight was present in the patient (based on ICD-9 diagnosis
them with logistic regression coefficients and summing ranges: pulmonary disease, cardiac disease, diabetes, coagulopa-
them. thy/anticoagulation, neurological disease or dementia, hepatic

insufficiency, chronic renal insufficiency on dialysis, active
RTS  0.9368(GCS)  0.7326(SBP)  0.2908(RR)
neoplasia of the hematological or lymphatic system, or meta-
The RTS score ranges from 0 to 7.84; lower scores translate static cancer). The end result was that the TRISSCOM model
into more physiological derangement. RTS is highly associated improved the predictive performance of TRISS but not its

with mortality and remains important in injury scoring ability to discriminate.
through its contribution to the TRISS model (see below).
Studies have also shown that the combined use of SBP and
GCS-M are just as effective at predicting patient survival as the
Combined Scoring Systems
RTS.33 The three types of risk adjustmentsanatomic, physiological,
The Acute Physiologic and Chronic Health Evaluation II and comorbidcan be easily combined so that information
(APACHE-II) was first introduced in 1985.34 It is calculated from all three sources is used to predict outcomes. The first
from 12 physiological parameters (the worst values within such attempt from resulted in the Trauma and Injury Severity
24 hours of ICU admission), age, and chronic health condi- Score (TRISS).44 TRISS has become the standard tool to esti-
tions. It has long been validated for the use in both medical mate survival probabilities. TRISS incorporates ISS (anatomic
and surgical ICU patients, though its use in the trauma inten- component), RTS (physiological component), and an age indi-
sive care unit (TICU) has been limited and debated. This is cator (55, 55; comorbidity component) to estimate sur-
because of APACHE-IIs poor correlation with ISS and its vival. Two separate equations, one each for blunt and
inability to predict hospital LOS.35 However, APACHE-II very penetrating patients, represent weighted sums of each of the
accurately predicts mortality in the TICU population.36,37 three components; the equations were calculated from data
APACHE-II has also been shown to be superior to TRISS and gathered in the Major Trauma Outcomes Study (MTOS).45
ISS at predicting TICU mortality,38 and we advocate for its use From these equations, a probability of survival can be calcu-
in risk adjustments in critically injured patients. lated for an individual patient (Table 5-6). This probability
(usually called the TRISS Score) can be used as a risk adjustor.
However, the TRISS approach has shortcomings.46 It
Comorbidity Scoring Systems requires 810 variables (depending on the number of injuries
Trauma outcomes research has long recognized the importance used by ISS); failing to capture even a single predictor renders
of comorbidities on patient outcomes. Morris et al., among TRISS incalculable. This is the case in as many as 28% of all
others, identified several preexisting conditions that worsen trauma cases. TRISS could be improved by replacing ISS with
prognosis following trauma, most notably liver cirrhosis, ISS squared or replacing it with a better anatomic predictor,
chronic obstructive pulmonary disease (COPD), congenital accounting for comorbidities more accurately, and updating the
coagulopathy, diabetes, and congenital heart disease.39 Morbid MTOS equations with more modern NTDB coefficients that
obesity has now been added to this list.40 Accordingly, specific reflect the advancements made since TRISS first appeared.47,48
comorbidity adjustments, such as the Charlson Comorbidity Other TRISS-like models aim to account for all three risk
Index (CCI), which are widely used in other disciplines,41 have adjustments.48 The ASCOT score (A Severity Characterization
been incorporated into current injury severity models in
attempts to enhance their predictive abilities. Results, however,
have been poor.42 TABLE 5-6 Equation for TRISS:
The incorporation of preexisting conditions into injury Probability of Survival  1/(1  e(LOGIT))
severity models is difficult because so many potential comor- where LOGIT is Given by: LOGIT  Intercept
bidities exist, each of which may itself occur with variable  ISS (ISS)  RTS (RTS)  AGE (AGE)
severity. Further, many are relatively rare, confounded by age,
and may be inconsistently recorded. One accepted convention
is to simply use patient age as a surrogate for comorbidities Mechanism Blunt Penetrating
because age is moderately associated with serious preexisting Intercept 1.2470 0.6029
disease. Another approach is to use the presence of individual ISS 0.0768 0.1516
comorbidities or classes of conditions (ICD-9 ranges) in risk RTS 0.9544 1.1430
adjustment methods. Either of these is acceptable but eventu- AGE 1.9052 2.6676
ally a generalized score that incorporates all of this information
might improve the accuracy of trauma scoring. Age is dichotomized as follows: 055 years  0;
One trauma-specific score that adjusts for comorbidities is  55 years  1.
available, based on adjustments to TRISS.43 The Trauma and ISS  Injury Severity Score; MCOT  Major Trauma
Injury Severity Score Comorbidity (TRISSCOM) adjusts the Outcomes Study; RTS  Revised Trauma Score;
initial TRISS model (see below) to dichotomize age at 65 years TRISS  Trauma and Injury Severity Score.
old (as opposed to 55 years old) and to include eight
86 Trauma Overview

of Trauma) was introduced to address some weaknesses in thought to influence/cause an outcome, either directly or indi-
TRISS, in particular its poor prediction for certain types of rectly. The practice of creating a conceptual model should fully
trauma (e.g., penetrating torso trauma) and the reliance upon elucidate the multifactorial and multidimensional nature of the
ISS.49 Like TRISS, ASCOT relies upon anatomic descriptors, outcome under study. As such, the conceptual model is the foun-

emergency department physiological status, age, and mecha- dation for outcomes research, and can be simplistically written as
nism. However, instead of ISS, the Anatomic Profile (AP), follows (and can be amended based on specific outcomes):
which is the basis for the APS score, is used to adjust for
anatomic severity.11 Further, age is parsed into five ordinal Outcomes  f (baseline, patient clinical characteristics, patient

