View source for Major trauma

{{Other uses|Trauma (disambiguation)}}
{{short description|Injury that could cause prolonged disability or death}}
{{Infobox medical condition (new)
| name            = Major trauma
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| image           = US Navy 040723-N-8977L-008 Navy Hospital Corpsmen and Medical Officers assess the treatment and prognosis of a patient with a gunshot wound.jpg
| alt             = Health care providers attending to a person on a stretcher with a gunshot wound to the head; the patient is intubated, and a mechanical ventilator is visible in the background
| caption         = Health care providers attending to a person on a stretcher with a [[Ballistic trauma|gunshot wound]] to the head; the patient is [[tracheal intubation|intubated]], and a mechanical ventilator is visible in the background
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| field           = [[Emergency medicine]], [[trauma surgery]]
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'''Major trauma''' is any [[injury]] that has the potential to cause prolonged [[disability]] or [[death]].<ref>{{cite web|title=Glossary|url=http://www.nhtsa.gov/people/injury/ems/emstraumasystem03/glossary.htm|work=National Highway Traffic Safety Administration|access-date=26 March 2014}}</ref> There are many causes of major trauma, [[blunt trauma|blunt]] and [[penetrating trauma|penetrating]], including [[Falling (accident)|falls]], [[motor vehicle collision]]s, [[stab wound|stabbing wounds]], and [[gunshot wound]]s. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility (called a [[trauma center]]) may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.{{cn|date=March 2022}}

In 2002, unintentional and intentional injuries were the fifth and seventh leading causes of deaths worldwide, accounting for 6.23% and 2.84% of all deaths. For research purposes the definition often is based on an [[Injury Severity Score]] (ISS) of greater than 15.<ref>{{cite journal|last=Palmer|first=C|title=Major trauma and the injury severity score—where should we set the bar?|journal=Annual Proceedings of the Association for the Advancement of Automotive Medicine |year=2007|volume=51|pages=13–29|pmid=18184482|pmc=3217501}}</ref>

==Classification==
Injuries generally are classified by either severity, the location of damage, or a combination of both.<ref>Moore 2013, p. 77{{fcn|date=December 2023}}</ref> <!--percentages of total incidence-->Trauma also may be classified by [[Demographics|demographic group]], such as age or gender.<ref name="Rosen2010">{{cite book|title=Rosen's emergency medicine: concepts and clinical practice|edition= 7th |last=Marx|first=J|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=978-0323054720|pages=243–842}}</ref> It also may be classified by the type of force applied to the body, such as [[blunt trauma]] or [[penetrating trauma]]. For research purposes injury may be classified using the [[Barell matrix]], which is based on [[International Statistical Classification of Diseases and Related Health Problems#ICD-9|ICD-9-CM]]. The purpose of the matrix is for international standardization of the classification of trauma.<ref>{{Cite web|url = https://www.cdc.gov/nchs/injury/ice/barell_matrix.htm|title = The Barell Injury Diagnosis Matrix, Classification by Body Region and Nature of the Injury|access-date = 19 June 2013|publisher = Center for Disease Control}}</ref> Major trauma sometimes is classified by body area; injuries affecting 40% are [[polytrauma]], 30% [[head injury|head injuries]], 20% [[chest trauma]], 10%, [[abdominal trauma]], and 2%, [[Limb (anatomy)|extremity]] trauma.<ref name="Rosen2010"/><!--percentages of total incidence--><ref name="ER2008" />

Various scales exist to provide a quantifiable metric to measure the severity of injuries. The value may be used for [[triage|triaging]] a patient or for statistical analysis. Injury scales measure damage to anatomical parts, physiological values (blood pressure etc.), [[comorbidity|comorbidities]], or a combination of those. The [[Abbreviated Injury Scale]] and the [[Glasgow Coma Scale]] are used commonly to quantify injuries for the purpose of triaging and allow a system to monitor or "trend" a patient's condition in a clinical setting.<ref>Moore 2013, pp. 77–98{{fcn|date=December 2023}}</ref> The data also may be used in epidemiological investigations and for research purposes.<ref>{{cite conference | url=https://www.cdc.gov/nchs/data/injury/DicussionDocu.pdf | title=Discussion document on injury severity measurement in administrative datasets | publisher=Centers for Disease Control and Prevention | access-date=2013-05-24 |date=September 2004 | pages=1–3}}</ref>

Approximately 2% of those who have experienced significant trauma have a spinal cord injury.<ref name="Ahn 1341–61">{{cite journal|last=Ahn|first=H|author2=Singh, J |author3=Nathens, A |author4=MacDonald, RD |author5=Travers, A |author6=Tallon, J |author7=Fehlings, MG |author8= Yee, A |title=Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines|journal=Journal of Neurotrauma|date=Aug 2011|volume=28|issue=8|pages=1341–61|pmid=20175667 |doi=10.1089/neu.2009.1168 |pmc=3143405}}</ref>

==Causes==
Injuries may be caused by any combination of external forces that act physically against the body.<ref>Moore 2013, p. 2{{fcn|date=December 2023}}</ref> The leading causes of traumatic death are [[blunt trauma]], [[Traffic collision|motor vehicle collisions]], and [[Falling (accident)|falls]], followed by [[penetrating trauma]] such as [[stab wound]]s or impaled objects.<ref name="EMT-BMcGraw">{{cite book|title=EMT-Basic|last=DiPrima Jr.|first=PA|pages=227–33|publisher=McGraw-Hill|isbn=978-0071496797|date=2008-03-21}}</ref> Subsets of blunt trauma are both the number one and two causes of traumatic death.<ref name="ec11">{{cite book|title=Emergency Care|vauthors=Dickenson ET, Limmer D, O'Keefe MF |isbn=978-0135005231|year=2009|publisher=Pearson Prentice Hall }}</ref>

For statistical purposes, injuries are classified as either intentional such as suicide, or unintentional, such as a motor vehicle collision. Intentional injury is a common cause of traumas.<ref name="isbn0-340-92826-3">{{cite book |author1=Jeff Garner |author2=Greaves, Ian |author3=Ryan, James R. |author4=Porter, Keith R. |title=Trauma care manual |publisher=Hodder Arnold |location=London |year=2009 |isbn=978-0340928264 }}</ref> Penetrating trauma is caused when a [[foreign body]] such as a bullet or a knife enters the [[tissue (biology)|body tissue]], creating an open wound. In the United States, most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms.<ref name="isbn078173200x">{{cite book|vauthors=Medzon R, Mitchell EJ |title=Introduction to Emergency Medicine|publisher=Lippincott Williams & Willkins|location=Philadelphia|year=2005|pages=393–431|isbn=978-0781732000}}</ref> [[Blast injury]] is a complex cause of trauma because it commonly includes both blunt and penetrating trauma, and also may be accompanied by a [[burn injury]]. Trauma also may be associated with a particular activity, such as an [[occupational injury|occupational]] or [[sports injury]].<ref>{{cite journal|last1=Kannus|first1=P.|last2=Parkkari|first2=J.|last3=Jarvinen|first3=T.|last4=Jarvinen|first4=A.|last5=Jarvinen|first5=M.|title=Basic science and clinical studies coincide: active treatment approach is needed after a sports injury|journal=Scandinavian Journal of Medicine & Science in Sports|date=June 2003|volume=13|issue=3|pages=150–54|doi=10.1034/j.1600-0838.2003.02225.x|pmid=12753486|s2cid=11161742}}</ref>

