Ebook Essentials of trauma anesthesia (2/E): Part 1

Essentials of Trauma
Anesthesia
Second Edition

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Essentials of Trauma
Anesthesia
Second Edition
Edited by

Albert J. Varon MD MHPE FCCM

Miller Professor and Vice Chair for Education, Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL,
USA; Chief of Anesthesiology, Ryder Trauma Center at Jackson Memorial Hospital, Miami, FL, USA

Charles E. Smith MD

Professor of Anesthesia, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Attending Anesthesiologist and Director
of Anesthesia Research, Department of Anesthesiology, MetroHealth Medical Center, Cleveland, OH, USA

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Second edition 2017
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Library of Congress Cataloging-in-Publication Data
Names: Varon, Albert J., editor. | Smith, Charles E., 1956– editor.
Title: Essentials of trauma anesthesia / edited by Albert J. Varon,
Charles E. Smith.
Description: Second edition. | Cambridge, United Kingdom ; New York,
NY : Cambridge University Press, 2017. | Includes bibliographical
references and index.
Identifiers: LCCN 2017014556 | ISBN 9781316636718 (pbk. : alk. paper)
Subjects: | MESH: Anesthesia | Wounds and Injuries | Critical Care |
Perioperative Care
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..................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and
practice at the time of publication. Although case histories are drawn from
actual cases, every effort has been made to disguise the identities of the
individuals involved. Nevertheless, the authors, editors and publishers can
make no warranties that the information contained herein is totally free
from error, not least because clinical standards are constantly changing
through research and regulation. The authors, editors and publishers
therefore disclaim all liability for direct or consequential damages
resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
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To my grandchildren, Lisa and Jack, for coming into our lives and giving us so much joy.
AJV
To the victims of blunt and penetrating trauma, and to all those who work long and hard
to transport, stabilize, diagnose, treat, and rehabilitate them. To my children Adrienne,
Emily, and Rebecca, grandchildren Jane and Lucy, and parents, Thelma and David for
their love.
CES

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Contents
List of Contributors ix
Preface xiii
List of Abbreviations xv

Section 1 – Core Principles in
Trauma Anesthesia
1.

2.

3.
4.

Trauma Epidemiology, Mechanisms
of Injury, and Prehospital Care 1
John J. Como and Charles E. Smith
Initial Evaluation and
Management 16
Thomas E. Grissom and Robert
Sikorski

11. Coagulation Monitoring of the
Bleeding Trauma Patient 154
Marc P. Steurer and Michael

T. Ganter
12. Postoperative Care of the Trauma
Patient 164
Jack Louro and Albert J. Varon

Section 2 – Anesthetic
Considerations for Trauma

Airway Management 29
Christian Diez and Albert J. Varon
Shock, Resuscitation, and Fluid
Therapy 44
Michelle E. Kim and Yvette Fouche

13. Anesthetic Considerations for Adult
Traumatic Brain Injury 173
K. H. Kevin Luk and Armagan Dagal
14. Anesthetic Considerations for Spinal
Cord Injury 187
K. H. Kevin Luk and Armagan Dagal

5.

Vascular Cannulation 56
Shawn E. Banks and Albert J. Varon

6.

Blood Component Therapy and
Trauma Coagulopathy 69

Craig S. Jabaley and Roman Dudaryk

7.

General Anesthesia for Trauma
Michael D. Bassett and Charles
E. Smith

8.

Regional Anesthesia for
Trauma 102
Monique Espinosa and Sripad Rao

17. Anesthetic Considerations for
Abdominal Trauma 232
Olga Kaslow

9.

Monitoring the Trauma Patient 124
Richard McNeer and Albert J. Varon

18. Anesthetic Considerations for
Musculoskeletal Trauma 246
Jessica A. Lovich-Sapola and Charles
E. Smith

82

10. Echocardiography in Trauma 138
Ashraf Fayad and Marie-Jo Plamondon

15. Anesthetic Considerations for
Ocular and Maxillofacial
Trauma 200
Suneeta Gollapudy and Olga Kaslow
16. Anesthetic Considerations for Chest
Trauma 212
John M. Albert and Charles E. Smith

vii
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viii

Table of Contents

Section 3 – Anesthetic
Management in Special Trauma
Populations
19. Anesthetic Management of the Burn
Patient 261
Hernando Olivar and Sam R. Sharar
20. Anesthetic Management of the
Pediatric Trauma Patient 275
Ramesh Ramaiah and Sam R. Sharar

21. Anesthetic Management of the

Geriatric Trauma Patient 290
Olga Kaslow and Rachel Budithi
22. Anesthetic Management of the
Pregnant Trauma Patient 304
Daria M. Moaveni and Albert J. Varon

Index

317

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Contributors
John M. Albert
Fellow, Cardiothoracic Anesthesia,
Weill Medical College of Cornell
University; New York–Presbyterian
Hospital, New York, NY
Shawn E. Banks
Associate Professor and Residency
Program Director, Department of
Anesthesiology, University of Miami Miller
School of Medicine; Attending
Anesthesiologist, Ryder Trauma Center at
Jackson Memorial Hospital, Miami, FL
Michael D. Bassett
Assistant Professor, Case Western Reserve
University School of Medicine; Attending
Anesthesiologist, MetroHealth Medical

Center, Cleveland, OH
Rachel Budithi
Assistant Professor, Department of
Anesthesiology, Medical College of
Wisconsin; Froedtert Memorial Lutheran
Hospital Milwaukee, WI
John J. Como
Professor of Surgery, Case Western Reserve
University School of Medicine; Associate
Trauma Medical Director, Division of
Trauma, Critical Care, Burns, and Acute
Care Surgery, MetroHealth Medical Center,
Cleveland, OH
Armagan Dagal
Associate Professor, Department of
Anesthesiology & Pain Medicine, Adjunct
Associate Professor, Department of
Neurological Surgery, Medical CoDirector, Enhanced Perioperative Recovery
Program, Division Head of Spine and
Orthopedic Anesthesia Services,