categories rather than two. Similar to TRISS, all the values are demographics, psychosocial characteristics, treat-
statistically weighted in such a manner as to produce a proba- ment, setting).2
bility of survival. Although ASCOT provides better predictions
than TRISS, it has failed to replace TRISS as the standard Quality outcomes research attempts to define the determi-
survival predictor. nants of an outcome in a quantifiable relationship. This
therefore depends on quality, comprehensive data collection.
Kane maintains that the ultimate goal of outcomes research
analysis is to isolate the true relationship between an outcome
OUTCOMES RESEARCH of interest and its determinants. In order to do this, the
Trauma outcomes research was at one point focused solely on researcher must risk adjust the data, meaning he must control
predicting patient survival. Today, it has become much more for the effects of the other relevant variables in the outcomes
complex, as contemporary trauma outcomes research keeps model (see below). Accordingly, the more accurate the data, the
pace with the changes in the medical and scientific research better the risk adjustment, and in turn the more valid the
communities on the whole. This has translated into a move statistical conclusions.
away from a predominate focus on quantitative outcome mea-
sures, such as mortality and hospital LOS, and toward much
more qualitative and subjective measures, such as health-related Identifying the Critical Variables
quality of life, chronic functional impairment, and quality- The goal of trauma outcomes research is to discover true
adjusted life years (QALYs). These changes reflect a trauma relationships between input variables and outcome variables,
community that has begun to embrace the World Health collectively known as the critical variables. To do this requires
Organizations definition of health, which is a state of complete statistical hypothesis testing, which enables inferences about
physical, mental, and social well-being and not merely the populations based on samples from those populations. From
absence of disease or infirmity.50 these samples powerful inferences can be made if studies are
Current severity scoring systems are inadequate for predict- properly designed and adequately powered. The statistical
ing nonfatal, subjective outcome measures. There is consider- model is usually the modus operandi for exploring relation-
able room for growth and advancement in the scores ability to ships among the critical variables. In general, three types of
predict myriad potential outcomes in trauma patients, such as variables are used in the statistical modeling of data.
appropriateness of care, cost-utility, satisfaction with care,
and functionality.5153 This will be essential given the renewed Outcome/Dependent Variables
national focus on comparative-effectiveness research (CER).54 The dependent, or outcome, variable is the one that is described
To create such tools requires a basic understanding of in terms of the other variables (the independent variables) in
the process of outcomes research, which is the focus of this the model under study. The outcome variables in trauma
section. research include mortality, ICU and hospital LOS, the presence
of some complication, functional status, and others. The data
Outcomes Research Basics type of the outcome (continuous, dichotomous, ordinal, etc.)
There are five essential steps in outcomes research as outlined by drives the type of statistical model chosen.
Kane,2 and each step is to be performed sequentially (Kane RL.
Understanding Health Care Outcomes Research. 2nd ed. Sudbury, Predictor/Independent Variables
MA: Jones & Bartlett Learning; 2005. The independent, or predictor, variables are those variables that
Reprinted with permission): are hypothesized to influence the outcome of interest (the
dependent variable). Independent variables are measured or
1. Define a research question
observed. Examples would be ICD-9 code of an injury or a
2. Develop a conceptual model
patients preexisting condition.
3. Identify the critical dependent and independent variables
4. Identify appropriate measures for each
5. Develop an analysis plan Covariates
Covariates are variables that are known to influence the study
Each step is critical, though none more so than refining your outcome, but whose relationship to the outcome is not of pri-
research question (step 1) by use of a conceptual model (step 2). mary interest. These variables are called covariates and their
Such a model (often a drawn diagram) outlines all the determinants purpose is to account for as much of the variance in the
Injury Severity Scoring and Outcomes Research 87

outcome as possible. Sometimes called confounders or nui- Risk adjustment in trauma outcomes research uses the
sance variables, covariates are included in the model so that the injury severity scoring systems mentioned above. Risk adjust-
association between predictors and outcomes is properly ment is increasingly simpler because of the advent of large
ascribed. The significance of the covariates are of no interest; all relational databases and powerful, easily implemented statistical

that matters is the association of the predictors to the outcome software. Researchers interested in risk adjustment should
in the presence of covariates. In observational and interventional choose carefully which methods best accommodate their data
studies, trauma severity scores are usually used as covariates, constraints. Here are some factors to consider when planning a
hence removing (or adjusting) the confounding effect coinci- risk-adjusted study.

dent with some other predictor of interest.
Database Choices
The type of patient database one uses for their research will
Analysis and Risk Adjustment Approaches determine what type of risk adjustments can be made
Unlike in randomized controlled trials, which are controlled (Table 5-7). Trauma registries, such as the NTDB,55 exist at
experiments under controlled conditions in populations most verified trauma centers for clinical documentation,
comparable on every level except the intervention being studied research, and quality control purposes. These data include the
(termed efficacy studies), outcomes research evaluates the pertinent medical records outcomes for each patient over a
results of interventions and health care processes in real-world range of variables, including anatomic injury measures,
conditions (termed effectiveness studies). In such studies, physiological parameters, and comorbidities. In most cases, any
patient populations can be vastly different, with varied degrees of the aforementioned risk adjustments can be made to NTDB
of injury severity, physiological derangement, and comorbidi- data. Absent large amounts of missing data, comprehensive
ties. To address these differences, risk adjustments are made TRISS-like risk models are fit and probabilities of survival
that allow accurate comparisons among such disparate patient are computed, if desired. This situation is optimal because the
populations. best available risk adjustments are derived from scoring

TABLE 5-7 Databases Used in Trauma Outcomes Research and to Populate Injury Severity Scores
Name (Year First
Introduced) Brief Description Primary Use Benefits Limitations
NTDB (1997, Dataset compiled by Quality improvement Widely used; over 10 Currently not
though trauma participating hospitals and research on all years of data; efforts standardized; not a
registries began and validated trauma aspects of trauma, to standardize data population-based
in 1973) centers; contains injury, which can lead collection with the dataset.
demographic, and to improvements NTDB National Trauma
hospitalization-related in outcomes and Data Standard.
information on admitted trauma care.
trauma patients.
Administrative Databases of discharge Primarily for billing Many options for No physiological
Databases data complied by medical purposes, though available datasets (on data; can often only
(database records specialists. Often increasingly used for national versus state risk adjust based on
dependent) have ICD-9 diagnosis and outcomes research. levels). anatomic severity
procedure codes, but no scores.
physiological parameters.
TQIP (2007) Uses NTDB-collected data Evaluation of trauma Similar to the NSQIP, Remains in pilot
to provide risk-adjusted outcomes and huge potential for stages; low incidence
mortality and morbidity improvements in overall improvements of penetrating trauma
analysis of participating trauma care, both on in trauma care; risk- makes benchmarking
trauma centers to track a local and national adjusted morbidity based on O/E ratios
outcomes and improve level. and mortality difficult; resource
patient care. measures; O/E ratios intense.
for benchmarking and

NTDB  National Trauma Data Bank; NSQIP  National Surgical Quality Improvement Program; O/E  Observed to
Expected Ratio; TQIP  Trauma Quality Improvement Project.
88 Trauma Overview

approaches that use all three types of trauma severity Evaluation of Trauma Severity Codes
adjustments. Several statistical criteria are employed when evaluating the
Administrative databases, on the other hand, exist primarily efficacy of the trauma severity scores. The choice of the model-
for billing purposes and arent meant specifically to be used for

based evaluation depends on the data type of the outcome.

clinical research. In many cases administrative databases will When the outcome is continuous, multiple linear regression
have at least some injury ICD-9 codes and some comorbidity analysis or analysis of variance methods including model
information, but seldom do they have physiological data. R-square values, information criterion, and tests of significance
Therefore, risk adjustments on administrative data are usually