==Pathophysiology==
The body responds to traumatic injury both systemically and at the injury site.<ref name="trauma care">{{cite book | title=Manual of Definitive Surgical Trauma Care | publisher=Hodder Arnold Publishers | author=Boffard, Kenneth | year=2007 | location=London, England | isbn=978-0340947647}}</ref> This response attempts to protect vital organs such as the liver, to allow further cell duplication and to heal the damage.<ref>{{Cite journal | last1 = Winterborn | first1 = R. J. | last2 = Cook | first2 = T. A. | doi = 10.1383/surg.21.9.240.16923 | title = The Pathophysiology of Severe Trauma | journal = Surgery | volume = 21 | issue = 9 | page = 240a | year = 2003 }}</ref> The healing time of an injury depends on various factors including sex, age, and the severity of injury.<ref name="ICU Book" />

The symptoms of injury may manifest in many different ways, including:<ref>Pietzman 2002, p. 21{{fcn|date=December 2023}}</ref>
* [[Altered mental status]]
* Fever
* [[Tachycardia|Increased heart rate]]
* Generalized [[edema]]
* Increased [[cardiac output]]
* Increased rate of metabolism

Various organ systems respond to injury to restore [[homeostasis]] by maintaining perfusion to the heart and brain.<ref>Pietzman 2002, p. 17{{fcn|date=December 2023}}</ref> [[Inflammation]] after injury occurs to protect against further damage and starts the healing process. Prolonged inflammation may cause [[multiple organ dysfunction syndrome]] or [[systemic inflammatory response syndrome]].<ref>Pietzman 2002, p. 19{{fcn|date=December 2023}}</ref> Immediately after injury, the body increases production of glucose through [[gluconeogenesis]] and its consumption of fat via [[lipolysis]]. Next, the body tries to replenish its energy stores of glucose and protein via [[anabolism]]. In this state the body will temporarily increase its maximum expenditure for the purpose of healing injured cells.<ref name="ICU Book">{{cite book |author1=Sutin, Kenneth M |author2=Marino, Paul L. |title=The ICU book |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |isbn=978-0781748025 }}</ref><ref name="pmid15910820">{{cite journal |vauthors=Keel M, Trentz O |title=Pathophysiology of polytrauma |journal=[[Injury (journal)|Injury]] |volume=36 |issue=6 |pages=691–709 |date=June 2005 |pmid=15910820 |doi=10.1016/j.injury.2004.12.037 }}</ref>

==Diagnosis==
[[File:Shotgun wound-xray.JPG|thumb|alt=Radiograph of a close-range shotgun blast injury to the knee. Birdshot pellets are visible within and around the shattered patella, distal femur and proximal tibia.|Radiograph of a close-range [[shotgun]] [[blast injury]] to the [[knee]]. [[Birdshot|Birdshot pellets]] are visible within and around the shattered [[patella]], distal [[femur]], and proximal [[tibia]]]]

The initial assessment is critical in determining the extent of injuries and what will be needed to manage an injury, and for treating immediate life threats.

===Physical examination===
Primary [[physical examination]] is undertaken to identify any life-threatening problems, after which the secondary examination is carried out. This may occur during transportation or upon arrival at the hospital. The secondary examination consists of a systematic assessment of the [[Abdomen|abdominal]], [[Human pelvis|pelvic]], and [[Chest|thoracic]] areas, a complete inspection of the body surface to find all injuries, and a [[neurological examination]]. Injuries that may manifest themselves later may be missed during the initial assessment, such as when a patient is brought into a hospital's emergency department.<ref name="ATLS2008" /> Generally, the physical examination is performed in a systematic way that first checks for any immediate life threats (primary survey), and then taking a more in-depth examination (secondary survey).<ref>Moore 2013, p{{fcn|date=December 2023}}</ref>

===Imaging===
[[File:Whole body radiograph in trauma.jpg|thumb|left|Whole body radiograph of traumatic injuries notable for fractures of both femurs (thigh bones), indicating major trauma]]
Persons with major trauma commonly have chest and pelvic [[Radiography|x-rays]] taken,<ref name="ER2008" /> and, depending on the mechanism of injury and presentation, a [[focused assessment with sonography for trauma]] (FAST) exam to check for internal bleeding. For those with relatively stable blood pressure, heart rate, and sufficient [[Oxygenation (medical)|oxygenation]], [[X-ray computed tomography|CT scans]] are useful.<ref name="ER2008" /><ref name="Trauma2010" /> [[Full-body CT scan]]s, known as pan-scans, improve the survival rate of those who have suffered major trauma.<ref name="Huber2009">{{cite journal |vauthors=Huber-Wagner S, Lefering R, Qvick LM, etal |title=Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study|journal=Lancet|volume=373|issue=9673|pages=1455–61|year=2009|pmid=19321199|doi=10.1016/S0140-6736(09)60232-4|s2cid=45335697}}</ref><ref>{{cite journal|last1=Jiang|first1=L|last2=Ma|first2=Y|last3=Jiang|first3=S|last4=Ye|first4=L|last5=Zheng|first5=Z|last6=Xu|first6=Y|last7=Zhang|first7=M|title=Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis|journal=Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine|date=September 2, 2014|volume=22|issue=1|page=54|pmid=25178942|doi=10.1186/s13049-014-0054-2|pmc=4347587|doi-access=free}}</ref> These scans use intravenous injections for the [[radiocontrast]] agent, but not oral administration.<ref name="Allen2004">{{cite journal|vauthors=Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH |title=Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma|journal=J Trauma|volume=56|issue=2|pages=314–22|year=2004|pmid=14960973|doi=10.1097/01.TA.0000058118.86614.51}}</ref> There are concerns that intravenous contrast administration in trauma situations without confirming adequate renal function may cause damage to kidneys, but this does not appear to be significant.<ref name="Trauma2010">{{cite journal |vauthors=McGillicuddy EA, Schuster KM, Kaplan LJ, et al |title=Contrast-induced nephropathy in elderly trauma patients|journal=J Trauma|volume=68|issue=2|pages=294–97|year=2010|pmid=20154540|doi=10.1097/TA.0b013e3181cf7e40}}</ref>

In the U.S., CT or [[Magnetic resonance imaging|MRI]] scans are performed on 15% of those with trauma in [[emergency department]]s.<ref name="Korley2010">{{cite journal|vauthors=Korley FK, Pham JC, Kirsch TD |title=Use of advanced radiology during visits to US emergency departments for injury-related conditions,1998–2007| journal=JAMA| volume=304| issue=13| pages=1465–71| year=2010| pmid=20924012| doi=10.1001/jama.2010.1408| doi-access=| pmc=11660594}}</ref> Where blood pressure is low or the heart rate is increased{{mdash}}likely from bleeding in the abdomen{{mdash}}immediate surgery bypassing a CT scan is recommended.<ref>{{cite journal  |vauthors=Neal MD, Peitzman AB, Forsythe RM, etal |title=Over reliance on computed tomography imaging in patients with severe abdominal injury: is the delay worth the risk? |journal=J Trauma |volume=70 |issue=2 |pages=278–84 |date=February 2011 |pmid=21307722 |doi=10.1097/TA.0b013e31820930f9 }}</ref> Modern 64-slice CT scans are able to rule out, with a high degree of accuracy, significant injuries to the neck following blunt trauma.<ref>{{cite journal|last=Kanji|first=HD|author2=Neitzel, A |author3=Sekhon, M |author4=McCallum, J |author5= Griesdale, DE |title=Sixty-four-slice computed tomographic scanner to clear traumatic cervical spine injury: systematic review of the literature.|journal=Journal of Critical Care|date=Apr 2014|volume=29|issue=2|pages=314.e9–13|pmid=24393410 |doi=10.1016/j.jcrc.2013.10.022}}</ref>