Harborview Medical Center,
University of Washington,
Seattle, WA
Christian Diez
Associate Professor and Vice Chair for
Clinical Affairs, Department of
Anesthesiology, University of Miami
Miller School of Medicine; Attending
Anesthesiologist, Ryder Trauma

Center at Jackson Memorial Hospital,
Miami, FL
Roman Dudaryk
Assistant Professor, Department of
Anesthesiology, University of Miami Miller
School of Medicine; Attending
Anesthesiologist and Intensivist, Ryder
Trauma Center at Jackson Memorial
Hospital, Miami, FL
Monique Espinosa
Assistant Professor of Anesthesiology,
University of Miami Miller School of
Medicine; Attending Anesthesiologist,
Ryder Trauma Center at Jackson Memorial
Hospital, Miami, FL
Ashraf Fayad
Associate Professor, Department of
Anesthesiology and Pain Medicine and
Director, Perioperative Echocardiography
for Non-cardiac Surgery Program,
University of Ottawa, Ottawa, Ontario,
Canada
L. Yvette Fouche
Assistant Professor of Anesthesiology,
University of Maryland School of
Medicine; Division Head, Trauma
Anesthesiology, R Adams Cowley Shock
Trauma Center, Baltimore, MD
ix
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x

Contributors

Michael T. Ganter
Professor of Anesthesiology and Critical
Care Medicine and Chair, Institute of
Anesthesiology – Emergency Medical
Service, Perioperative Medicine, Pain
Therapy, Kantonsspital Winterthur,
Winterthur, Switzerland
Suneeta Gollapudy
Associate Professor, Department
of Anesthesiology, Medical College
of Wisconsin; Director, Division
of Neuroanesthesia and
Director, Division of Post
Anesthesia Care Unit, Froedtert
Memorial Lutheran Hospital,
Milwaukee, WI
Thomas E. Grissom
Associate Professor of Anesthesiology,
University of Maryland School of
Medicine; Attending Anesthesiologist,
R Adams Cowley Shock Trauma Center,
Baltimore, MD
Craig S. Jabaley
Assistant Professor of Anesthesiology,

Emory University School of Medicine;
Department of Anesthesiology, Division of
Critical Care Medicine, Emory University
Hospital, Atlanta, GA
Olga Kaslow
Associate Professor, Department of
Anesthesiology, Medical College of
Wisconsin; Director, Trauma
Anesthesiology Service, Froedtert
Memorial Lutheran Hospital,
Milwaukee, WI
Michelle E. Kim
Assistant Professor of Anesthesiology,
University of Maryland School of
Medicine; Attending Anesthesiologist,
R Adams Cowley Shock Trauma Center,
Baltimore, MD

Jack Louro
Assistant Professor of Anesthesiology,
University of Miami Miller School of
Medicine; Attending Anesthesiologist,
Ryder Trauma Center at Jackson Memorial
Hospital, Miami, FL
Jessica A. Lovich-Sapola
Associate Professor, Case Western Reserve
University School of Medicine; Attending
Anesthesiologist, Department of
Anesthesiology, MetroHealth Medical
Center, Cleveland, OH

K. H. Kevin Luk
Assistant Professor, Divisions of
Neuroanesthesiology & Perioperative
Neurosciences, and Critical Care Medicine,
Department of Anesthesiology & Pain
Medicine, Harborview Medical Center,
University of Washington, Seattle, WA
Richard McNeer
Associate Professor of Anesthesiology and
Biomedical Engineering, University of
Miami Miller School of Medicine;
Attending Anesthesiologist, Ryder Trauma
Center at Jackson Memorial Hospital,
Miami, FL
Daria M. Moaveni
Assistant Professor of Anesthesiology,
University of Miami Miller School of
Medicine; Director, Obstetric
Anesthesiology Fellowship Program,
Jackson Memorial Hospital, Miami, FL
Hernando Olivar
Clinical Associate Professor, Department of
Anesthesiology & Pain Medicine,
Harborview Medical Center/University of
Washington, Seattle, WA
Marie-Jo Plamondon
Assistant Professor, Department of
Anesthesiology and Pain Medicine;

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Contributors

xi

Director Trauma and Vascular
Anesthesiology, University of Ottawa,
Ottawa, Ontario, Canada

Director of Trauma Anesthesiology, The
Johns Hopkins Hospital, Baltimore,
Maryland

Ramesh Ramaiah
Assistant Professor, Department of
Anesthesiology & Pain Medicine,
Harborview Medical Center/University of
Washington, Seattle, WA

Charles E. Smith
Professor, Case Western Reserve University
School of Medicine; Attending
Anesthesiologist and Director of
Anesthesia Research, Department of
Anesthesiology, MetroHealth Medical
Center, Cleveland, OH

Sripad Rao
Assistant Professor of Anesthesiology,

University of Miami Miller School of
Medicine; Attending Anesthesiologist,
Ryder Trauma Center at Jackson Memorial
Hospital, Miami, FL
Sam R. Sharar
Professor, Department of Anesthesiology &
Pain Medicine, Harborview Medical
Center/University of Washington,
Seattle, WA
Robert Sikorski
Assistant Professor, Department of
Anesthesiology and Critical Care Medicine,
The Johns Hopkins School of Medicine;

Marc P. Steurer
Associate Professor of Anesthesiology,
Department of Anesthesia and
Perioperative Care, University of California
San Francisco; Director of Trauma
Anesthesiology, San Francisco General
Hospital, San Francisco, CA
Albert J. Varon
Miller Professor and Vice Chair for
Education, Department of Anesthesiology,
University of Miami Miller School of
Medicine; Chief of Anesthesiology, Ryder
Trauma Center at Jackson Memorial
Hospital, Miami, FL

