Introduction to Trauma Care
Amy N. Hildreth
R. Shayn Martin
J. Wayne Meredith
I. Introduction
Trauma is mechanical damage to the body caused by an external force. The trauma patient has been defined as “an injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability.” This chapter describes the current impact of injury on society, the structure of modern trauma systems, and the way injuries are measured and quantified as well as common patterns of injury seen with blunt, penetrating, and blast injury mechanisms.
II. Epidemiology
Overall, trauma is the fifth leading cause of death in the United States and is the leading source of mortality for patients between 1 and 44 years of age. In 2007, 182,479 people died secondary to injury, representing 60 deaths per 100,000 population. Of these, 123,706 were unintentional in nature while 53,371 were caused by violence. A fatal injury occurs approximately every 5 minutes.
Mortality after trauma can be characterized by three time periods during which the majority of deaths occur. As seen in Figure 1-1, approximately 50% of deaths occur immediately and are usually secondary to severe neurologic injuries or exsanguination from major blood vessel injuries. These deaths can only be avoided through injury prevention. The second peak of approximately 30% of deaths occurs during the initial hours post-injury, and preventing these deaths is the goal of modern trauma. Finally, 20% of deaths occur late (1 to 2 weeks from injury) and are secondary to sepsis and multiple organ failure. It is believed that improved early management of injury and associated shock may prevent these late complications.
In 2009, there were over 36 million medically attended, non-fatal injuries in the United States. Data from 2007 reveal an estimated 42.4 million injury-related emergency departments and 80 million office-based visits. Injury represents the greatest cause of years of potential life lost (YPLL) before age 65, totaling over 2.4 million years or 20.1% of all YPLL. The total cost for injuries occurring in 2005 including medical expenses and lost wages was estimated to be 355.3 billion dollars.
Specific injury patterns and mechanism
Age. While people 44 years old and younger account for the majority of fatal and non-fatal injuries, the impact of trauma on the elderly is far more severe. The death rate for injuries among patients 0 to 44 years old is approximately 45 per 100,000 population, whereas this rate is 113 per 100,000 for people over 65 years old and 169 per 100,000 for people over 75 years old.
Gender. Sixty-nine percent of all injury-related deaths occur in males, accounting for twice the number of female deaths.
Mechanism
Motor vehicle crashes (MVC) are the leading cause of injury-related death, accounting for 42,031 deaths in 2007 or 13.8 deaths per 100,000 population. Over 2.6 million people sustained non-fatal injuries secondary to MVC in 2009. Despite this, the death rate per vehicle miles traveled (VMT) has declined steadily throughout the century.
Firearm-related injury resulted in 31,224 deaths in 2007 and was the third leading cause of injury-related mortality for all ages. Fifty-six percent were a
result of suicide while 41% were homicide-related. Non-fatal gunshot wounds were identified in 66,769 patients in 2009. Predominately, fatal shootings involve young males; the number of deaths in the 15- to 34-year-old age range is over seven times the number of female deaths. Firearm-related injuries peak at 19 years of age.
Figure 1-1. Distribution of death after injury. Adapted from: Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983;249(2):28–35.
Falls are the leading cause of non-fatal injury, resulting in approximately 8.8 million injuries and 23,443 deaths throughout all age groups. Falls are most common among the young and the elderly with both groups demonstrating injury rates of greater than 4,000 injuries per 100,000 population. Despite this similarity, falls are the leading cause of death in patients 65 years or older while death in children is uncommon. The death rate due to falls in elderly patients is more than 170 times that of children less than 10 years old. The peak incidence occurs at age 85.
Other common mechanisms contributing to trauma mortality include poisoning, suffocation, drowning, cutting/piercing, and burns.
III. Trauma Systems
Overview
As defined by the Trauma System Agenda for the Future, “A trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients and is integrated with the local public health system.”