===Surgical techniques===
Surgical techniques, using a tube or catheter to [[Diagnostic peritoneal lavage|drain fluid from the peritoneum]], [[chest tube|chest]], or the [[pericardiocentesis|pericardium around the heart]], often are used in cases of severe blunt trauma to the chest or abdomen, especially when a person is experiencing early signs of [[shock (circulatory)|shock]]. In those with [[hypotension|low blood-pressure]], likely because of bleeding in the abdominal cavity, [[laparotomy|cutting through the abdominal wall surgically]] is indicated.<ref name="ER2008" />

==Prevention==
{{main|Injury prevention}}

By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems may help to enhance the overall health of a population.<ref name="Hoyt2007">{{cite journal|last1=Hoyt|first1=DB|last2=Coimbra|first2=R|title=Trauma systems|journal=Surgical Clinics of North America|volume=87|issue=1|pages=21–35, v–vi|year=2007|pmid=17127121|doi=10.1016/j.suc.2006.09.012}}</ref> Injury prevention strategies are commonly used to prevent injuries in children, who are a high risk population.<ref name="child prevention">{{cite book | title=Injury Prevention for Young Children: A Research Guide | publisher=Greenwood | author=Walker, Bonnie | year=1996 | page=[https://archive.org/details/injuryprevention0000unse/page/2 2] | isbn=978-0313296864 | url=https://archive.org/details/injuryprevention0000unse/page/2 }}</ref> Injury prevention strategies generally involve educating the general public about specific risk factors and developing strategies to avoid or reduce injuries.<ref name="cdcinjury">{{cite book | title=CDC Injury Fact Book | publisher=National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, Georgia | year=2006 | location=Atlanta, Georgia | pages=35–101}}</ref> Legislation intended to prevent injury typically involves seatbelts, child car-seats, helmets, alcohol control, and increased enforcement of the legislation.{{CN|date=December 2023}} Other controllable factors, such as the use of drugs including [[alcoholic beverage|alcohol]] or [[cocaine]], increases the risk of trauma by increasing the likelihood of traffic collisions, violence, and abuse occurring.<ref name="ER2008" /> Prescription drugs such as [[benzodiazepine]]s may increase the risk of trauma in [[old age|elderly]] people.<ref name="ER2008" />

The care of acutely injured people in a public health system requires the involvement of bystanders, community members, health care professionals, and health care systems. It encompasses [[pre-hospital trauma assessment]] and care by [[emergency medical services]] personnel, emergency department assessment, treatment, stabilization, and in-hospital care among all age groups.<ref name="CDC">{{cite web|url=https://www.cdc.gov/injuryresponse/acute_injury.html|title=Centers for Disease Control and Prevention Injury Prevention and Control: Injury Response: Acute Injury Care|access-date=2017-09-09|archive-url=https://web.archive.org/web/20150924040725/http://www.cdc.gov/injuryresponse/acute_injury.html|archive-date=2015-09-24|url-status=dead}}</ref> An established trauma system network is also an important component of community disaster preparedness, facilitating the care of people who have been involved in disasters that cause large numbers of casualties, such as earthquakes.<ref name="Hoyt2007" />

==Management==
[[File:US Navy 010531-N-3889M-004 Navy Corpsman Field Training Exercise.jpg|thumb|alt=Color photograph of a United States Navy hospital corpsman listening for correct placement of an endotracheal tube in a simulated trauma victim during a search and rescue exercise. His assistant is holding a bag of intravenous fluid.|A [[Hospital_corpsman|Navy corpsman]] listens for the correct tube placement on an [[tracheal intubation|intubated]] trauma victim during a [[search and rescue]] exercise]]
[[File:Schockraum Uniklinik MA.jpg|thumb|alt=Color photograph of a room designed to handle major trauma. Visible are an anesthesia machine, a Doppler ultrasound device, a defibrillator, a suction device, a gurney, and several carts for storing surgical instruments and disposable supplies.|Typical trauma room]]

===Pre-hospital===
The pre-hospital use of [[Stabilization (medicine)|stabilization]] techniques improves the chances of a person surviving the journey to the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at a [[trauma center]] as well as provide primary stabilization by checking and treating [[ABC (medicine)|airway, breathing, and circulation]] as well as assessing for disability and gaining exposure to check for other injuries.<ref name="ATLS2008">{{cite book|first=American College of Surgeons|last=Committee on Trauma|author-link=American College of Surgeons|title=ATLS: Advanced Trauma Life Support Program for Doctors|publisher=American College of Surgeons|location=Chicago|edition=8th|year=2008|isbn=978-1880696316}}</ref>

[[spinal immobilization|Spinal motion restriction]] by securing the neck with a [[cervical collar]] and placing the person on a [[long spine board]] was of high importance in the pre-hospital setting, but due to lack of evidence to support its use, the practice is losing favor. Instead, it is recommended that more exclusive criteria be met such as age and neurological deficits to indicate the need of these adjuncts.<ref>{{Cite journal|last1=Sundstrøm|first1=Terje|last2=Asbjørnsen|first2=Helge|last3=Habiba|first3=Samer|last4=Sunde|first4=Geir Arne|last5=Wester|first5=Knut|date=2013-08-20|title=Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review|journal=Journal of Neurotrauma|volume=31|issue=6|pages=531–40|doi=10.1089/neu.2013.3094|issn=0897-7151|pmc=3949434|pmid=23962031}}</ref><ref>{{Cite journal|last1=Singletary|first1=Eunice M.|last2=Charlton|first2=Nathan P.|last3=Epstein|first3=Jonathan L.|last4=Ferguson|first4=Jeffrey D.|last5=Jensen|first5=Jan L.|last6=MacPherson|first6=Andrew I.|last7=Pellegrino|first7=Jeffrey L.|last8=Smith|first8=William “Will” R.|last9=Swain|first9=Janel M.|date=2015-11-03|title=Part 15: First Aid|journal=Circulation|language=en|volume=132|issue=18 suppl 2|pages=S574–89|doi=10.1161/CIR.0000000000000269|issn=0009-7322|pmid=26473003|doi-access=free}}</ref> This may be accomplished with other medical transport devices, such as a  [[Kendrick Extrication Device|Kendrick extrication device]], before moving the person.<ref name="Karbi1988">{{cite journal|first1=OA|last1=Karbi|first2=DA|last2=Caspari|first3=CH|last3=Tator|title=Extrication, immobilization and radiologic investigation of patients with cervical spine injuries|journal=[[Canadian Medical Association Journal]]|volume=139|issue=7|pages=617–21|year=1988|pmc=1268249|pmid=3046734}}</ref> It is important to quickly control severe bleeding with direct pressure to the wound and consider the use of [[hemostatic agents]] or [[tourniquet]]s if the bleeding continues.<ref name="Moore2013p154">Moore 2013, pp. 154–66{{fcn|date=December 2023}}</ref> Conditions such as impending airway obstruction, enlargening neck hematoma, or unconsciousness require intubation. It is unclear, however, if this is best performed before reaching hospital or in the hospital.<ref name="Bulger2007">{{cite journal|last=Bulger|first=EM|author2=Maier, RV|title=Prehospital care of the injured: what's new.|journal=The Surgical Clinics of North America|date=Feb 2007|volume=87|issue=1|pages=37–53, vi|pmid=17127122|doi=10.1016/j.suc.2006.09.009}}</ref>