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Preface
Traumatic injuries kill more than five million people annually. Millions more suffer the
physical and psychologic consequences of injury, which have an enormous impact on
patients, their families, and society. In the United States, trauma is the third leading cause
of death in people of all ages, and the leading cause of death in individuals 46 years and
younger. Trauma is also the single largest cause for years of life lost.
Although few anesthesiologists care exclusively for trauma patients, most will treat
trauma patients at one time or another in their clinical practice. These encounters can
occur at the end of the day or in the middle of the night and challenge clinicians to
expeditiously manage multisystem derangements despite incomplete patient information.
Active participation of anesthesiologists in the care of severely injured patients provides
the best opportunity for improved outcome. We believe participation should not only
include involvement in anesthetic management, but also the initial evaluation, resuscitation,
and perioperative care of these patients. Unfortunately, current training does not expose
trainees to the entire spectrum of trauma care. Although there are a few textbooks that deal
with trauma anesthesia, these books are quite extensive, serve mostly as reference books,
and are not meant to be read cover-to-cover.
Our intention in creating the first edition of Essentials of Trauma Anesthesia was to
provide anesthesiology trainees and practitioners with a concise review of the essential
elements in the care of the severely injured patient and to emphasize the role of anesthesiologists in all aspects of trauma care: from time of injury until the patient leaves the critical care
areas of the facility. This second edition of Essentials of Trauma Anesthesia continues to
pursue that goal while identifying many recent advances in trauma care including paradigm
shifts in the management of bleeding and coagulopathy, new neuromuscular blockade and
anticoagulant reversal drugs, and updated clinical practice guidelines.
As in the first edition, we present, in three parts, the essential elements of trauma

anesthesia care. The first section deals with the core principles of trauma anesthesia including epidemiology, mechanisms of injury and prehospital care, initial evaluation and management, airway management, shock, resuscitation and fluid therapy, vascular cannulation,
blood component therapy, general and regional anesthesia for trauma, monitoring, echocardiography, and postoperative care of the trauma patient. A new chapter dealing with
coagulation monitoring of the bleeding trauma patient has been added to the first section.
The second section reviews the anesthetic considerations for traumatic injuries by anatomical area, and includes chapters on traumatic brain injury, spinal cord injury, ocular and
maxillofacial trauma, and chest, abdominal and musculoskeletal trauma. The last section
discusses anesthetic management of specific trauma populations including burn, pediatric,
geriatric, and pregnant patients. Although we have maintained the structure, style, and
format of the previous edition, all chapters have undergone extensive revisions to ensure
content is current.
The editors of this book are academic trauma anesthesiologists, each with 30 years of
experience caring for trauma patients. We were fortunate to recruit expert contributors who
are actively engaged in clinical care at leading United States and Canadian trauma centers.
The chapter contributors were given the task of creating an easily readable and clinically
xiii
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xiv

Preface

relevant review of current trauma management. As editors, we have worked closely with the
contributors to attain a consistent style, cover the subject matter in a coherent and logical
manner, prevent unnecessary duplication, and provide cross-referencing between chapters.
The liberal use of bullet-points and tables facilitated the creation of a portable text that is
conducive to the rapid appreciation of the essential elements in trauma care.
We hope the second edition of this textbook will serve as a useful, practical guide to
anesthesiology trainees and practitioners who currently manage or will manage trauma
patients. We hope that all anesthesia providers, from the novice to advanced practitioners,

will benefit from this book and, more importantly, that this will improve their care of
trauma patients.
The editors thank the members of the American Society of Anesthesiologists’ Committee of Trauma and Emergency Preparedness (COTEP) and our trauma anesthesiology
colleagues at MetroHealth Medical Center and the Ryder Trauma Center for helping us
select the topics for this book. The editors are also grateful to the chapter authors for
contributing to this effort despite their already heavy clinical workload. Most of the
contributors of this book are members of the Trauma Anesthesiology Society (TAS), which
has enthusiastically supported and endorsed this project. Finally, we wish to acknowledge
the support of Sarah Payne, Jade Scard, and all the staff at Cambridge University Press in
the preparation and timely publication of Essentials of Trauma Anesthesia.
Albert J. Varon, MD, MHPE, FCCM
Charles E. Smith, MD

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Abbreviations
AANS
ABA
ABG
ABSI
ACE
ACES
ACL
ACLS
ACS
ACT
ADH
AEC

AI
AIS
AKI
aPTT
ARBs
ARDS
ASA
ASD
ASE
ASIA
ASRA
ATC
ATLS
AVDO2
AVN
AX
BAI
BIS
BP
bpm
BSA
BtpO2
BVM
CBC
CBF
CDC
CFD
CMAP
CMRO2
CNS

CO
COHb
COPD
COT
CP
CPB
CPDA
CPP
CPR

American Association of Neurological Surgeons
American Burn Association
Arterial blood gas
Abbreviated burn severity index
Angiotensin-converting enzyme
Abdominal cardiac evaluation with sonography in shock
Anterior cruciate ligament
Advanced cardiac life support
American College of Surgeons
Activated clotting time
Antidiuretic hormone
Airway exchange catheter
Aortic insufficiency
American Spinal Injury Association impairment scale
Acute kidney injury
Activated partial thromboplastin time
Angiotensin-receptor blockers
Acute respiratory distress syndrome
American Society of Anesthesiologists
Atrial septal defect

