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INTRODUCTION AND EPIDEMIOLOGY

Traumatic injury accounts for more than 40 million ED visits in the United States each year,1 and worldwide, about 6 million people die each year as a result of injuries. By 2030, road traffic crashes are predicted to become the fifth leading cause of death worldwide.2 In the United States, firearm, suffocation, and drowning/submersion have the highest case fatality rates.2 Trauma remains the leading cause of death among children and adults under the age of 46 years, accounting for nearly half of all deaths in these age groups.3 In all countries, the incidence of death from injury increases more than threefold with increasing poverty. For the 90% of patients who survive the initial trauma, the burden of ongoing morbidity from traumatic brain injury, loss of limb function, and ongoing pain is even more significant.

The major causes of death following trauma are head injury, chest injury, and major vascular injury. Trauma care should be organized according to the concepts of rapid assessment, triage, resuscitation, diagnosis, and therapeutic intervention.4 Worldwide, there are few countries or regions that have comprehensive systems of trauma care, from roadside to rehabilitation, and that incorporate effective injury prevention strategies.

TRAUMA SYSTEMS AND TIMELY TRIAGE

A systematic approach is required to reduce the morbidity and mortality that occur after traumatic injury (Figure 254-1).

FIGURE 254-1.

Phases of a preplanned trauma care continuum. ICU = intensive care unit. [Reproduced from U.S. Department of Health and Human Services, Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: U.S. Department of Health and Human Services; 2006. Available at: https://www.facs.org/quality-programs/trauma/vrc/resources. Accessed February 12, 2018.]

Recognizing the need to establish a system to triage injured patients rapidly to the most appropriate setting and to promote collaboration among emergency medicine, trauma surgery, and trauma care subspecialists, the U.S. Congress passed the Trauma Care Systems Planning and Development Act of 1990.5 This act provided for the development of a model trauma care system plan to serve as a reference document for each state in creating its own system. Each state must determine the appropriate facility for treatment of various types of injuries. Trauma centers are certified based on the institution’s commitment of personnel and resources to maintain a condition of readiness for the treatment of critically injured patients. Some states rely on a verification process offered by the American College of Surgeons for the designation of certain hospitals as trauma centers.4 In a well-run trauma center, the critically injured patient undergoes a multidisciplinary evaluation, and diagnostic and therapeutic interventions are performed with smooth transitions between the ED, diagnostic radiology suite, operating room, and postoperative intensive care setting. Table 254-1 details the requirements for designation as a Level 1 trauma center.

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