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Injury is the fourth leading killer of Americans and the single greatest cause of death before the age of 45 years both in the U.S. and internationally.1 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.2 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.

A systems approach is required to reduce morbidity and mortality that occur after traumatic injury, as illustrated by the roughly trimodal distribution of the peak incidence of trauma mortality (Table 250-1).

Table 250-1 Trimodal Distribution of Trauma Deaths

Recognizing the need to establish a system to triage injured patients rapidly to the most appropriate setting and the importance of promoting collaboration among emergency medicine, trauma surgery, and trauma care subspecialists, the U.S. Congress passed the Trauma Care Systems Planning and Development Act of 1990.3 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.2 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, radiography or CT suite, operating room, and postoperative intensive care setting. Table 250-2 details the requirements for designation as a level 1 trauma center. A complete list of trauma center requirements is available at

Table 250-2 Essential Characteristics of Level 1 Trauma Centers

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