American Society of Echocardiography
American Spinal Injury Association
American Society of Regional Anesthesia and Pain Medicine
Acute traumatic coagulopathy
Advanced trauma life support
Arteriovenous oxygen content difference
Avascular necrosis
Axillary
Blunt aortic injury
Bispectral index
Blood pressure
Beats per minute
Body surface area
Brain tissue O2 partial pressure
Bag-valve-mask
Complete blood count
Cerebral blood flow
Centers for Disease Control and Prevention
Color flow Doppler
Compound muscle action potential
Cerebral metabolic rate of oxygen
Central nervous system
Cardiac output
Carboxyhemoglobin
Chronic obstructive pulmonary disease
Committee on Trauma
Cricoid pressure
Cardiopulmonary bypass
Citrate-phosphate-dextrose with adenine
Cerebral perfusion pressure

Cardiopulmonary resuscitation
xv
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xvi

CR
CRASH-2
CRM
CSF
CSFP
C-spine
CT
CTA
CVC
CVP
CXR
DC
DIC
DLT
DOACs
DPL
DVT
EACA
ECG
ED
eFAST
EMG
EMS

EMT-A
EPCR
EtCO2
Ex fix
EXT
FAST
FB
FC
FDA
FES
FFP
FOCUS
FS
GABA
GCS
GSW
Hb
HTS
ICH
ICP
ICU
IJ
INR
INT
IO
IOP
IV
IVC
LA
LAX

LMA
LTA
LV

List of Abbreviations

Clot rate
Clinical randomization of an antifibrinolytic in significant hemorrhage 2 study
Crisis resource management
Cerebrospinal fluid
Cerebrospinal fluid pressure
Cervical spine
Computed tomography
Computed tomography angiography
Central venous catheter
Central venous pressure
Chest X-ray
Decompressive craniectomy
Disseminated intravascular coagulation
Double-lumen tube
Direct oral anticoagulants
Diagnostic peritoneal lavage
Deep venous thrombosis
Epsilon-aminocaproic acid
Electrocardiogram/electrocardiography
Emergency department
Extended FAST
Electromyography
Emergency medical services
Emergency medical technician – ambulance

Endothelial protein C receptor
End-tidal carbon dioxide
External fixation
External
Focused assessment with sonography for trauma
Flexible bronchoscopy/bronchoscope/bronchoscopic
Fibrinogen concentrate
Food and Drug Administration
Fat embolism syndrome
Fresh frozen plasma
Focused cardiac ultrasound
Fractional shortening
Gamma-aminobutyric acid
Glasgow Coma Scale
Gunshot wound
Hemoglobin
Hypertonic saline
Intracranial hypertension
Intracranial pressure
Intensive care unit
Internal jugular vein
International normalized ratio
Internal
Intraosseous
Intraocular pressure
Intravenous
Inferior vena cava
Left atrium
Long axis
Laryngeal mask airway

Laryngeal tube airway
Left ventricular/left ventricle
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List of Abbreviations

MA
MAC
MAP
MATTERs
MCF
MEP
MILS
MR
MRI
MTP
MVC
N2O
nACHRs
NBR
NG
NHTSA
NIH
NMBD
NMDA
NSAIDs
OCR
OLV
OR

ORIF
PA
PaCO2
PACU
PaO2
PAOP
PAR1
PBW
PCA
PCC
PE
PEEP
Perc
PFO
POC
Pplat
ppm
PPV
PRBCs
PROPPR
PT
PvCO2
PvO2
RA
RBC
RCTs
REBOA
rFVIIa
Rh(D)
ROTEM

RR
RSI
RUSH

xvii

Maximum amplitude
Minimum alveolar concentration
Mean arterial pressure
Military application of tranexamic acid in trauma emergency resuscitation study
Maximum clot firmness
Motor evoked potential
Manual in-line stabilization
Mitral regurgitation
Magnetic resonance imaging
Massive transfusion protocol
Motor vehicle collision
Nitrous oxide
Nicotinic acetylcholine receptors
National Burn Repository
Nasogastric tube
National Highway Traffic Safety Administration
National Institutes of Health
Neuromuscular blocking drug
N-methyl-D-aspartate
Non-steroidal anti-inflammatory drugs
Oculocardiac reflex
One-lung ventilation
Operating room
Open reduction internal fixation

Pulmonary artery
Arterial carbon dioxide tension
Postanesthesia care unit
Arterial oxygen tension
Pulmonary artery occlusion pressure
Protease-activated receptor 1
Predicted body weight
Patient-controlled analgesia
Prothrombin complex concentrate
Pulmonary emboli
Positive end-expiratory pressure
Percutaneous
Patent foramen ovale
Point-of-care
Plateau pressure
Parts per million
Pulse pressure variation
Packed red blood cells
Pragmatic, randomized, optimal platelets, and plasma ratios
Prothrombin time
Mixed venous carbon dioxide tension
Mixed venous oxygen tension
Right atrium
Red blood cell
Randomized controlled trials
Resuscitative endovascular balloon occlusion of the aorta
Recombinant Factor VIIa
Rhesus antigen D
Rotational thromboelastometry
Respiratory rate

Rapid sequence induction
Rapid ultrasound for shock and hypotension
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xviii

List of Abbreviations

RV
RWMA
SAX
SBP
SCA
SCCP
SCI
SCIWORA
SCM
SCV
ScvO2
SGA
SjvO2
SpO2
SPV
SSEP
START
STE
SV
SvO2
SVR

SVV
TAFI
TBI
TBSA
TCPA
TEE
TEG
TEVAR
TF
TIG
TIVA
TOF
TT
TTE
TXA
VHA
VL
VWF

Right ventricular/right ventricle
Regional wall motion abnormality
Short axis
Systolic blood pressure
Society of Cardiovascular Anesthesiologists
Spinal cord perfusion pressure
Spinal cord injury
Spinal cord injury without radiographic abnormality
Sternocleidomastoid
Subclavian vein
Central venous oxygen saturation