of risk factors suffice to evaluate the association of these scores

limited to anatomic severity adjustments.56 If only a principal to the outcome.58
ICD-9 diagnosis code exists, then the worst injury approach is If the outcome is dichotomous (i.e., it takes on one of the
indicated and the SRR for this code is used for adjustments. If two possible values), then logistic regression is warranted.59,60
a complete set of injury codes is present, the evidence suggests Logistic regression has two important functions. First, it estab-
that ICISS should be used. lishes the relationships between the outcome and the predictors.
Finally, the Trauma Quality Improvement Program (TQIP) Within logistic models, the strength of the association between
uses NTDB-collected data to provide risk-adjusted mortality predictors and outcomes is directly measured and inferences
and morbidity analysis of participating trauma centers to track about statistical significance are made. Second, logistic regres-
outcomes and improve patient care.57 Although still in its pilot sion returns an estimated probability of exposure to the out-
stages, TQIP will eventually lead to the creation of an entire come of interest. This estimated (expected) probability can be
risk-adjusted database. The risk adjustment will be based on compared with the observed outcomes in the following ways:
observed outcome to expected outcome ratios (O/E ratio; see
below) for both survival and complications.
Tests of Discriminationa score that discriminates well is
able to efficiently separate dichotomies. For example, survi-
Risk Adjustment Choices vors get accurately classified as survivors with minimal prob-
The use of AIS severities for risk adjustment have the advantage ability for misclassification as nonsurvivors. Popular tests of
of familiarity, but studies show that SRR approaches account discrimination include the area under the Receiver Operating
for more variance in the outcome, discriminate dichotomies Characteristic (ROC) curve and Harrells c-index.60,61
better, and contain more information. The problem is that Tests of Goodness-of-FitThese tests measure the degree of
conglomerate scores such as TRISS and ASCOT use AIS agreement between empirically observed and statistically pre-
severities, and no established, empirically based alternative dicted probabilities. The HosmerLemeshow (HL) statistic is
exists. Hence, it is advisable to take empirical approaches such probably used the most, but it has severe limitations.60 Many
as TRAIS or ICISS when adjusting only with anatomic scores. researchers prefer to graph predicted and observed classes in
Otherwise, TRISS-like combined scores that are AIS-based deciles and compare them visually.
offer a substantial improvement over single anatomic adjust-
Information Criterion ScoresBecause models can be com-
ments. Finally, O/E ratios in databases such as TQIP provide
pared using different criteria (ROC, HL, etc.) that may dis-
population-based expected outcome probabilities, which can be
agree among themselves as to which model is preferred it is
used for risk stratification. Overall, a low O/E ratio indicates
desirable to have a mathematically consistent approach
better than expected outcome and a high O/E ratio indicates
to comparing models. Based upon the work of Kullback and
poorer than expected outcome.
Leibler, it is possible to measure the distance between any
two models in terms of the amount of information contained
Injury Coding/Classification Choices in each model.62 In order to compare two models of a system
Injury classification is based on either AIS or ICD taxonomy. (say, two models predicting death from trauma), it is enough
When the variables necessary for TRISS or ASCOT are avail- to measure the KullbackLeibler distance from each putative
able then AIS codes should be used. TRAIS may be calcu- model to the true model. The true model is never known
lated for any case where AIS codes are present, though it only (of course, otherwise we would have no interest in modeling
represents the effect due to anatomic injury. Alternatively, it), but by means of a mathematically rigorous sleight of
when only ICD-9 codes are available (as with most adminis- hand it is possible to substitute another measure of informa-
trative databases), the literature suggests that the ICISS score tion content, the Akaike Information Criterion (AIC), for
be used rather than mapping software. When both types of the KullbackLeibler distance and avoid the need to explic-
codes are available, the decision is more difficult and no itly specify the true model.60 Fortuitously, the AIC is a simple
consensus exists. AIS codes possess more specificity in function of the likelihood function (available from all stan-
describing the trauma landscape and have in the past been dard statistical software) and the number of parameters esti-
used for these types of adjustments. However, ICD-9 scores mated for the model of interest, and is thus straightforward
repeatedly have been shown to possess similar statistical to calculate. Once the AICs for each model are available, it is
properties. Although most trauma surgeons will prefer AIS a simple matter to order them and to further assign probabil-
scoring, these decisions are usually guided by other facets of ities to each model as to the likelihood that it is, in fact, the
the study design. true model.63
Injury Severity Scoring and Outcomes Research 89

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42. Gabbe BJ, Magtengaard K, Hannaford AP, Cameron PA. Is the Charlson
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17. Kilgo PD, Osler TM, Meredith W. The worst injury predicts mortality
43. Bergeron E, Rossignol M, Osler T, Clas D, Lavoie A. Improving the
outcome the best: rethinking the role of multiple injuries in trauma
TRISS methodology by restructuring age categories and adding
outcome scoring. J Trauma. 2003;55(4):599606; discussion 606607.
comorbidities. J Trauma. 2004;56(4):760767.
18. Sacco WJ, MacKenzie EJ, Champion HR, Davis EG, Buckman RF.
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anatomic descriptors. J Trauma. 1999;47(3):441446; discussion
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19. Meredith JW, Evans G, Kilgo PD, et al. A comparison of the abilities of
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621628; discussion 628629.
46. Gabbe BJ, Cameron PA, Wolfe R. TRISS: does it get better than this?
20. Harwood PJ, Giannoudis PV, Probst C, et al. Which AIS based scoring
Acad Emerg Med. 2004;11(2):181186.
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modification of TRISS markedly improves calibration. J Trauma. 2002;
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22. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen,
49. Champion HR, Copes WS, Sacco WJ, et al. A new characterization of
liver, and kidney. J Trauma. 1989;29(12):16641666.
injury severity. J Trauma. 1990;30(5):539545; discussion 545546.
23. Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II:
50. WHO|WHO Constitution. Available at:
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52. Holtslag HR, van Beeck EF, Lindeman E, Leenen LPH. Determinants of
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extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus
90 Trauma Overview

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2010. Information-Theoretic Approach. New York: Springer; 2010.



Acute Care Surgery

Gregory J. Jurkovich

The training and scope of practice of todays trauma surgeon tals, these surgeons were also typically referred the most chal-
has evolved into a burgeoning field known as acute care sur- lenging surgical problems from the surrounding city or region,
gery. Acute care surgery both defines an advanced surgical particularly if there was a financial disincentive to providing
training paradigm and describes a type of surgical practice. The care in a private for-profit hospital. As a result, the citycounty
history of this evolution is short, and somewhat cyclic. In 1922 or safety net hospital trauma surgeons developed an active
Charles L. Scudder, a general surgeon from Boston who had a elective and emergency surgical practice while providing
strong academic interest in fracture management, established trauma coverage and care to the most critically ill and injured
the Committee on Fractures within the American College of surgical patients.3
Surgeons. This early forerunner of todays Committee on The academic success of these leading trauma surgeons
Trauma was composed of 22 fellows of the College, and the (Blaisdell, Carrico, Davis, Freeark, Lucas, Ledgerwood, Mattox,
work of this committee encouraged the specialization of trauma Moore, Shires, Feliciano) fostered their incorporation into uni-
surgeons and laid the foundation for the modern concept of versity hospitals, and the economic viability of civilian blunt
quality improvement. As the results of physical force injury trauma care, particularly in no-fault auto insurance states, led to
from wars, motor vehicle crashes, and interpersonal violence an expansion of trauma programs out of the safety net hospitals
fostered the training of trauma care during the mid-20th and into private hospitals. The American College of Surgeons
century, the scope of the trauma surgeon encompassed more contributed to the widespread adoption of trauma programs by
than fracture management. In 1950 the Regents of the College the remarkably successful and innovated activities of the
authorized the current titlethe Committee on Traumato Committee on Trauma, including hospital verification, the
emphasize this expanding scope of practice.1 ATLS course, and the National Trauma Data Bank (NTDB).
Further advancement of a surgical discipline uniquely dedi- The federal government fostered the inclusive trauma system
cated to the care of the injured patient in the United States concept and encouraged the widespread development of trauma
occurred in the 1960s with the establishment of civilian trauma centers, in large part by reports of high preventable death rates
centers. These early trauma centers were almost exclusively in nontrauma hospitals, and by publications from the presti-
within the domain of citycounty hospitals in urban areas such gious and influential National Research Council that character-
as Chicago, Dallas, and San Francisco, but their impact and ized trauma as the neglected disease of modern society.4 The
influence was rapidly spread by devotees of the charismatic result is that today there are over 1,600 trauma centers in the
leaders of these centers.2 During the ensuing two decades, United States, including 203 Level I centers, 271 Level II cen-
trauma surgery became an attractive career based largely on the ters, 392 Level III centers, and 43 pediatric-specific trauma
mentorship of trauma surgeons in urban citycounty hospitals centers,5,6 with 84% of the population within 1 hour of a Level I
who epitomized the master technician, and who developed an or II trauma center.7 This remarkable adaptation of regionalized
academically productive career based on the physiology of the medical care is nearly unique to trauma, and has been fostered
injured patient and lessons learned from the Vietnam War. by the recognition of the specialty of its care model and the
These trauma surgeons operated confidently and effectively in evidence of its survival benefit.8
all body cavities, and perhaps were the last of the master sur- Yet the attractiveness of this career, and indeed this type of
geons that once were the hallmark of general surgery. practice, has been challenged and changed by a number of
Operating primarily in large-volume public, safety net hospi- forces. As trauma surgery became more specialized and expanded
92 Trauma Overview

