Major trauma
Major trauma is any injury that has the potential to cause prolonged disability or death.[1] There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. 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.
For other uses, see Trauma (disambiguation).Major trauma
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.[2]
Classification[edit]
Injuries generally are classified by either severity, the location of damage, or a combination of both.[3] Trauma also may be classified by demographic group, such as age or gender.[4] 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 ICD-9-CM. The purpose of the matrix is for international standardization of the classification of trauma.[5] Major trauma sometimes is classified by body area; injuries affecting 40% are polytrauma, 30% head injuries, 20% chest trauma, 10%, abdominal trauma, and 2%, extremity trauma.[4][6]
Various scales exist to provide a quantifiable metric to measure the severity of injuries. The value may be used for triaging a patient or for statistical analysis. Injury scales measure damage to anatomical parts, physiological values (blood pressure etc.), 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.[7] The data also may be used in epidemiological investigations and for research purposes.[8]
Approximately 2% of those who have experienced significant trauma have a spinal cord injury.[9]
Causes[edit]
Injuries may be caused by any combination of external forces that act physically against the body.[10] The leading causes of traumatic death are blunt trauma, motor vehicle collisions, and falls, followed by penetrating trauma such as stab wounds or impaled objects.[11] Subsets of blunt trauma are both the number one and two causes of traumatic death.[12]
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.[13] Penetrating trauma is caused when a foreign body such as a bullet or a knife enters the 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.[14] 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 or sports injury.[15]
The body responds to traumatic injury both systemically and at the injury site.[16] This response attempts to protect vital organs such as the liver, to allow further cell duplication and to heal the damage.[17] The healing time of an injury depends on various factors including sex, age, and the severity of injury.[18]
The symptoms of injury may manifest in many different ways, including:[19]
Various organ systems respond to injury to restore homeostasis by maintaining perfusion to the heart and brain.[20] 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.[21] 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.[18][22]
Prognosis[edit]
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 hemorrhages in the outer meningeal layer of the brain, torn arteries, blood around the lungs, air around the lungs, ruptured spleen, 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[23] and often are related to infection.[73] Prognosis is better in countries with a dedicated trauma system where injured persons are provided quick and effective access to proper treatment facilities.[6]
Long-term prognosis frequently is complicated by pain; more than half of trauma patients have moderate to severe pain one year after injury.[74] Many also experience a reduced quality of life years after an injury,[75] with 20% of victims sustaining some form of disability.[76]
Physical trauma may lead to development of post-traumatic stress disorder (PTSD).[77] One study has found no correlation between the severity of trauma and the development of PTSD.[78]
History[edit]
The human remains discovered at the site of Nataruk in 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.[84] 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.[85]
Society and culture[edit]
Economics[edit]
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 US$334,000 per person, making it costlier than the treatment of cancer and cardiovascular diseases.[86] 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.[87] 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.[88] 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 US$693.5 billion in the United States.[89]
Low- and middle-income countries[edit]
Citizens of low- and middle-income countries (LMICs) often have higher mortality rates from injury. These countries accounted for 89% of all deaths from injury worldwide.[82] 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.[90][91] By 2020, the amount of trauma-related deaths is expected to decline in high-income countries, while in low- to middle-income countries it is expected to increase.