Rapid transportation of severely injured patients improves the outcome in trauma.<ref name="ER2008">{{cite journal|last1=Bonatti|first1=H|last2=Calland|first2=JF|title=Trauma|journal=Emergency Medicine Clinics of North America|volume=26|issue=3|pages=625–48|year=2008|pmid=18655938|doi=10.1016/j.emc.2008.05.001}}</ref><ref name="ATLS2008" /> Helicopter EMS transport reduces mortality compared to ground-based transport in adult trauma patients.<ref>{{cite journal|last=Sullivent|first=EE|author2=Faul, M |author3=Wald, MM |title=Reduced mortality in injured adults transported by helicopter emergency medical services|journal=Prehospital Emergency Care |date=Jul–Sep 2011|volume=15|issue=3|pages=295–302|pmid=21524205|doi=10.3109/10903127.2011.569849|s2cid=26089433|url=https://zenodo.org/record/1235833}}</ref> Before arrival at the hospital, the availability of [[advanced life support]] does not greatly improve the outcome for major trauma when compared to the administration of [[basic life support]].<ref name="Stiell2008">{{cite journal |vauthors=Stiell IG, Nesbitt LP, Pickett W, et al |title=The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity|journal=CMAJ|volume=178|issue=9|pages=1141–52|year=2008|pmid=18427089|pmc=2292763|doi=10.1503/cmaj.071154}}</ref><ref name="Liberman2007">{{cite journal|vauthors=Liberman M, Roudsari BS |title=Prehospital trauma care: what do we really know?|journal=Curr Opin Crit Care|volume=13|issue=6|pages=691–96|year=2007|pmid=17975392|doi=10.1097/MCC.0b013e3282f1e77e|s2cid=44694756}}</ref> Evidence is inconclusive in determining support for pre-hospital [[Intravenous therapy|intravenous fluid resuscitation]] while some evidence has found it may be harmful.<ref name="Dretzke2004">{{cite journal|vauthors=Dretzke J, Sandercock J, Bayliss S, Burls A |title=Clinical effectiveness and cost-effectiveness of prehospital intravenous fluids in trauma patients|journal=Health Technol Assess|volume=8|issue=23|pages=iii, 1–103|year=2004|pmid=15193210|doi=10.3310/hta8230|doi-access=free}}</ref> Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them,<ref name="ER2008" /> and outcomes may improve when persons who have experienced trauma are transferred directly to a trauma center.<ref name="Nirula2010">{{cite journal|vauthors=Nirula R, Maier R, Moore E, Sperry J, Gentilello L |title=Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer's effect on mortality|journal=J Trauma|volume=69|issue=3|pages=595–99; discussion 599–601|year=2010|pmid=20838131|doi=10.1097/TA.0b013e3181ee6e32}}</ref>

Improvements in pre-hospital care have led to "unexpected survivors", where patients survive trauma when they would have previously been expected to die.<ref>Anes - Combat Anesthesia: The First 24 Hours https://medcoeckapwstorprd01.blob.core.usgovcloudapi.net/pfw-images/dbimages/Anes%20%20Ch%203.pdf</ref> However these patients may struggle to rehabilitate.<ref>Royal Society Trauma recovery: new science and technology for mental and physical health https://royalsociety.org/-/media/about-us/industry/tof-conference-reports/trauma-recovery-report-2020.pdf</ref>

===In-hospital===
Management of those with trauma often requires the help of many healthcare specialists including physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. Generally, the first step of managing trauma is to perform a primary survey that evaluates a person's airway, breathing, circulation, and neurologic status.<ref>Moore 2013, p. 160{{fcn|date=December 2023}}</ref> These steps may happen simultaneously or depend on the most pressing concern such as a [[tension pneumothorax]] or major arterial bleed. The primary survey generally includes assessment of the cervical spine, though [[clearing the cervical spine|clearing]] it is often not possible until after imaging, or the person has improved. After immediate life threats are controlled, a person is either moved into an operating room for immediate surgical correction of the injuries, or a secondary survey is performed that is a more detailed head-to-toe assessment of the person.<ref>Moore 2013, p. 163{{fcn|date=December 2023}}</ref>

Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure.<ref>{{cite journal|last=Nemeth|first=J|author2=Maghraby, N |author3=Kazim, S |title=Emergency airway management: the difficult airway.|journal=Emergency Medicine Clinics of North America|date=May 2012|volume=30|issue=2|pages=401–20, ix|pmid=22487112|doi=10.1016/j.emc.2011.12.005}}</ref> Examples of these indications include penetrating neck trauma, expanding neck hematoma, and being unconscious. In general, the method of intubation used is [[rapid sequence intubation]] followed by ventilation, though intubating in shock due to bleeding can lead to arrest, and should be done after some resuscitation whenever possible. Trauma resuscitation includes control of active bleeding. When a person is first brought in, vital signs are checked, an [[ECG]] is performed, and, if needed, vascular access is obtained. Other tests should be performed to get a baseline measurement of their current blood chemistry, such as an [[arterial blood gas]] or [[thromboelastography]].<ref>Moore 2013, p. 161{{fcn|date=December 2023}}</ref> In those with [[cardiac arrest]] due to trauma chest compressions are considered futile, but still recommended.<ref name=AHAPart12>{{cite journal |vauthors=Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A |title=Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care|journal=Circulation|date=2010-11-02|volume=122|issue=18 Suppl 3|pages=S829–61|pmid=20956228|doi=10.1161/CIRCULATIONAHA.110.971069|doi-access=free}}</ref> Correcting the underlying cause such as a [[pneumothorax]] or [[pericardial tamponade]], if present, may help.<ref name=AHAPart12/>

A [[focused assessment with sonography for trauma|FAST]] exam may help assess for internal bleeding. In certain traumas, such as [[maxillofacial]] trauma, it may be beneficial to have a highly trained health care provider available to maintain airway, breathing, and circulation.<ref name="Maxillofacial">{{cite journal|vauthors=Krausz AA, El-Naaj IA, Barak M |title=Maxillofacial trauma patient: coping with the difficult airway |journal=[[World Journal of Emergency Surgery]] |volume=4 |page=21 |year=2009|pmid=19473497 |pmc=2693512 |doi=10.1186/1749-7922-4-21 |doi-access=free }}</ref>

===Intravenous fluids===
Traditionally, high-volume [[intravenous fluids]] were given to people who had poor perfusion due to trauma.<ref name="EMB11" /> This is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries.<ref name="COCC2010">{{cite journal|vauthors=Roppolo LP, Wigginton JG, Pepe PE |title=Intravenous fluid resuscitation for the trauma patient|journal=Curr Opin Crit Care|volume=16|issue=4|pages=283–88|year=2010|pmid=20601865|doi=10.1097/MCC.0b013e32833bf774|s2cid=22449600}}</ref> In general, however, giving lots of fluids appears to increase the risk of death.<ref>{{cite journal|last=Wang|first=CH|author2=Hsieh, WH |author3=Chou, HC |author4=Huang, YS |author5=Shen, JH |author6=Yeo, YH |author7=Chang, HE |author8=Chen, SC |author9= Lee, CC  |title=Liberal Versus Restricted Fluid Resuscitation Strategies in Trauma Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies|journal=Critical Care Medicine|date=Dec 11, 2013|pmid=24335443 |doi=10.1097/CCM.0000000000000050 |volume=42 |issue=4|pages=954–61|s2cid=44411659}}</ref> Current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist.<ref name="Rosen2010"/><ref name="COCC2010" /> Targets include a [[mean arterial pressure]] of 60&nbsp;mmHg, a [[systolic blood pressure]] of 70–90&nbsp;mmHg,<ref name="EMB11" /><ref name="Tint10">{{cite book |author=Tintinalli, Judith E. |title=Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli))|publisher=McGraw-Hill Companies |location=New York |year=2010 |page=176 |isbn=978-0071484800 }}</ref> or the re-establishment of peripheral pulses and adequate ability to think.<ref name="EMB11" /> [[Hypertonic saline]] has been studied and found to be of little difference from normal saline.<ref name=Kob2012>{{cite journal|last=Kobayashi|first=L|author2=Costantini, TW |author3=Coimbra, R |title=Hypovolemic shock resuscitation|journal=The Surgical Clinics of North America|date=Dec 2012|volume=92|issue=6|pages=1403–23|pmid=23153876|doi=10.1016/j.suc.2012.08.006}}</ref>