out of the domain of the urban safety net hospital, the trauma operative caseload primarily because of technological advances.
surgeon no longer remained the renaissance surgeon of the Vascular surgeons have responded to this challenge by adding
urban/county hospitals of the 1970s. This success may in and of required training in endovascular techniques to their fellowship
itself have paradoxically led to a declining interest and commit- programs, and have been rewarded by a renewed interest in resi-

ment to the practice of trauma surgery. The requirement of a dent applicant. Cardiothoracic surgery has chosen to increase its
surgical presence for the resuscitation and early decision making focus on thoracic surgical procedures. There is a common thread
was interpreted by many hospitals (and surgeons) as a preclusion here. Specialties that have declining operative caseloads are not as
to developing a competitive elective practice, thereby discourag- attractive to those interested in a career in surgery.16
ing technically proficient and talented clinicians from accepting In response to these changing social, economic, and demo-
such positions. Yet perhaps most importantly, as pointed out in graphic forces, a joint meeting of the leadership of the American
an essay by Gene Moore and his senior active trauma surgeon College of Surgeons, the Association for the Surgery of Trauma
colleagues, a declining interest in trauma surgery as a career was (AAST), Eastern Association for the Surgery of Trauma
influenced by the loss of operative practice due to a number of (EAST), and Western Trauma Association (WTA) was held in
factors: the nonoperative management of solid organ injuries, August 2003, with the AAST taking the lead in considering
effective injury prevention strategies, the emergence of surgical how to restructure the training and practice of trauma surgery
specialties diverting thoracic and vascular injuries away from to make it a viable, attractive, and sustainable career, in the best
trauma surgeons, the explosion of technical capabilities of inter- interest of patient care, and, importantly, to keep trauma a
ventional radiology, and the emergence of surgical critical care surgical care disease. The result was the formation of a working
as a part and parcel of trauma care.9 These forces challenged the group within the AAST to develop a surgical training curricu-
viability of a career in trauma surgery, noted by a lack of interest lum that would be attractive to new trainees, and provide the
in a trauma by residents and students toward the end of the 20th training for a practice that would be viable, sustainable, and,
century. A number of articles have focused on the perceived lack importantly, in the best interest of the patients.17
of interest in any on-call practice, the aging of the trauma sur- Surveys of membership of the major trauma societies of the
geon workforce, the focus on lifestyle residencies that result in United States were undertaken to document the factors influenc-
highly remunerative and restricted practices, and concern that ing the thinking of current trauma surgeons in both academic
trauma surgery was primarily a nonoperative field.1013 and nonacademic settings.18 The average workweek was 80 hours,
Equally pressing has been the continued and unabated with one half reporting mandatory in-house night call. Two
emphasis on specialty training beyond core general surgery thirds (67%) of the respondents care for trauma, surgical critical
training. This is a universal trend in medicine as evidenced by care, and emergency general surgery while on call. Widely valued
the 145 subspecialty certificates awarded by the 24 member and enjoyed by these surgeons were the intellectual challenges
boards of the American Board of Medical Specialties (ABMS).14 and the diverse aspect of a trauma career, but the major disincen-
The exodus of general surgery trainees into surgical subspecial- tives to participating in trauma care were the disproportionately
ties has created a void of general surgeons with broad-based poor income, irregular-hour time demands, and an inadequate
training who are capable of providing the expertise needed to trauma operative practice spurred by a preponderance of blunt
continue the type of practice once common in citycounty trauma and interference or prohibition from developing an elec-
hospitals as well as in many rural communities. Many general tive general surgical practice. These practicing trauma surgeons
surgeons, particularly those in group practices, will subspecial- largely felt the best current model of trauma care was a training
ize within their group by virtue of additional training. and practice paradigm that included trauma, surgical critical
Increasingly, surgical subspecialists exhibit less interest in pro- care, and emergency general surgery, and also allowed the option
viding emergency and trauma on-call coverage, often conclud- of an elective surgical practice if desired. They generally endorsed
ing that they arent comfortable or dont feel qualified to do an option to include limited orthopedic and neurosurgical skills
so. Lifestyle interests and an elective practice volume that does such as external fixation of uncomplicated long-bone fractures
not require taking emergency room call to enhance billing often and ICP monitoring, but only if such specialty coverage was
fuel this attitude. This is a reflection of both a demand in surgi- unavailable. They envision the ideal practice model as one
cal manpower that has not yet been addressed and a tendency involving a group practice at a designated trauma center, sup-
of hospitals and surgical departments to acquiesce to this ported financially by the hospital and regionalized care. They
demand in order to attract and retain these lucrative and desir- would not mind mandatory in-house night call if such call was
able elective clinical practices. necessary for good care, limited in its frequency, predictable,
Stitzenberg and Sheldon report that 70% of trainees who compensated, and earns the next day off.
complete general surgery residencies pursue further training.15 These results, along with a careful consideration of the needs
The greatest interest has been in newer subspecialties, particularly of society and access to emergency surgical care, result in the
surgical oncology (including breast surgery), endocrine surgery, development of a recommendation for a new advanced training
and minimally invasive surgery, which usually includes gastro- fellowship to provide the expert surgical workforce to manage
intestinal and bariatric diseases. In contrast, cardiothoracic sur- trauma and surgical emergencies. The AAST Committee on
gery and vascular surgery have experienced a decline in interest as Acute Care Surgery developed and has promulgated a training
evidenced by the marked reduction of applicants to fellowships curriculum for a specialist that has broad training in elective and
in these areas and a number of vacant positions in the match. emergency general surgery, trauma surgery, and surgical critical
Each of these specialties has had a decline in traditional open care.17 As reflected by the name of this committee, this new
Acute Care Surgery 93

surgical specialist has been called the acute care surgeon. A reduced. Finally, in academic centers, the ready availability of
graduate of these fellowship-training programs is trained for a an in-house surgical specialist will increase the exposure of
career in managing acute general surgical problems, providing medical students and residents to surgical attendings. The acute
surgical critical care and managing acute trauma. A group prac- care surgeon specialist will be filling a niche, which now might