Supraglottic airway device
Jugular venous oxygen saturation
Oxygen saturation measured by pulse oximeter
Systolic pressure variation
Somatosensory evoked potentials
Simple triage and rapid assessment
Speckle-tracking echocardiography
Stroke volume
Mixed venous oxygen saturation
Systemic vascular resistance
Stroke volume variation
Thrombin-activated fibrinolysis inhibitor
Traumatic brain injury
Total body surface area
Traumatic cardiopulmonary arrest
Transesophageal echocardiography
Thrombelastography
Thoracic endovascular aortic repair
Tissue factor
Tetanus immune globulin
Total intravenous anesthesia
Train-of-four
Tracheal tube
Transthoracic echocardiography
Tranexamic acid
Viscoelastic hemostatic assay
Videolaryngoscopy/videolaryngoscope
von Willebrand factor

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Section 1
Chapter

1

Core Principles in Trauma Anesthesia

Trauma Epidemiology, Mechanisms
of Injury, and Prehospital Care
John J. Como and Charles E. Smith

Trauma Epidemiology
Trauma is defined as physical damage to the body as a result of mechanical, chemical,
thermal, electrical, or other energy that exceeds the tolerance of the body. Although trauma
is often thought of as a series of unavoidable accidents, in reality it is a disease with known
risk factors. Like other diseases such as cancer and heart disease, trauma risk factors are
modifiable and injuries can be avoided before their occurrence. There are three phases of
injury:
1. Pre-injury
2. Injury
3. Post-injury
The pre-injury phase includes the events prior to trauma and is impacted by risk factors such
as drug and alcohol intoxication, medical and environmental conditions, and behavioral
factors. The injury phase is when energy is transferred to the victim’s body through a series
of mechanisms related to blunt, penetrating, crush, blast, and rotational injury. The postinjury phase commences as soon as transfer of energy is complete. Since approximately 50%
of trauma deaths are catastrophic events (massive head injury, upper spinal cord, heart, and
great vessel trauma) that occur within moments of the injury, the only way to avoid them is
through preventive strategies. An understanding of the basic epidemiology of traumatic

injury is thus imperative if we wish to decrease the burden of this disease on society.
The most effective means of reducing mortality from trauma is modification of risk
factors and prevention of injuries through education, legislation, and research. Examples of
preventive measures for motor vehicle trauma include:
 Legislation concerning alcohol consumption
 Proper child occupant restraint in cars
 Front and rear seat belts
 Air bags
 Speed limit controls
 Laminated windshields
 Crash resistant fuel systems
 Energy absorbing steering wheels
The problem of traumatic injury in the United States is enormous. In the United States,
trauma (including unintentional injury, homicide, and suicide) was the third leading cause
of death in 2014 after heart disease and malignant neoplasms for people of all ages; it was
also the leading cause of death in children and in adults up to 44 years of age (see Figure 1.1).
1
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2