As no intravenous fluids used for initial resuscitation have been shown to be superior, warmed [[Lactated Ringer's solution]] continues to be the solution of choice.<ref name="EMB11">{{cite journal|last=Cherkas |first=David |title=Traumatic Hemorrhagic Shock: Advances In Fluid Management |journal=Emergency Medicine Practice |date=Nov 2011 |volume=13 |issue=11 |pages=1-19; quiz 19-20 |pmid=22164397 |url=http://www.ebmedicine.net/store.php?paction=showProduct&catid=8&pid=244 |url-status=dead |archive-url=https://web.archive.org/web/20120118152838/http://www.ebmedicine.net/store.php?paction=showProduct&catid=8&pid=244 |archive-date=2012-01-18 }}</ref> If blood products are needed, a greater use of [[fresh frozen plasma]] and [[platelet]]s instead of only [[packed red blood cells]] has been found to improve survival and lower overall blood product use;<ref name="Greer2010">{{cite journal|vauthors=Greer SE, Rhynhart KK, Gupta R, Corwin HL |title=New developments in massive transfusion in trauma|journal=Curr Opin Anesthesiol|volume=23|issue=2|pages=246–50|year=2010|pmid=20104173|doi=10.1097/ACO.0b013e328336ea59|s2cid=35694962}}</ref> a ratio of 1:1:1 is recommended.<ref name="Tint10" /> The success of platelets has been attributed to the fact that they may prevent [[coagulopathy]] from developing.<ref name="wsj">{{cite news |url=https://www.wsj.com/articles/SB10001424127887324712504578131360684277812 |title=In Medical Triumph, Homicides Fall Despite Soaring Gun Violence|work=Wall street Journal|date=8 December 2012|access-date=2012-12-09}}</ref> [[Cell salvage and autotransfusion]] also may be used.<ref name="EMB11" />

[[Blood substitutes]] such as [[hemoglobin-based oxygen carriers]] are in development; however, as of 2013 there are none available for commercial use in North America or Europe.<ref name="EMB11" /><ref name="UPT2008">{{cite web|url=http://www.uptodate.com/online/content/topic.do?topicKey=transfus/11560&selectedTitle=1~8&source=search_result|title=UpToDate Inc.|access-date=2010-11-13}}</ref><ref name="Spahn2005">{{cite journal|vauthors=Spahn DR, Kocian R|title=Artificial O2 carriers: status in 2005|journal=Curr. Pharm. Des.|volume=11|issue=31|pages=4099–114|year=2005|pmid=16378514|doi=10.2174/138161205774913354|url=http://www.bentham-direct.org/pages/content.php?CPD/2005/00000011/00000031/0011B.SGM|archive-url=https://archive.today/20120724042425/http://www.bentham-direct.org/pages/content.php?CPD/2005/00000011/00000031/0011B.SGM|url-status=usurped|archive-date=2012-07-24|url-access=subscription}}</ref> These products are only available for general use in South Africa and Russia.<ref name="UPT2008" />

===Medications===
[[Tranexamic acid]] decreases death in people who are having ongoing bleeding due to trauma, as well as those with mild to moderate traumatic brain injury and evidence of intracranial bleeding on CT scan.<ref name="CRASH2010">{{cite journal |collaboration=CRASH-2 trial |vauthors=Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T |title=Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial |journal=The Lancet |volume=376 |issue=9734 |pages=23–32 |year=2010 |pmid=20554319 |doi=10.1016/S0140-6736(10)60835-5|s2cid=10407122 |hdl=20.500.12959/415 |hdl-access=free }}</ref><ref>{{cite journal|vauthors=Cap AP, Baer DG, Orman JA, Aden J, Ryan K, Blackbourne LH |title=Tranexamic acid for trauma patients: a critical review of the literature|journal=The Journal of Trauma|date=July 2011|volume=71|issue=1 Suppl|pages=S9–14|pmid=21795884|doi=10.1097/TA.0b013e31822114af}}</ref><ref>{{Cite journal|date=2019-11-09|title=Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial|url= |journal=The Lancet|language=en|volume=394|issue=10210|pages=1713–1723|doi=10.1016/S0140-6736(19)32233-0|issn=0140-6736|pmid=31623894|pmc=6853170|author1=((CRASH-3 trial collaborators))}}</ref> It  only appears to be beneficial, however, if administered within the first three hours after trauma.<ref>{{cite journal|last1=Napolitano|first1=LM|last2=Cohen|first2=MJ|last3=Cotton|first3=BA|last4=Schreiber|first4=MA|last5=Moore|first5=EE|title=Tranexamic acid in trauma: how should we use it?|journal=The Journal of Trauma and Acute Care Surgery|date=June 2013|volume=74|issue=6|pages=1575–86|pmid=23694890|doi=10.1097/ta.0b013e318292cc54|s2cid=9569603}}</ref> For severe bleeding, for example from [[Coagulopathy|bleeding disorders]], [[recombinant factor VIIa]]{{mdash}}a protein that assists blood clotting{{mdash}}may be appropriate.<ref name="ER2008" /><ref name="COCC2010" /> While it decreases blood use, it does not appear to decrease the mortality rate.<ref>{{cite journal  |vauthors=Hauser CJ, Boffard K, Dutton R, etal |title=Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage |journal=J Trauma |volume=69 |issue=3 |pages=489–500 |date=September 2010 |pmid=20838118 |doi=10.1097/TA.0b013e3181edf36e }}</ref> In those without previous factor VII deficiency, its use is not recommended outside of trial situations.<ref>{{cite journal|last=Simpson|first=E|author2=Lin, Y |author3=Stanworth, S |author4=Birchall, J |author5=Doree, C |author6= Hyde, C |title=Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia|journal=Cochrane Database of Systematic Reviews |date=Mar 14, 2012|volume=3|issue=3|page=CD005011|pmid=22419303|doi=10.1002/14651858.CD005011.pub4|hdl=10871/13808|hdl-access=free}}</ref>