tice of these surgical specialists would allow for rotating cover- be termed a void in our provision of acute surgical care to the
age, with dedicated time off or protected time for elective American public. This void needs to be filled as many of our
practice, administration, or research. The training of this surgi- surgical specialty brethren are increasingly refusing to partici-
cal specialist requires core general surgery training, as well as pate in the surgical call schedule. Although the field of trauma
advanced thoracic, vascular, and GI surgery, so as to not just surgery would benefit from these changes, those who will ben-
allow but also encourage the development of a diverse elective efit most are our patients. With this in mind, these changes
surgical practice, as local practice patterns permit. It has also should be welcome in the future of trauma surgery.9
been proposed that the acute care surgeon specialist could also The Acute Care Surgery Fellowship is also designed to have
perform selected and limited neurosurgical, orthopedic, or the flexibility to adapt to the possible shortening of core gen-
interventional radiology procedures, with national and local eral surgery training to 4 years, or the concept of early special-
support from these fellow surgical and interventional specialists, ization. Early specialization is an attractive option to many
and when such subspecialty coverage is not immediately avail- surgical specialties (but not all) if the core general surgery
able. While there has been considerable resistance to this part of training can be adequately defined, and completion or
the proposal, the fact that many hospitals are having difficulty advancement dependent on the accomplishment of measures
with surgical emergency coverage argues for its addition.19 of competency. This is a distinct change from the paradigm of
Current practicing trauma surgeons find that this new spe- immersion training that has been evident in surgical training
cialty makes sense. The broadened training in thoracic, vascular, for the past 50 years. No longer are the work hours unlimited,
and GI operative skills and techniques makes this a more desir- no longer is independent experience of residents acceptable,
able surgical specialty. Further training in these areas is required and the operative experience of surgery residents continues to
given the shrinking training time brought on by the limited fall. Extensive discussions and the development of the Surgical
workweek and the siphoning of advanced operative cases by Council on Resident Education (SCORE) curriculum are a
other fellowship trainees. The option of working on a preset direct response to these changes, and hold the possibility of a
schedule allows for a more controllable lifestyle, and potentially competency-based core curriculum for all surgeons, with care-
makes this specialty more attractive to surgeon who wishes to ful integration into early specialization by limiting core general
take a more active part in childrearing or other family activities. surgery to 3 or 4 years, followed by self-selected area of con-
This is more than a surgical hospitalist who would only cover centration.20 This pathway for vascular surgery was approved
the on-call window or take care of the patients of other physi- by the American Board of Surgery (ABS) in 2003.21 The train-
cians during undesirable hours; rather, the acute care surgeon ing paradigm of the acute care surgeon would fit well within
could well be seen as the most experienced surgeon for most this construct, with core general surgery followed by 23 years
circumstances in most hospitals, a resource for all the medical of trauma, surgical critical care, and advanced general surgical
staff. Also, since this surgical specialist will most commonly be procedures. The genesis of this concept can be traced to rec-
in-house 24 hours a day, the likelihood of significant compli- ommendations of some members of American Surgical
cations due to lack of an experienced surgeon at night and on Association committee on the future of surgical training in
weekends will be reduced; thus, the cost of care is likely to be 2004 and modified in Fig. 6-1.22 This concept of abbreviated

Core surgery 2-3 years

Verification of competency

Specialists in General Surgery

lead to board certification

Optional research track

Urban track Rural track Subspecialty in surgery

3 years 3 years 3 years

Cardiothoracic Plastics Vascular Transplant Acute care surgery Pediatrics Colo-rectal Surgical oncology

FIGURE 6-1 Proposal for restructured surgical residency training.

94 Trauma Overview

core training followed by specialty training ultimately leading for general surgery residency training. This competency-based
to board certification in both general surgery and the specialty curriculum is meant to define the specialty of general surgery
of choice is being considered and trialed or considered at this and provide greater assurance that residents are receiving suf-
time by thoracic, vascular, and plastic surgery. The ABS has ficient training in all areas. The curriculum design is to focus

also recently added four new Advisory Councils, including one on the 5 years of progressive education and training, which
in Trauma, Burns, and Critical Care, along with Advisory constitute general surgery residency, but prior to independent
Councils in Surgical Oncology (including breast and endo- practice.24
crine), Transplantation, and Gastrointestinal Surgery (includes
endoscopy, hepatobiliary, and bariatric surgery) to provide
advise and guidance from these specialty areas,23 and in 2006
the ABS hired Dr Richard H. Bell, Jr, MD, for a newly created Acute care surgery is an advanced surgical training paradigm
administrative leadership role of assistant executive director to (fellowship) that is 2 years in length and follows general sur-
specifically facilitate the development of a standardized surgery gery training (residency). The outline of this curriculum is
residency curriculum defined by the SCORE (http://www. presented in Table 6-1. The curriculum includes a dedicated The SCORE is a nonprofit consortium minimum of 9 months of surgical critical care, as mandated
formed in 2006 by the principal organizations involved in US for Residency Review Committee (RRC)approved surgical
surgical education. SCOREs mission is to improve the educa- critical care residencies. Only programs with an RRC-approved
tion of general surgery residents (trainees) in the United States surgical critical care training residency can be acute care sur-
through the development of a standard national curriculum gery training programs. The remaining 15 months are focused

TABLE 6-1 Acute Care Surgery Curriculum

Required clinical rotation
Surgical critical care including
Trauma/surgical critical care, including other relevant 12 months
critical care rotations
This portion of the fellowship must comply with ACGME requirements

for a surgical critical care residency

Emergency and elective surgery including 12 months
Trauma/emergency surgery 23 months
Total 24 months
Suggested clinical rotations
Thoracic 23 months
Transplant/hepatobiliary/pancreatic 23 months
Vascular/interventional radiology 23 months
Orthopedic surgery 1 month
Neurological surgery 1 month
Electives 13 months
Recommended: burn surgery and pediatric surgery
Also include: endoscopy, imaging, plastic surgery, etc.

Total 12 months

Notes to curriculum outline: It is a requirement that over the 2-year fellowship, trainees participate in acute care
surgery call for no less than 12 months. Fellows are required to take 52 night calls in trauma and emergency surgery
during the 2-year fellowship.
1. Flexibility in the timing of these rotations and the structure of the 24-month training should be utilized to optimize
the training of the fellow.
2. Rational for out-of-system rotations for key portions of the training must be based on educational value to the fellow.
3. Acute Care Surgery Fellowship sites must have RRC approval for surgical critical care residency.
4. Experience in elective surgery is an essential component of fellowship training.
5. An academic environment is mandatory and fellows should be trained to teach others and conduct research in acute
care surgery.
Acute Care Surgery 95

on operative rotations in emergency and elective surgery, with the clinical challenges of emergency surgery. Limited time is
the expectation that there will be at least 12 months of acute suggested on orthopedics and neurosurgical services, with
care surgical on-call experience, or a minimum of 52 nights of additional elective time to be allocated to meet the needs of the
trauma and emergency general surgery call. The 15 months of trainee. The expectation is that trainees will be competent in

operative rotations are as a foundation time spent on an intact, the management of a wide spectrum of acute care surgical
functioning, active Acute Care Surgical service. This is supple- needs, and have specific operative competency in the proce-
mented by three core rotations in thoracic, vascular, and dures listed in Table 6-2.
hepatobiliarypancreatic surgery, with the expectation that Essential elements of the training program will be the
these rotations will provide adequate exposure to advanced operative experience, the presence of an RRC-approved surgical
surgical skills and patient care challenges that often are inade- critical care fellowship, and the commitment of the hospital
quate in core general surgery training to prepare a surgeon for and surgical colleagues to support this new paradigm. The