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.002

Rank

<1

1–4

5–9

10–14

15–24

25–34

35–44

45–54

55–64

65+

Total

1

Congenital
Anomalies
4,746

Unintentional
Injury
1,216

Unintentional
Injury
730

Unintentional
Injury
750

Unintentional
Injury
11,836

Unintentional
Injury
17,357

Unintentional
Injury
16,048

Malignant
Neoplasms
44,834

Malignant
Neoplasms
115,282

Heart
Disease

489,722

Heart
Disease
614,348

2

Short
Gestation
4,173

Congenital
Anomalies
399

Malignant
Neoplasms
436

Suicide
425

Suicide
5,079

Suicide
6,569

Malignant

Neoplasms
11,267

Heart
Disease
34,791

Heart
Disease
74,473

Malignant
Neoplasms
413,885

Malignant
Neoplasms
591,699

3

Maternal
Pregnancy
Comp.
1,574

Homicide
364

Congenital

Anomalies
192

Malignant
Neoplasms
416

Homicide
4,144

Homicide
4,159

Heart
Disease
10,368

Unintentional
Injury
20,610

Unintentional
Injury
18,030

Chronic Low.
Respiratory
Disease
124,693

Chronic Low.
Respiratory
Disease
147,101

4

SIDS
1,545

Malignant
Neoplasms
321

Homicide
123

Congenital
Anomalies
156

Malignant
Neoplasms
1,569

Malignant
Neoplasms
3,624

Suicide

6,706

Suicide
8,767

Chronic Low.
Respiratory
Disease
16,492

Cerebrovascular
113,308

Unintentional
Injury
136,053

5

Unintentional
Injury
1,161

Heart
Disease
149

Heart
Disease
69

Homicide
156

Heart
Disease
953

Heart
Disease
3,341

Homicide
2,588

Liver
Disease
8,627

Diabetes
Mellitus
13,342

Alzheimer's
Disease
92,604

Cerebrovascular
133,103

6

Placenta Cord.
Membranes
965

Influenza &
Pneumonia
109

Chronic Low.
Respiratory
Disease
68

Heart
Disease
122

Congenital
Anomalies
377

Liver
Disease
725

Liver
Disease
2,582

Diabetes
Mellitus
6,062

Liver
Disease
12,792

Diabetes
Mellitus
54,161

Alzheimer's
Disease
93,541

7

Bacterial
Sepsis
544

Chronic Low
Respiratory
Disease
53

Influenza &
Pneumonia

57

Chronic Low
Respiratory
Disease
71

Influenza &
Pneumonia
199

Diabetes
Mellitus
709

Diabetes
Mellitus
1,999

Cerebrovascular
5,349

Cerebrovascular
11,727

Unintentional
Injury
48,295

Diabetes

Mellitus
76,488

8

Respiratory
Distress
460

Septicemia
53

Cerebrovascular
45

Cerebrovascular
43

Diabetes
Mellitus
181

HIV
583

Cerebrovascular
1,745

Chronic Low.
Respiratory

Disease
4,402

Suicide
7,527

Influenza &
Pneumonia
44,836

Influenza &
Pneumonia
55,227

9

Circulatory
System
Disease
444

Benign
Neoplasms
38

Benign
Neoplasms
36

Influenza &

Pneumonia
41

Chronic Low
Respiratory
Disease
178

Cerebrovascular
579

HIV
1,174

Influenza &
Pneumonia
2,731

Septicemia
5,709

Nephritis
39,957

Nephritis
48,146

10

Neonatal

Hemorrhage
441

Perinatal Period
38

Septicemia
33

Benign
Neoplasms
38

Cerebrovascular
177

Influenza &
Pneumonia
549

Influenza &
Pneumonia
1,125

Septicemia
2,514

Influenza &
Pneumonia
5,390

Septicemia
29,124

Suicide
42,773

Data Source: National Vital Statistics System, National Center for Health Statistics, CDC.
Produced by: National Center for Injury Prevention and Control, CDC using WISQARS™.

Figure 1.1. Leading causes of death by age group in the United States – 2014.


Chapter 1: Trauma Epidemiology

3

Figure 1.2. Years of potential life lost (YPLL) before age 65, United States – 2014.

In total, about one person will die every 3 minutes due to injury in the United States. As the
majority of fatal injuries occur in the young, trauma is also responsible for more years of
potential life lost before age 65 than any other disease, accounting for 31.7% of years lost
from all causes (see Figure 1.2). The two leading causes of injury death are those due to
vehicular injuries and those due to firearms, which together account for about half of fatal
injuries (see Figure 1.3).
In addition to death, the problem of non-fatal injury is staggering. In 2014, a total of
26.9 million people in the United States suffered non-fatal injuries requiring medical
treatment. Of those, 2.5 million required hospitalization. The economic impact is immense.
In 2013, the total lifetime medical and work cost of injury and violence in the United States
was $671 billion, of which $457 billion was the cost associated with non-fatal injuries. The

10 leading causes of non-fatal injuries stratified by age in the United States in 2013 are listed
in Figure 1.4. In almost every age group, the leading cause of non-fatal trauma admissions
is falls.
The costs to society are tremendous and include:
 Emergency medical services (EMS)
 In-hospital medical care
 Rehabilitation
 Wage and productivity loss
 Damage to property and goods
 Costs to employers, such as having to train and hire new workers
 Administrative costs
17:52:19, subject to the Cambridge Core
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4
Rank

<1

1–4

5–9

10–14

15–24

25–34

35–44

45–54

55–64

65+

Total

1

Unintentional
Suffocation
991

Unintentional
Drowning
388

Unintentional
MV Traffic
345

Unintentional
MV Traffic
384

Unintentional
MV Traffic

6,531

Unintentional
Poisoning
9,334

Unintentional
Poisoning
9,116

Unintentional
Poisoning
11,009

Unintentional
Poisoning
7,013

Unintentional
Fall
27,044

Unintentional
Poisoning
42,032

2

Homicide
Unspecified

119

Unintentional
MV Traffic
293

Unintentional
Drowning
125

Suicide
Suffocation
225

Homicide
Firearm
3,587

Unintentional
MV Traffic
5,856

Unintentional
MV Traffic
4,308

Unintentional
MV Traffic
5,024

Unintentional
MV Traffic
4,554

Unintentional
MV Traffic
6,373

Unintentional
MV Traffic
33,736

3

Homicide
Other Spec.,
Classifiable
83

Homicide
Unspecified
149

Unintentional
Fire/Burn
68

Suicide
Firearm
174

Unintentional
Poisoning
3,492

Homicide
Firearm
3,260

Suicide
Firearm
2,830

Suicide
Firearm
3,953

Suicide
Firearm
3,910

Suicide
Firearm
5,367

Unintentional
Fall
31,959

Homicide

Firearm
58

Homicide
Firearm
115

Suicide
Firearm
2,270

Suicide
Firearm
2,829

Suicide
Suffocation
2,057

Suicide
Suffocation
2,321

Unintentional
Fall
2,558

Unintentional
Unspecified
4,590

Suicide
Firearm
21,334

4

Unintentional MV Unintentional
Traffic
Suffocation
61
120

17:52:19, subject to the Cambridge Core
.002

5

Undetermined
Suffocation
40

Unintentional
Fire/Burn
117

Unintentional
Other Land
Transport
36

Unintentional
Drowning
105

Suicide
Suffocation
2,010

Suicide
Suffocation
2,402

Homicide
Firearm
1,835

Suicide
Poisoning
1,795

Suicide
Poisoning
1,529

Unintentional
Suffocation
3,692

Suicide

Suffocation
11,407

6

Unintentional
Drowning
29

Unintentional
Suffocation
34

Unintentional
Fire/Burn
49

Unintentional
Drowning
507

Suicide
Poisoning
800

Suicide
Poisoning
1,274

Unintentional

Fall
1,340

Suicide
Suffocation
1,509

Unintentional
Poisoning
1,993

Homicide
Firearm
10,945

7

Homicide
Suffocation
26

Unintentional
Pedestrian,
Other
107
Homicide
Other Spec.,
Classifiable
73

Unintentional
Other Land
Transport
49

Suicide
Poisoning
363

Undetermined
Poisoning
575

Undetermined
Poisoning
637

Homicide
Firearm
1,132

Unintentional
Suffocation
698

Adverse
Effects
1,554

Suicide

Poisoning
6,808

8

Unintentional
Natural/
Environment
17

Homicide
Firearm
47

Unintentional
Suffocation
33

Homicide
Cut/Pierce
314

Homicide
Cut/Pierce
430

Unintentional
Fall
504

Undetermined
Poisoning
820

Undetermined
Poisoning
539

Unintentional
Fire/Burn
1,151

Unintentional
Suffocation
6,580

9

Undetermined
Unspecified
16

Unintentional
Poisoning
22

Undetermined
Poisoning
229

Unintentional
Drowning
399

Unintentional
Drowning
363

Unintentional
Suffocation
452

Homicide
Firearm
538

Suicide
Poisoning
1,028

Unintentional
Unspecified
5,848

10

Unintentional
Fire/Burn
15

Unintentional
Struck by
or Against
38
Unintentional
Natural/
Environment
35

Unintentional
Natural/
Environment
22
Unintentional
Pedestrian,
Other
18
Unintentional
Struck by
or Against
16
Unintentional
Firearm
(Tied)
14