Other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury.<ref name="Rosen2010" /> While positive [[inotrope|inotropic medications]] such as [[norepinephrine (drug)|norepinephrine]] sometimes are used in hemorrhagic shock as a result of trauma, there is a lack of evidence for their use.<ref>{{cite journal|last=Senz|first=A|author2=Nunnink, L|title=Review article: inotrope and vasopressor use in the emergency department|journal=Emergency Medicine Australasia |date=Oct 2009|volume=21|issue=5|pages=342–51|pmid=19694785|doi=10.1111/j.1742-6723.2009.01210.x|s2cid=20328839|doi-access=free}}</ref> Therefore, as of 2012 they have not been recommended.<ref name=Kob2012/> Allowing a low blood pressure may be preferred in some situations.<ref>{{cite web|title=Vasopressor and Inotrope Usage in Shock|url=http://www.surgicalcriticalcare.net/Guidelines/Vasopressors%20and%20Inotropes%20in%20Shock.pdf|work=Department of Surgical Education, Orlando Regional Medical Center|access-date=4 May 2014|date=Apr 19, 2011}}</ref>

===Surgery===
The decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. Bleeding must be controlled before definitive repair may occur.<ref>{{cite book |author1=Andrew B., MD Peitzman |author2=Andrew B. Peitzman |author3=Michael, MD Sabom |author4=Donald M., MD Yearly |author5=Timothy C., MD Fabian |title=The trauma manual |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2002 |isbn=978-0781726412 }}</ref> [[Damage control surgery]] is used to manage severe trauma in which there is a [[Trauma triad of death|cycle]] of [[metabolic acidosis]], [[hypothermia]], and [[hypotension]] that may lead to death, if not corrected.<ref name="ER2008" /> The main principle of the procedure involves performing the fewest procedures to save life and limb; less critical procedures are left until the victim is more stable.<ref name="ER2008" /> Approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require exploratory surgery. The majority of preventable deaths from trauma result from unrecognised intra-abdominal bleeding.<ref name="Management of Abdominal Trauma">{{cite book |last1=Fitzgerald |first1= J.E.F. |last2=Larvin |first2=Mike |year=2009 |chapter= Chapter 15: Management of Abdominal Trauma |editor1-last=Baker |editor1-first=Qassim |editor2-last=Aldoori |editor2-first=Munther |title=Clinical Surgery: A Practical Guide |publisher=[[CRC Press]] |pages=192–204 |isbn=978-1444109627}}</ref>

==Prognosis==
Trauma deaths occur in immediate, early, or late stages. Immediate deaths usually are due to [[apnea]], severe brain or high spinal cord injury, or rupture of the heart or of large blood vessels. Early deaths occur within minutes to hours and often are due to [[subdural hematoma|hemorrhages in the outer meningeal layer of the brain]], [[epidural hematoma|torn arteries]], [[hemothorax|blood around the lungs]], [[pneumothorax|air around the lungs]], [[ruptured spleen]], [[Abdominal trauma#Liver|liver laceration]], or [[pelvic fracture]]. Immediate access to care may be crucial to prevent death in persons experiencing major trauma. Late deaths occur days or weeks after the injury<ref name="ATLS2008" /> and often are related to infection.<ref>Moore 2013, p. 330{{fcn|date=December 2023}}</ref> Prognosis is better in countries with a dedicated trauma system where injured persons are provided quick and effective access to proper treatment facilities.<ref name="ER2008" />

Long-term prognosis frequently is complicated by pain; more than half of trauma patients have moderate to severe pain one year after injury.<ref name="Rivara2008">{{cite journal|vauthors=Rivara FP, Mackenzie EJ, Jurkovich GJ, Nathens AB, Wang J, Scharfstein DO |title=Prevalence of pain in patients 1 year after major trauma|journal=Arch Surg|volume=143|issue=3|pages=282–87; discussion 288|year=2008|pmid=18347276|doi=10.1001/archsurg.2007.61|doi-access=}}</ref> Many also experience a reduced [[quality of life]] years after an injury,<ref name="Ulvik2008">{{cite journal|vauthors=Ulvik A, Kvåle R, Wentzel-Larsen T, Flaatten H |title=Quality of life 2–7 years after major trauma|journal=Acta Anaesthesiol Scand|volume=52|issue=2|pages=195–201|year=2008|pmid=18005377|doi=10.1111/j.1399-6576.2007.01533.x|s2cid=13256047}}</ref> with 20% of victims sustaining some form of disability.<ref name="Peitzman2008">{{cite book|veditors=Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC |title=The Trauma Manual|edition=3rd|year=2008|chapter=Pediatric Trauma|pages=499–514|publisher=Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0781762755}}</ref>
Physical trauma may lead to development of [[post-traumatic stress disorder]] (PTSD).<ref name="DSM">{{cite book|title=Diagnostic and Statistical Manual of Mental Disorders|chapter=309.81 Posttraumatic Stress Disorder|pages=424–29|chapter-url=http://www.cirp.org/library/psych/ptsd2/ |edition=fourth |publisher=American Psychiatric Association|location=Washington, USA|year=1994}}</ref> One study has found no correlation between the severity of trauma and the development of PTSD.<ref name="Feinstein1991">{{cite journal|first1=A|last1=Feinstein|first2=Ray|last2=Dolan|title=Predictors of post-traumatic stress disorder following physical trauma: an examination of the stressor criterion|journal=Psychological Medicine|year=1991|volume=21|issue=1|pages=85–91|pmid=2047509|publisher=Cambridge University Press|doi=10.1017/S0033291700014689|hdl=21.11116/0000-0001-A23A-7|s2cid=28663482 |hdl-access=free}}</ref>

==Epidemiology==
{{Further|List of preventable causes of death}}
[[File:Injuries world map - Death - WHO2004.svg|thumb|upright=1.3|Deaths from injuries per 100,000&nbsp;inhabitants in 2004<ref name="WHO">{{cite web|url=https://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates2004.xls|title=Death and DALY estimates for 2004 by cause for WHO Member States|format=xls|work=World Health Organization|year=2004|access-date=2010-11-13}}</ref>
{{Col-begin}}
{{Col-break}}
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|< 25}}
{{legend|#fff200|25–50}}
{{legend|#ffdc00|50–75}}
{{legend|#ffc600|75–100}}
{{legend|#ffb000|100–125}}
{{legend|#ff9a00|125–150}}
{{Col-break}}
{{legend|#ff8400|150–175}}
{{legend|#ff6e00|175–200}}
{{legend|#ff5800|200–225}}
{{legend|#ff4200|225–250}}
{{legend|#ff2c00|250–275}}
{{legend|#cb0000|> 275}}
{{col-end}}]]
[[File:Accidents.svg|thumb|upright=1.3|Incidence of accidents by activity in Denmark]]

Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually.<ref name="Epi09" /><ref name="Oxford2010" /> It is the fifth leading cause of significant disability.<ref name="Epi09">{{cite journal|author=Søreide K|title=Epidemiology of major trauma|journal=The British Journal of Surgery|volume=96|issue=7|pages=697–98|year=2009|pmid=19526611|doi=10.1002/bjs.6643|s2cid=10670345|doi-access=free}}</ref> About half of trauma deaths are in people aged between 15 and 45 years and trauma is the leading cause of death in this age group.<ref name="Oxford2010">{{cite book|editor=Jason Smith |editor2=Ian Greaves |editor3=Keith Porter |title=Major trauma |year=2010 |publisher=Oxford University Press |location=Oxford |isbn=978-0199543328 |page=2 |edition=1. publ.}}</ref> Injury affects more males; 68% of injuries occur in males<ref name="2013nejm" /> and death from trauma is twice as common in males as it is in females, this is believed to be because males are much more willing to engage in risk-taking activities.<ref name="Oxford2010" /> Teenagers and young adults are more likely to need hospitalization from injuries than other age groups.<ref name="p23">Moore 2013, p. 23{{fcn|date=December 2023}}</ref> While elderly persons are less likely to be injured, they are more likely to die from injuries sustained due to various physiological differences that make it more difficult for the body to compensate for the injuries.<ref name="p23" /> The primary causes of traumatic death are central nervous system injuries and [[exsanguination|substantial blood loss]].<ref name="Epi09" /> Various classification scales exist for use with trauma to determine the severity of injuries, which are used to determine the resources used and, for statistical collection.