TABLE 6-2 Operative Management Principles and Technical Procedure Requirements of

Acute Care Surgery Fellowship
Area/Procedure Essential Desirable
Cricothyroidotomy X
Nasal and oral endotracheal intubation including rapid sequence induction X
Tracheostomy, open and percutaneous X
Nasal packing (for complex facial fracture bleeding) X
ICP monitor X
Lateral canthotomy X
Ventriculostomy X
Exposure and definitive management of vascular and aerodigestive injuries X
Elective neck dissection X
Parathyroidectomy X
Advanced thoracoscopic techniques as they pertain to the described X
Bronchoscopy: diagnostic and therapeutic for injury, infection, and X
foreign body removal
Damage control techniques X
Definitive management of empyema: decortication (open and VATS) X
Diaphragm injury, repair X
Exposure and definitive management of cardiac injury, pericardial tamponade X
Exposure and definitive management of esophageal injuries and perforations X
Exposure and definitive management of thoracic vascular injury X
Exposure and definitive management of tracheobronchial and lung injuries X
Pulmonary resections X
Spine exposure: thoracic and thoracoabdominal X
Video-assisted thoracic surgery (VATS) for management of injury X
and infection
Partial left heart bypass X
Repair blunt thoracic aortic injury: open or endovascular X
Abdomen and pelvis
Abdominal wall reconstruction following resectional debridement for X
infection, ischemia
Advanced laparoscopic techniques as they pertain to the described X
Damage control techniques X

96 Trauma Overview

TABLE 6-2 Operative Management Principles and Technical Procedure Requirements of

Acute Care Surgery Fellowship (continued)
Area/Procedure Essential Desirable

Abdomen and pelvis

Exposure and definitive management of duodenal injury X
Exposure and definitive management of gastric, small intestine X
and colon inflammation, bleeding, perforation, and obstructions
Exposure and definitive management of gastric, small intestine X
and colon injuries
Exposure and definitive management of major abdominal and pelvic X
vascular injury
Gastrostomy (open and percutaneous) and jejunostomy X
Hepatic resections X
Management of abdominal compartment syndrome X
Management of all grades of liver injury X
Management of pancreatic injury, infection, and inflammation X
Management of rectal injury X
Abdomen and pelvis
Management of renal, ureteral, and bladder injury X
Management of splenic injury, infection, inflammation, or disease X
Pancreatic resection and debridement X
Exposure and definitive management of major abdominal and pelvic vascular X
rupture or acute occlusion
Management of acute operative conditions in the pregnant patient X
Management of injuries to the female reproductive tract X
Place IVC filter X
Amputations, lower extremity (hip disarticulation, AKA, BKA, trans-met.) X
Damage control techniques in the management of extremity vascular X
injuries, including temporary shunts
Exposure and management of lower extremity vascular injuries X
Exposure and management of upper extremity vascular injuries X
Fasciotomy, lower extremity X
Radical soft tissue debridement for necrotizing infection X
Acute thromboembolectomy X
Applying femoral/tibial traction X
Fasciotomy, upper extremity X
Hemodialysis access, permanent X
On-table arteriography X
Reducing dislocations X
Splinting fractures X
Other procedures
Skin grafting X
Treatment of hypothermia X
Lower GI endoscopy X
Operative management of burn injuries X
Thoracic and abdominal organ harvesting for transplantation X
Upper GI endoscopy X
Pediatric surgical procedures
Inguinal hernia repair X
Trauma management X
Treatment of bowel obstruction X
Ventral hernia repair X
Acute Care Surgery 97

curriculum will meet the ACGME requirements for compe- group practice of trauma care has closely exemplified the acute
tency-based training, and the evaluation of the fellows perfor- care surgeon model, in that their trauma service is designed to
mance will reflect that expectation. The ABS, along with the include all emergency operations and inpatient consults, and
RRC and the American Council on Graduate Medical indeed is referred to as the crucible, where high-volume, high-

Education, will be considering how all of surgical training intensity, results matter, life or death decisions are made, and
might be evolving over this time as well, and specifically how treatment is provided.29 Additionally, all (trauma) surgeons are
Acute Care Surgery Fellowship training meets the needs of encouraged (and supported) to pursue an elective surgical prac-
patients, the populations, and trainees. tice. The acute care surgery paradigm is exactly that, where
The clinical component of these fellowships includes the trauma and general surgery together create a specialist that has
following key areas: broad training in elective and emergency surgery, trauma sur-
gery, and surgical critical care.17 A large number of academic
1. The program should supply the necessary volume and urban trauma centers, mostly safety net hospitals, have always
variety of trauma, critical care, and emergency general employed this model to ensure optimal care of the injured
surgery to assure adequate training of fellows. patientconvinced that emergent torso trauma surgery and
2. Each fellow must have ample opportunity and elective general surgery are inseparable.30 Moreover, this has
responsibility for the care of patients with acute surgical always been the scope of practice for rural trauma surgeons, and
problems, and the operative experience consistent with the possibility of Acute Care Surgery Fellowship training that is
developing competency in technical skills and procedures tailored to the rural trauma surgeon has great appeal.3133
required to provide acute surgical care. Likewise, the training of modern military surgeons seems ideally
3. Elective general surgery is an essential component of the suited to the acute care surgeon model, as exemplified by the
training of acute care surgeons. incorporation of military surgeons into urban trauma center
4. Emergency surgical call and trauma call are mandatory hospital staffs to expand their clinical operative experience.
components of the training curriculum. Fellows will take a The options of including surgical skills and patients with
minimum of 52 trauma and emergency surgery night calls some orthopedic and neurological injuries with the domain of
during the 2-year fellowship. the acute care surgeons (option 2 above) has been challenged by
5. Elective operative experience in thoracic, vascular, and the leadership of neurosurgical societies and the Orthopedic
complex hepatobiliary and pancreatic procedures is Trauma Association. The initial proposals ranged from includ-
encouraged as a means of developing competency in ing decompressive craniotomies for mass lesions from bleeding
the management of acute surgical emergencies in these and ORIF of all long bone fractures to as little as splinting
anatomic regions. simple fractures, reducing dislocations, and placing ICP moni-
6. Experience in the diagnosis, management, and operative tors. All have been met with significant resistance, which seems
treatment of neurosurgical and orthopedic injuries is incongruous given the data on lack of specialty coverage from
encouraged. many hospitals for exactly this type of care.25,34 While this rep-
7. Experience with the use of interventional radiology resents the model of much of European trauma care,35,36
techniques is encouraged. without the support of these leading organizations, the lack of
8. Experience and competency with diagnostic upper neurosurgical and orthopedic emergency surgical coverage
and lower GI endoscopy and bronchoscopy are affecting many hospitals will not be solved by acute care sur-
encouraged. gery. These societies and professional organizations recognized
this, and are taking step to encourage regionalization of trauma/
Further details on the program requirements and the currently emergency care, and the training and practice interests in
approved acute care surgery training sites can be found on the trauma/emergency care.
AAST Web site ( The name acute care surgery was chosen carefully. The
Default.aspx). As of mid-2010 there were 7 formally approved term surgical hospitalist, no doubt appealing to hospital
training sites, with another estimated 1020 programs in various administrators, was rejected because the connotation of pri-
stages of considering submitting applications for approved train- marily providing surgical care deemed burdensome and unde-
ing sites. sirable to other surgical disciplines. Emergency surgery is a
The AAST Committee on Acute Care Surgery had consid- recent discipline championed in Europe, including a new
ered two other options for the future of trauma surgery: (1) World Journal of Emergency Surgery. This name, however, was
de-emphasize the field from surgery, that is, encourage nonsur- viewed as suboptimal because of the implication that acute
geons to assume responsibility for initial care and SICU man- surgical care can be relegated to shift work and is limited to
agement (United Kingdom model), and (2) expand the patients seen in the ED. Acute care surgery, as with existing
discipline of trauma surgery to include more orthopedics trauma surgery, must provide comprehensive patient manage-
(European model). The vast majority of current trauma sur- ment from ED arrival to hospital discharge and seamless
geons are unwilling to abandon trauma care to nonsurgical dis- 24/7 services.
ciplines.18,25 Others, exampled by the writing of Richardson and In some ways current trauma surgeons are responding to the
Malangoni, have argued that the acute care surgeon is a general stresses of health care that are external to the discipline of sur-
surgeon, and that trauma training and practice is part of the gery, and are effecting a change in all fields of medicine. The
broader practice of general surgery.16,2628 Yet the Louisville public, payers, and legislators are expecting improvements in
98 Trauma Overview