Homicide
Cut/Pierce
19

Unintentional
Other Land
Transport
177

Unintentional
Fall
285

Homicide
Cut/Pierce
313

Unintentional
Drowning
442

Unintentional
Unspecified
530

Suicide
Suffocation
880

Unintentional
Drowning
3,406

Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System.

Produced by: National Center for Injury Prevention and Control, CDC using WISQARS™.

Figure 1.3. Leading causes of injury deaths by age group highlighting unintentional injury deaths, United States – 2014. MV, motor vehicle.


5

Age Groups
15–24
25–34

Rank

<1

1–4

5–9

10–14

35–44

45–54

55–64

65+

Total

1

Unintentional
Fall
134,229

Unintentional
Fall
852,884

Unintentional
Fall
624,890

Unintentional
Struck
By/Against
561,690

Unintentional
Struck
By/Against
905,659

Unintentional
Fall
742,177

Unintentional

Fall
704,264

Unintentional
Fall
913,871

Unintentional
Fall
930,521

Unintentional
Fall
2,495,397

Unintentional
Fall
8,771,656

Unintentional
Struck
By/Against
28,786
Unintentional
Other
Bite/Sting
12,186

Unintentional
Struck

By/Against
336,917
Unintentional
Other
Bite/Sting
158,587

Unintentional
Struck
By/Against
403,522

Unintentional
Fall
558,177

Unintentional
Fall
814,829

Unintentional
Overexertion
638,745

Unintentional
Overexertion
530,422

Unintentional
Overexertion

461,114

Unintentional
Overexertion
266,126

Unintentional
Struck
By/Against
281,279

Unintentional
Struck
By/Against
4,214,125

Unintentional
Cut/Pierce
112,633

Unintentional
Overexertion
294,669

Unintentional
Overexertion
672,946

Unintentional
Struck

By/Against
599,340

Unintentional
Struck
By/Against
444,089

Unintentional
Struck
By/Against
261,840

Unintentional
Overexertion
212,293

Unintentional
Overexertion
3,256,567

4

Unintentional
Foreign Body
10,650

Unintentional
Foreign Body
139,597

Unintentional
Other
Bite/Sting
107,975

Unintentional
Cut/Pierce
114,285

Unintentional
MV-Occupant
627,565

Unintentional
MV-Occupant
526,303

Unintentional
MV-Occupant
374,231

Unintentional
Struck
By/Against
390,931
Unintentional
Other
Specified
385,221

Unintentional
MV-Occupant
227,620

Unintentional
MV-Occupant
197,646

Unintentional
MV-Occupant
2,462,684

5

Unintentional
Other
Specified
10,511

Unintentional
Cut/Pierce
83,575

Unintentional
Overexertion
93,612

Unintentional
Pedal Cyclist

84,732

Unintentional
Cut/Pierce
431,691

Unintentional
Cut/Pierce
402,197

Unintentional
Other
Specified
300,154

Unintentional
MV-Occupant
343,470

Unintentional
Other
Specified
212,168

Unintentional
Cut/Pierce
156,693

Unintentional
Cut/Pierce

2,077,775

6

Unintentional
Fire/Burn
9,816

Unintentional
Overexertion
81,588

Unintentional
Pedal Cyclist
74,831

Unintentional
Unknown/
Unspecified
84,668

Unintentional
Cut/Pierce
297,769

Unintentional
Cut/Pierce
282,353

Unintentional

Cut/Pierce
189,440

Unintentional
Poisoning
100,988

Unintentional ** Unintentional
Inhalation/
Other
Suffocation
Specified
8,294
65,120

Unintentional
Foreign Body
63,450

Other Assault*
Struck
By/Against
207,287

Unintentional
Poisoning
237,328

Unintentional
Poisoning

153,767

Unintentional
Other
Bite/Sting
90,850
Unintentional
Other
Specified
86,729
Unintentional
Unknown/
Unspecified
74,864
Unintentional
Other
Transport
68,022

Unintentional
Other
Specified
1,767,630
Other Assault*
Struck
By/Against
1,291,100
Unintentional
Other
Bite/Sting

1,174,267

2

3

7

17:52:19, subject to the Cambridge Core
.002

8

Unintentional
Cut/Pierce
7,139

Unintentional
Fire/Burn
52,884

Unintentional
MV-Occupant
58,114

9

Unintentional
Unknown/
Unspecified

5,735

Unintentional
Unknown/
Unspecified
41,297

Unintentional
Dog Bite
43,499

10

Unintentional
Overexertion
4,985

Unintentional
Poisoning
32,443

Unintentional
Unknown/
Unspecified
35,303

Other Assault * Other Assault *
Struck
Struck
By/Against

By/Against
381,522
342,514
Unintentional
Unintentional
Unintentional
Other
Other
MV-Occupant
Specified
Specified
73,692
321,914
336,990
Unintentional
Unintentional
Unintentional
Other
Other
Other
Bite/Sting
Bite/Sting
Bite/Sting
64,848
177,665
180,922
Other Assault * Unintentional
Unintentional
Struck
Unknown/

