Epidemiology of major trauma

Major injury is a leading cause of death and disability around the world. For both sexes, one in every ten deaths is the result of injury. Globally, unintentional injuries are ranked as the sixth leading cause of death and the fifth leading cause of moderate and severe disability1. Road traffic accidents alone cause 1·3 million deaths annually – a sobering 148 deaths every hour. For those under 35 years of age, injury is the leading cause of death2, and males aged 15–24 years are responsible for the greatest share of the burden of injury2,3. Furthermore, 45 million people each year – more than 2000 per hour – suffer moderate to severe disability following unintentional injuries1. While those who live in lowincome regions are associated with over 80 per cent of this global injury total, 3·9 million people in highincome countries are also disabled from injuries every year. Those in the latter group tend to be affected at a young age and, as a consequence, many years of productivity are lost at both an individual and a societal level. The ‘disability-adjusted lifeyear’ (DALY) is a time-based measure that combines years of life lost owing to premature death and years of life lost due to time lived in states of less than full health. In 2004, the World Health Organization (WHO) ranked road traffic accidents as the ninth leading cause of DALYs. By 2030, such accidents are projected by the WHO to rank third1. Regrettably, trauma is a worldwide problem that has a particular impact on mortality and life expectancy among young people. ‘Major trauma’ is a generic term and different regions have different dominating injuries. Outside of war zones and areas of armed conflict, penetrating trauma from firearms makes up a relatively small share, typically less than 15 per cent. However, urban epidemics of civilian penetrating injuries are seen in the USA (20–45 per cent) and South Africa (as high as 60 per cent). Interestingly, the easy availability of handguns has a dramatic impact on homicide and suicide statistics, with more than 50 per cent of all suicides in the USA being related to handguns4, and several thousands of murders each year. Knife violence is proportionately similar in the UK and USA5. For Europe in general, it is highest in Spain and Portugal, and lowest in Scandinavia and Greece. Where there is a high prevalence of penetrating injury, major trauma tends to be associated with socioeconomic deprivation, high alcohol consumption, drug abuse and, in some regions, a higher prevalence of bloodborne viral diseases. Most injuries in Europe are blunt trauma, commonly from falls or motor vehicle collisions. Spinal cord and brain injuries are responsible for the greatest injury burden due to permanent disability3. Differences exist between countries. In the Netherlands and the UK, the injury burden and related costs per capita are relatively low, whereas the opposite is true for Austria, Denmark, Norway and Ireland3. For all countries, costs per capita increase greatly for those over 65 years old, but costs are high at both extremes of age. The injury pattern in blunt trauma is a preponderance of serious head, thoracic and limb injuries. Severe thoracic and/or abdominal injuries affect less than 20 per cent of all blunt trauma victims; about a third are abdominal injuries and about a fifth include both body cavities. In the abdomen, solid organ damage occurs most often to the liver (36 per cent), followed by the spleen (32 per cent) and kidney (24 per cent)6. Surgery is required for less than 5 per cent of thoracic injuries, and for less than