Historical perspective. The systematic care of trauma changed significantly with the publication of, “Accidental Death and Disability: The Neglected Disease of Modern Society” in 1966. This document revealed the deficiencies in injury management and initiated the development of systems to improve trauma care. The Emergency Medical Services Systems Act was passed in 1973 to support the development of regionalized Emergency Medical Services (EMS systems. In 1976, the American College of Surgeons (ACS) Committee on Trauma (COT) published, “Optimal Hospital Resources for the Care of the Seriously Injured” which established criteria that identified hospitals as trauma centers. This document has been revised as knowledge about trauma systems has evolved. More recently, the Model Trauma Care System Plan created by the Health Resources Services Administration (HRSA) was published to further define and guide trauma system development.
Function. Trauma systems have been designed to be inclusive in nature and use all available resources to provide appropriate care to all injured patients.
Designation and verification. Facilities within a trauma system require identification of injury management capabilities so that resource assessments can be achieved. A government group designates a hospital as a trauma center after evaluating the facility’s resources and the ability to provide a specific level of care.
Fundamental components
Injury prevention has become an essential focus for all trauma systems in order to proactively reduce the impact of injury.
Prehospital care includes community access and communication systems as well as EMS systems and triage protocols. Universal access to emergency care (i.e., 911) is essential to allow efficient activation of the system. A robust communication system provides coordination of prehospital resources as well as proper transfer of information to receiving facilities. Standardized curricula for training EMS personnel provide a more consistent knowledge base and skills set. Developed trauma systems have insured more efficient emergency response through improved geographical placement of EMS providers versus only facility-based responders.
Acute care facilities provide a range of injury management from initial stabilization and transfer to all-inclusive definitive care. On the basis of available resources, facilities are characterized by injury management capabilities and many are designated as trauma centers using a scale of 1 to 4, with Level 1 centers providing the most comprehensive level of care.
Post-hospital care is an important part of reducing disability and improving an injured patient’s long-term outcome.
Trauma system infrastructure elements
Leadership. A lead agency should be established to coordinate trauma system development and provide necessary administration.
Professional resources. Successful trauma systems rely on competent and energetic health care providers to insure optimal injury care.
Education/Advocacy. Trauma systems must endeavor to improve public awareness about trauma as a disease state and the ability of injury prevention to reduce the societal impact of trauma.
Information Management. Trauma data registries at the local and national levels provide an invaluable resource for performance improvement, research, and trauma system management. Ideally, trauma data should be consistently captured and incorporated into regional and national databases to provide the most accurate depiction of the status of injury care.
Finances. Adequate financial support is essential for both trauma system development and the continued provision of trauma care. Increased public and political awareness of the magnitude of the problem is required to improve governmental funding.
Research. To continue improving the care of the injured, research endeavors must be encouraged and efforts to increase financial support for trauma research are crucial.
Technology. The potential of novel and developing technologies must be adopted and applied to the field of trauma care.
Disaster preparedness and response. Trauma systems are charged with the task of being prepared to respond to potential disasters by developing a systematic and organized approach that can be implemented if the need arises.
IV. Injury Scoring
Principles
Purpose. Injury scoring systems have been developed to accurately and consistently quantify the magnitude of injury from an anatomic, physiologic, or a combined standpoint. Scoring systems are used in triage decision making, quality improvement and benchmarking initiatives, prevention program analyses, and research endeavors.
Database use. Scoring systems are commonly included in trauma databases to provide a quantifiable means of patient comparison. (See Chapter 20.)
Correct use of scoring. Systems used for triage decision making must be easy to calculate from rapidly available information. Scoring is commonly used in the research setting and in this case, should be able to identify patients with comparable injuries. Evaluation of responses to therapy may benefit from applying
a physiologic scoring system. The combined scores are valuable when assessing outcome after injury.
Limitations. Since each injured patient is unique, there is no single scoring system that can provide a perfect description.
Scoring Systems (see Chapter 60)
Anatomic scores
Abbreviated Injury Score (AIS), Injury Severity Score (ISS), New Injury Severity Score (NISS)
American Association for the Surgery of Trauma (AAST), Organ Injury Scale (OIS)
Survival Risk Ratios (SRR)/ICD-based Injury Severity Score (ICISS)Related posts:
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