==History==
The human remains discovered at the site of [[Nataruk]] in [[Turkana County|Turkana]], Kenya, are claimed to show major trauma—both blunt and penetrating—caused by violent trauma to the head, neck, ribs, knees, and hands, which has been interpreted by some researchers as establishing the existence of warfare between two groups of hunter-gatherers 10,000 years ago.<ref>{{Cite journal|title = Inter-group violence among early Holocene hunter-gatherers of West Turkana, Kenya|journal = Nature|pages = 394–98|volume = 529|issue = 7586|doi = 10.1038/nature16477|pmid = 26791728|first1 = M. Mirazón|last1 = Lahr|first2 = F.|last2 = Rivera|first3 = R. K.|last3 = Power|first4 = A.|last4 = Mounier|first5 = B.|last5 = Copsey|first6 = F.|last6 = Crivellaro|first7 = J. E.|last7 = Edung|first8 = J. M. Maillo|last8 = Fernandez|first9 = C.|last9 = Kiarie|year = 2016|bibcode = 2016Natur.529..394L|s2cid = 4462435|url = https://www.repository.cam.ac.uk/handle/1810/253726}}</ref> The evidence for blunt-force trauma at Nataruk has been challenged, however, and the interpretation that the site represents an early example of warfare has been questioned.<ref>{{cite journal|last1=Stojanowski|first1=Christopher M.|last2=Seidel|first2=Andrew C.|last3=Fulginiti|first3=Laura C.|last4=Johnson|first4=Kent M.|last5=Buikstra|first5=Jane E.|title=Contesting the Massacre at Nataruk|journal=Nature|date=24 Nov 2016|volume=539|issue=7630|doi=10.1038/nature19778|pmid=27882979|pages=E8–E10|s2cid=205250945}}</ref>

==Society and culture==

===Economics===
The financial cost of trauma includes both the amount of money spent on treatment and the loss of potential economic gain through absence from work. The average financial cost for the treatment of traumatic injury in the United States is approximately {{USD|334,000}} per person, making it costlier than the treatment of cancer and [[cardiovascular disease]]s.<ref name="PHTLS">{{cite book |title=PHTLS: Prehospital Trauma Life Support |publisher=Mosby/JEMS |year=2010 |isbn=978-0323065023}}</ref> One reason for the high cost of the treatment for trauma is the increased possibility of complications, which leads to the need for more interventions.<ref name="pmid18656640">{{cite journal  |vauthors=Hemmila MR, Jakubus JL, Maggio PM, etal |title=Real money: complications and hospital costs in trauma patients |journal=[[Surgery]] |volume=144 |issue=2 |pages=307–16 |date=August 2008 |pmid=18656640 |pmc=2583342 |doi=10.1016/j.surg.2008.05.003  }}</ref> Maintaining a trauma center is costly because they are open continuously and maintain a state of readiness to receive patients, even if there are none.<ref name="pmid14706578">{{cite journal |vauthors=Taheri PA, Butz DA, Lottenberg L, Clawson A, Flint LM |title=The cost of trauma center readiness |journal=[[American Journal of Surgery]] |volume=187 |issue=1 |pages=7–13 |date=January 2004 |pmid=14706578 |doi= 10.1016/j.amjsurg.2003.06.002}}</ref> In addition to the direct costs of the treatment, there also is a burden on the economy due to lost wages and productivity, which in 2009, accounted for approximately {{USD|693.5 billion}} in the United States.<ref>{{cite web | url=http://www.nsc.org/Documents/Injury_Facts/Injury_Facts_2011_w.pdf | title=Injury Facts | publisher=National Safety Council | access-date=July 17, 2012}}</ref>

===Low- and middle-income countries===

Citizens of [[Developing country|low-]] and [[middle income country|middle-income]] countries (LMICs) often have higher mortality rates from injury. These countries accounted for 89% of all deaths from injury worldwide.<ref name="2013nejm">{{cite journal |vauthors=Norton R, Kobusingye O |title=Injuries |journal=[[The New England Journal of Medicine]] |volume=368 |issue=18 |pages=1723–30 |date=May 2013 |pmid=23635052 |doi=10.1056/NEJMra1109343 |doi-access=free }}</ref> Many of these countries do not have access to sufficient surgical care and many do not have a trauma system in place. In addition, most LMICs do not have a pre-hospital care system that treats injured persons initially and transports them to hospital quickly, resulting in most casualty patients being transported by private vehicles. Also, their hospitals lack the appropriate equipment, organizational resources, or trained staff.<ref name="care">{{cite journal |vauthors=Sakran JV, Greer SE, Werline EC, McCunn M |title=Care of the injured worldwide: trauma still the neglected disease of modern society |journal=[[Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine]] |volume=20 |issue=1 |page=64 |date=September 2012 |pmid=22980446 |doi=10.1186/1757-7241-20-64 |pmc=3518175 |doi-access=free }}</ref><ref name="strength">{{cite journal |vauthors=Mock C, Quansah R, Krishnan R, Arreola-Risa C, Rivara F |title=Strengthening the prevention and care of injuries worldwide |journal=[[The Lancet|Lancet]] |volume=363 |issue=9427 |pages=2172–79 |date=June 2004 |pmid=15220042 |doi=10.1016/S0140-6736(04)16510-0 |s2cid=33390855 }}</ref> By 2020, the amount of trauma-related deaths is expected to decline in [[high income country|high-income countries]], while in low- to middle-income countries it is expected to increase.{{CN|date=December 2023}}

==Special populations==

===Children===
{{Main|Pediatric trauma}}
{| class="wikitable" style = "float: right; margin-left:15px; text-align:center"
|-
! Cause
! Deaths per year
|-
| [[Traffic collision]]
|
260,000
|-
| [[Drowning]]
|
175,000
|-
| [[Burn]]s
|
96,000
|-
| [[Falling (accident)|Falls]]
|
47,000
|-
| [[Toxin]]s
|
45,000
|}
Due to anatomical and physiological differences, injuries in children need to be approached differently from those in adults.<ref name="Dickinson2008">{{cite book|vauthors=Dickinson E, Limmer D, O'Keefe MF, Grant HD, Murray R |title=Emergency Care|publisher=Prentice Hall|location=Englewood Cliffs, New Jersey|year=2008|pages=848–52|isbn=978-0135005248|edition=11th}}</ref> Accidents are the leading cause of death in children between 1 and 14 years old.<ref name="Peitzman2008" /> In the United States, approximately sixteen million children go to an emergency department due to some form of injury every year,<ref name="Peitzman2008" /> with boys being more frequently injured than girls by a ratio of 2:1.<ref name="Peitzman2008" /> The world's five most common unintentional injuries in children as of 2008 are road crashes, drowning, burns, falls, and poisoning.<ref name="BBC">{{cite news|title=UN raises child accidents alarm|author=BBC News Online|author-link=BBC News Online|agency=[[BBC News]]|publisher=BBC|location=London|date=December 10, 2008|url=http://news.bbc.co.uk/2/hi/in_depth/7776127.stm|access-date=2010-10-31}}</ref>