both the process and outcome of care. The expectation of a 15. Stitzenberg KB, Sheldon GF. Progressive specialization within general
surgery: adding to the complexity of workforce planning. J Am Coll Surg.
continuous in-house physician is no longer confined to the 2005;201(6):925932.
emergency room, but extends to the ICU, the trauma team, 16. Malangoni M. Acute care surgery: the general surgeons perspective.
and the inpatient floors. Yet this expectation of continuous Surgery. 2007;141(3):324326.

17. Committee to Develop the Reorganized Specialty of Trauma Surgical

presence is challenged by equally strong expectations of a Critical Care and Emergency Surgery. Acute care surgery: trauma, critical
limited workweek, and a nonsustainable health care budget. care, and emergency surgery. J Trauma. 2005;58(3):614616.
The demographics of medicine are changing as well, with more 18. Esposito T, Leon L, Jurkovich G. The shape of things to come: results
from a national survey of trauma surgeons on issues concerning their
women entering higher education, medical school, and surgery. future. J Trauma. 2006;60(1):816.
This changing demographic will inevitably impact the future of 19. Gore L, Huges C. Two-Thirds of Emergency Department Directors Report
surgery. Acute care surgery is part of this evolution. On-Call Specialty Coverage Problems; 2004. Available at: http://www.acep.
REFERENCES Cited February 16, 2006.
20. Lewis FJ. The American Board of Surgery. Bull ACS. 2004;69(4):5255.
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and Activities of the Committee on Trauma. Chicago: American College of Surgery; 2010. Available at:
Surgeons; 2005. Available at: policyesp. Cited July 20, 2010.
bluebook2005.pdf. 22. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in
2. Blaisdell FW. Development of the citycounty (public) hospital. Arch the 21st century: a new paradigm. Surgery. 2004;136(5):953965.
Surg. 1994;129(7):760764. 23. ABS Newsletter. Winter 2005. Available at:
3. Moore EE. Acute care surgery: the safety net hospital model. Surgery. default.jsp?newsletter&ref=news. Cited 16 February, 2006.
2007;141(3):297298. 24. American Board of Surgery News. Philadelphia: American Board of
4. Division of Medical Sciences, Committee on Trauma and Shock. Surgery; 2006. Available at:
Accidental Death and Disability: The Neglected Disease of Modern Society. newsdrbell.
Washington, DC: National Academy of SciencesNational Research 25. Esposito TJ, Rotondo M, Barie PS, Reilly P, Pasquale MD. Making the
Council; 1966. case for a paradigm shift in trauma surgery. J Am Coll Surg.
5. American Trauma Society. Trauma Centers by State or Regional Designation; 2006;202(4):655667.
2010. Available at: 26. Cheadle WG, Franklin GA, Richardson JD, Polk HC Jr. Broad-based
Status.jsp. Cited July 20, 2010. general surgery training is a model of continued utility for the future. Ann
6. MacKenzie EJ, Hoyt DB, Sacra JC, et al. National inventory of hospital Surg. 2004;239(5):627632 [discussion 632636].
trauma centers. JAMA. 2003;289(12):15661567. 27. Richardson JD. Training surgeons to care for the injured: the general
7. Branas CC, MacKenzie EJ, Williams JC, et al. Access to trauma centers in surgery model. Bull Am Coll Surg. 1994;79(8):3137.
the United States. JAMA. 2005;293(21):26262633. 28. Richardson JD, Miller FB. Is there an ideal model for training the trauma
8. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of surgeons of the future? J Trauma. 2003;54(4):795797.
the effect of trauma-center care on mortality. N Engl J Med. 2006:354(4): 29. Richardson JD. Trauma centers and trauma surgeons: have we become too
366378. specialized? J Trauma. 2000;48(1):17.
9. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD. Acute care 30. Ciesla DJ, Moore EE, Moore JB, Johnson JL, Cothren CC, Burch JM.
surgery: eraritjaritjaka. J Am Coll Surg. 2006;202(4):698701. The academic trauma center is a model for the future trauma and acute
10. Meredith J, Miller P, Chang M. Operative Experience at ACS Verified Level care surgeon. J Trauma. 2005;58(4):657661 [discussion 661662].
I Trauma Centers. Cashiers, NC: Halstead Society; 2002. 31. Finlayson SR. Surgery in rural America. Surg Innov. 2005;12(4):
11. Fakhry SM, Watts DD, Michetti C, Hunt JP; EAST Multi-Institutional 299305.
Blunt Hollow Viscous Injury Research Grup. The resident experience on 32. Hunter J, Deveny K. Training the rural surgeon. Bull Am Coll Surg.
trauma: declining surgical opportunities and career incentives? Analysis of 2003;88(5):1317.
data from a large multi-institutional study. J Trauma. 2003;54(1):18. 33. Cogbill T. What is a career in trauma. J Trauma. 1996;41(2):203207.
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differences between trauma care and other surgical emergencies: results 35. Goslings JC, Ponsen KJ, Luitse JS, Jurkovich GJ. Trauma surgery in the
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14. American Board of Medical Specialties. 2010. Available at: http://www 2006;61:111115. Cited July 20, 2010. 36. Allgower M. Trauma systems in Europe. Am J Surg. 1991;161:226229.




Prehospital Care
Jeffrey P. Salomone and Joseph A. Salomone III

Critically injured patients must receive high-quality care from care began about four decades ago. J.D. Deke Farrington
the earliest postinjury moment to have the best chance of sur- and Sam Banks instituted the first trauma course for ambu-
vival. Most trauma victims first receive health care from the lance personnel in 1962.1 This course, initiated with the
emergency medical services (EMS) system, which is responsible Chicago Committee on Trauma and the Chicago Fire
for rendering aid and transporting the trauma patient to an Academy, marked the beginning of formal training in prehos-
appropriate facility. pital care of injured patients. Farrington is generally acknowl-
The practice of medicine in the prehospital setting presents edged as the father of modern EMS.2
numerous challenges not encountered in the hospital. Hazardous In September, 1966, the National Academy of Sciences and
materials along with environmental and climatic conditions National Research Council published the landmark mono-
may pose dangers to rescuers as well as to patients. If the patient graph, Accidental Death and Disability: The Neglected Disease of
is entrapped in a mangled vehicle or a collapsed building, there Modern Society.3 This document argued that there were no
must be meticulous coordination of medical and rescue teams. standards for ambulances with respect to design, equipment, or
Providers of prehospital care are expected to deliver high-qual- training of personnel. As a direct result of this monograph, the
ity medical care in situations that are austere and unforgiving Department of Transportation funded the development of the
and, often, for prolonged periods. Emergency Medical TechnicianAmbulance (EMT-A) curric-
The role of the EMS system is far more complex than simply ulum, which was published in 1969. Continued public pressure
transporting the trauma victim to a medical facility. In most resulted in the passage of the Emergency Medical Services
EMS systems in the United States, specially trained health care (EMS) Systems Act of 1973 (PL 93-154). This act revolution-
professionals are responsible for the initial assessment and man- ized EMS in this country and resulted in federal funding for the
agement of the injured patient. Experience from the last several establishment of EMS systems.
decades has shown that these paraprofessionals can safely per- In the late 1960s, Pantridge, an Irish physician practicing in
form many of the interventions that were previously performed Belfast, developed a mobile coronary care unit that was staffed
only by physicians or nurses in the emergency department. by physicians.4 He conceived of a system in which the victim
While many of these procedures have proven beneficial for of an acute myocardial infarction was stabilized at the scene by
victims of cardiac emergencies, critically injured patients may bringing advanced life support (ALS) to the patient. The phy-
need two items not available on an ambulanceblood and a sicians worked to restore normal cardiac rhythm through
surgeon. As EMS systems mature and additional prehospital medications and defibrillation at the location where the victim
care research is conducted, the question is no longer, What was stricken.
can the Emergency Medical Technician (EMT) do for the In the United States, the concept of advanced prehospital
trauma patient in the prehospital setting? but rather, What care involved training emergency medical technicians (EMTs)
should the EMT do? to perform these lifesaving skills. The original paramedic
programs began in Los Angeles, California; Houston, Texas;
Jacksonville, Florida; and Columbus, Ohio; and were often
associated with fire departments. Paramedics were trained to
While the roots of prehospital trauma care can be traced back serve as the eyes and ears of the physicians in their base hos-
to military physicians, modern civilian prehospital trauma pitals and provide care under their direction.
Prehospital Care 101

While prehospital ALS proved beneficial for victims of car- retained the original 1985 curriculum. The Blueprint divided
diac emergencies, it was not until the 1980s that it became the major areas of prehospital instruction into 16 core ele-
obvious that definitive care for trauma patients was fundamen- ments. For each core element, there are progressively increas-
tally different than that for the cardiac patient. Efforts to restore ing knowledge and skill objectives, representing a continuum of

circulating blood volume proved to be unsuccessful in the face education and practice. A National Standard Curriculum
of ongoing internal hemorrhage. The exsanguinating trauma (NSC) provided lesson plans for each level.
patient requires operative intervention, and any action that With the publication of the EMS Education Agenda for the
delays the trauma patients arrival in the operating room is Future, the foundation was laid to replace the NSC with a
ultimately detrimental to survival. During this period, signifi- system that would hopefully standardize EMS training and
cant controversy surrounded prehospital ALS for trauma certification across the country. This system is based on a
patients as expert panels and editorialists debated its pros and medical model that includes a defined scope of practice,
cons.5,6 Several studies documented the detrimental effect of accredited education programs, certifying exams that assure
prolonged attempts at field stabilization on seriously injured baseline competency, and licensure to permit one to practice.
trauma patients,79 while others showed that paramedics could Three of the five components of this system focus on the levels
employ ALS measures in an expeditious manner.1013 and education of EMS providers, and each had input from
national stakeholder organizations and the public during its
EMERGENCY MEDICAL SERVICES SYSTEM National EMS Core Content. Published in 2005, this
The modern EMS system involves the integration of a number document describes the domain of prehospital care, identi-
of complex components. Essential elements include the follow- fying the universal body of knowledge and skills that could
ing: personnel, equipment, communications, transport modali- potentially be utilized by EMS providers who do not func-
ties, medical control, and an ongoing quality improvement tion as independent practitioners.18
process. Different configurations of EMS systems result when National EMS Scope of Practice Model. Published in
these components are integrated in varying combinations. The 2007, this document identifies four new levels of prehospital
EMS system represents a significant component of the trauma care practitioners19 (Table 7-1). The knowledge and skills
system, described elsewhere (see Chapter 4). described in the Core Content are divided among the four
The Department of Transportation, through the EMS levels. During the development of the Scope of Practice
Office of the National Highway Traffic Safety Administration, Model, there was insufficient support in the EMS and
provides federal leadership for the EMS system. With input medical communities to support the development of a fifth
from national stakeholder organizations, NHTSA developed level of EMS provider with a scope of practice greater than
the EMS Agenda for the Future, published in 1996.14 This that of the paramedic.
document detailed a vision for improving 14 aspects of EMS National EMS Education Standards. Published in 2009,
including the following: integration of health services, EMS these standards describe the minimal, entry-level compe-
research, legislation and regulation, system finance, human tencies that EMS personnel must achieve for each of the
resources, medical direction, education systems, public educa- levels described in the Scope of Practice.20 Compared to
tion, prevention, public access, communication systems, the NSC, the Education Standards allow for more diverse
clinical care, information systems, and evaluation. Two related methods of implementation, more frequent updates of
documents that expand on concepts addressed in the original content, and some variation at the state or local level.
Agenda are the EMS Education Agenda for the Future: A Each level builds upon the knowledge and skills of the
Systems Approach (2000) and the National EMS Research previous level.
Agenda (2001).15,16

EMS Personnel
EMTs comprise the vast majority of prehospital care provid- TABLE 7-1 EMS Provider Levels
ers employed in the United States, and only a small number National EMS Standard National EMS Scope
of nurses and physicians deliver care in the out-of-hospital Curricula of Practice (2007)
setting. First Responder (FR) Emergency Medical
Emergency Medical Responder (EMR)
Emergency Medical Technicians Technician-Basic (EMT-B) Emergency Medical
For more than a decade, the National Emergency Medical Emergency Medical Technician (EMT)
Services Education and Practice Blueprint, published by NHTSA Technician-Intermediate Advanced Emergency
in 1993, provided the basis for the levels and training of EMTs (EMT-I) Medical Technician
utilized in the United States.17 The four levels of EMTs Emergency Medical