[[Body weight#Estimation in children|Weight estimation]] is an important part of managing trauma in children because the accurate dosing of medicine may be critical for resuscitative efforts.<ref name="pmid20825816">{{cite journal |vauthors=Rosenberg M, Greenberger S, Rawal A, Latimer-Pierson J, Thundiyil J |title=Comparison of Broselow tape measurements versus physician estimations of pediatric weights |journal=[[The American Journal of Emergency Medicine]] |volume=29 |issue=5 |pages=482–8–8 |date=June 2011 |pmid=20825816 |doi=10.1016/j.ajem.2009.12.002 }}</ref> A number of methods to estimate weight, including the [[Broselow tape]], [[Leffler formula]], and [[Theron formula]] exist.<ref name="Ped09">{{cite journal|vauthors=So TY, Farrington E, Absher RK |title=Evaluation of the accuracy of different methods used to estimate weights in the pediatric population|journal=Pediatrics|volume=123|issue=6|pages=e1045–51|year=2009|pmid=19482737|doi=10.1542/peds.2008-1968|s2cid=6009482}}</ref>

===Pregnancy===
Trauma occurs in approximately 5% of all pregnancies,<ref name="EMP2008">{{cite journal|last=Tibbles|first=Carrie|title=Trauma In Pregnancy: Double Jeopardy|journal=Emergency Medicine Practice|date=July 2008|volume=10|issue=7|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=88}}</ref> and is the leading cause of maternal death. Additionally, pregnant women may experience [[placental abruption]], [[Premature birth|pre-term labor]], and [[uterine rupture]].<ref name="EMP2008" /> There are diagnostic issues during pregnancy; [[ionizing radiation]] has been shown to cause birth defects,<ref name="Rosen2010" /> although the doses used for typical exams generally are considered safe.<ref name="EMP2008" /> Due to normal [[Maternal physiological changes in pregnancy|physiological changes that occur during pregnancy]], shock may be more difficult to diagnose.<ref name="Rosen2010" /><ref name="BTLS">{{cite book |author=Campbell, John Creighton |title=Basic trauma life support for paramedics and other advanced providers |publisher=Brady/Prentice Hall Health |location=Upper Saddle River, N.J |year=2000 |pages=239–47 |isbn=978-0130845849}}</ref> Where the woman is more than 23 weeks pregnant, it is recommended that the fetus be monitored for at least four hours by [[cardiotocography]].<ref name="EMP2008" />

A number of treatments beyond typical trauma care may be needed when the patient is pregnant. Because the weight of the uterus on the [[inferior vena cava]] may decrease blood return to the heart, it may be very beneficial to lay a woman in late pregnancy on her left side.<ref name="EMP2008" /> also recommended are [[Rho(D) immune globulin]] in those who are rh negative, [[corticosteroids]] in those who are 24 to 34 weeks and may need delivery or a [[caesarian section|caesarean section]] in the event of cardiac arrest.<ref name="EMP2008" />
{{Clear}}

==Research==
{{See also|Traumatology}}
Most research on trauma occurs during war and military conflicts as militaries will increase trauma research spending in order to prevent combat related deaths.<ref name="pmid18483051">{{cite journal |author=Gulland A |title=Emergency Medicine: Lessons from the battlefield |journal=[[BMJ]] |volume=336 |issue=7653 |pages=1098–100 |date=May 2008 |pmid=18483051 |pmc=2386631 |doi=10.1136/bmj.39568.496424.94 }}</ref> Some research is being conducted on patients who were admitted into an [[intensive care unit]] or trauma center, and received a trauma diagnosis that caused a negative change in their health-related quality of life, with a potential to create anxiety and symptoms of depression.<ref name="pmid19088550">{{cite journal|vauthors=Ringdal M, Plos K, Lundberg D, Johansson L, Bergbom I |title=Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care|journal=J Trauma|volume=66|issue=4|pages=1226–33|year=2009|pmid=19088550|doi=10.1097/TA.0b013e318181b8e3}}</ref> New preserved blood products also are being researched for use in pre-hospital care; it is impractical to use the currently available blood products in a timely fashion in remote, rural settings or in theaters of war.<ref name="pmid21718901">{{cite journal |vauthors=Alam HB, Velmahos GC |title=New trends in resuscitation |journal=[[Current Problems in Surgery]] |volume=48 |issue=8 |pages=531–64 |date=August 2011 |pmid=21718901 |doi=10.1067/j.cpsurg.2011.04.002  |pmc=3128790}}</ref>

==References==
{{Reflist}}

==Bibliography==
* {{cite book |author1=Jeff Garner |author2=Greaves, Ian |author3=Ryan, James R. |author4=Porter, Keith R. |title=Trauma Care Manual |publisher=Hodder Arnold |location=London, England|year=2009 |isbn=978-0340928264}}
* {{cite book |author1=Feliciano, David V. |author2=Mattox, Kenneth L. |author3=Moore, Ernest J |title=Trauma, Seventh Edition (Trauma (Moore)) |publisher=McGraw-Hill Professional |year=2012 |isbn=978-0071663519}}
* {{cite book |author1=Andrew B., Peitzman |author2=Michael, MD Sabom |author3=Donald M., MD Yearly |author4=Timothy C., MD Fabian |title=The trauma manual |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2002 |isbn=978-0781726412 }}

==Further reading==
* {{cite book|title=Emergency War Surgery|editor-last=Editorial Board|editor-first=Army Medical Department Center & School|publisher=[[Borden Institute]]|location=Washington, DC|edition=3rd|year=2004|url=http://www.bordeninstitute.army.mil/other_pub/ews.html|access-date=2010-10-31|archive-url=https://web.archive.org/web/20110623060552/http://www.bordeninstitute.army.mil/other_pub/ews.html|archive-date=2011-06-23|url-status=dead}}
* {{cite book|title=Textbook of Military Medicine, Part IV: Surgical Combat Casualty Care|volume=1: Anesthesia and Perioperative Care of the Combat Casualty|editor-last=Zajtchuk|editor-first=R|editor2-last=Bellamy|editor2-first=RF|editor3-last=Grande|editor3-first=CM|publisher=Borden Institute|location=Washington, DC|year=1995|url=http://www.bordeninstitute.army.mil/published_volumes/anesthesia/anesthesia.html|access-date=2010-10-31|archive-url=https://web.archive.org/web/20110622093251/http://www.bordeninstitute.army.mil/published_volumes/anesthesia/anesthesia.html|archive-date=2011-06-22|url-status=dead}}

== External links ==
{{Medical resources
|  DiseasesDB      = 28858
|  ICD10           = {{ICD10|T|79||S|00}}
|  ICD9            = {{ICD9|900}}-{{ICD9|957}}
|  ICDO            =
|  OMIM            =
|  OMIM_mult       =
|  MedlinePlus     = 000024
|  eMedicineSubj   =
|  eMedicineTopic  =
|  eMedicine_mult  = [http://emedicine.medscape.com/trauma/ trauma]
|  MeshID          = D014947
}}
{{commons|Wounds}}
* [https://web.archive.org/web/20080524041147/http://www.emrap.tv/ Emergency Medicine Research and Perspectives] (emergency medicine procedure videos)


{{Trauma |state=collapsed}}
{{General injuries}}
{{Emergency medicine}}
{{Authority control}}
{{Portal bar|Medicine}}

[[Category:Medical emergencies]]
[[Category:Critical emergency medicine]]
[[Category:Traumatology]]
[[Category:Causes of death|Trauma]]
[[Category:Acute pain]]
[[Category:Trauma types]]