Poisoning
By/Against
Unspecified
180,448
62,829
163,923
Unintentional
Unintentional
Unintentional
Other
Unknown/
Poisoning
Transport
Unspecified
152,962
35,609
129,308

Unintentional
Poisoning
175,870
Unintentional
Other
Bite/Sting
138,410
Unintentional
Unknown/
Unspecified
106,498

Other Assault * Unintentional
Struck
Other
By/Against
Bite/Sting
169,688
97,474
Unintentional Other Assault *
Other
Struck
Bite/Sting
By/Against
145,349
73,674
Unintentional
Unintentional
Unknown/
Unknown/
Unspecified
Unspecified
110,102
67,974

Unintentional
Poisoning
1,055,960
Unintentional
Unknown/
Unspecified
819,878

* The “Other Assault” category includes all assaults that are not classified as sexual assault. It represents the majority of assaults.
** Injury estimate is unstable because of small sample size.
Data Source: NEISS All Injury Program operated by the Consumer Product Safety Commission (CPSC).
Produced by: National Center for Injury Prevention and Control, CDC using WISQARS™.

Figure 1.4. National estimates of the 10 leading causes of non-fatal injuries treated in hospital emergency departments, United States –
2013. MV: motor vehicle


Section 1: Core Principles in Trauma Anesthesia

6

 Private and public health insurance
 Police and legal costs
 Costs arising from fatal and non-fatal trauma
In addition, multiple recent terrorist events in both Europe and the United States, along
with the continued issue of inner-city urban violence, have alerted the public to the
potential for mass casualties at any time without warning, along with the need for effective
care of victims of trauma. The necessity of injury prevention together with the need for
efficient care of the injured patient are crucial public health issues, given the enormity of
this problem.

Funding for Research
While there are well-funded research and prevention programs for chronic diseases like
cancer, cardiovascular disease, and HIV/AIDS due to high public awareness, trauma is often
viewed as the result of unavoidable accidents, and support for research or prevention
programs is comparatively small. In 2015, the National Institutes of Health (NIH) appropriated $399 million for injury research. In the same year $5.4 billion was spent on cancer
research, $2.0 billion on research for cardiovascular disease, and $3.0 billion on HIV/AIDS.

These amounts have not changed significantly since 2010.

Prevention
Many factors often hamper the efforts of trauma prevention programs, such as the decisions
by motorcyclists and bicycle riders not to use helmets and the reluctance of employers and
laborers to invest in safety devices for workplace/machinery safety. Regulations in the form
of incentives, laws, or oversight are often required to increase compliance and improve
trauma prevention. Unfortunately, special interest groups have commonly opposed seat belt
or helmet laws, as these are viewed as a restriction of freedom and individual rights. When
laws to prevent injuries have been introduced, significant improvements in mortality are
often demonstrated.
As an example, the use of helmets by motorcycle riders reduces the risk of death by 37%
and is 67% effective in preventing brain injuries. States with helmet laws have an 86%
compliance rate for wearing helmets, while states without such laws have only a 55% rate of
helmet use. All states that have introduced helmet laws have experienced significant
decreases in motorcycle fatalities (see Table 1.1).
Table 1.1. Reduction in motorcycle fatalities after enacting motorcycle helmet law

State

Reduction (%)

California

37

Oregon

33

Nebraska

32

Texas

23

Maryland

20

Washington

15

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Chapter 1: Trauma Epidemiology

7

Table 1.2. Lives saved by restraint use and minimum drinking age laws (21 years), and additional lives that
would have been saved at 100% compliancy with seat belt and motorcycle helmet use, 2011–2015

Lives
saved,
Lives saved, age 5

age 4 and and
older
younger

Lives
saved,
age 13
and
older

Lives
saved,
all ages

Lives
saved

Additional lives
that would have
been saved at
100% use

Year

Child
restraints

Seat
belts

Frontal
air bags

Motorcycle
helmets

Minimum
drinking
age law

Seat
belts

Motorcycle
helmets

2011†

262

12,071

2,341

1,622

543

3,396

707

2012

285

12,386

2,422

1,715

537

3,051

782

2013

263

12,644

2,398

1,640

507

2,812

717

2014

253

12,801

2,400

1,673

486

2,815

661

2015

266

13,941

2,573

1,772

537

2,804

740

†

†

Source: 2011–2014 Fatality Analysis Reporting System (FARS) Final Files and FARS 2015 Annual Report Files.
†
2011–2012 estimates differ from previously published estimates due to a computational correction. Previous
estimates did not properly account for 2011 through 2013 model year passenger vehicles.

The National Highway Traffic Safety Administration (NHTSA) estimates that threepoint safety belts in frontal positions are 45–60% effective in preventing fatalities in frontal
collisions and 50–65% effective in preventing moderate-to-critical injuries. Despite this
knowledge, the national rate of seat belt usage is only 82%. States that have enacted primary
seat belt laws have increased seat belt usage rates by an average of 14% over states without
seat belt laws. According to the NHTSA, nationally 250 additional lives could be saved per
year and 6400 serious injuries prevented for every one percentage-point increase in safety
belt use. Table 1.2 details lives saved with various public health initiatives from 2011
to 2015.

Mechanisms of Injury
Transfer of energy occurs due to blunt and penetrating trauma according to Sir Isaac
Newton’s first law of motion, which states that “a body in motion will stay in motion unless
acted upon by an outside force.”
Severity of injury is related to three factors:
1. Kinetic energy absorbed by the body (KE = mass  velocity2/2)

2. Direction the energy travels through the body
3. Body structure density: solid (water dense) organs are more likely to rupture than
hollow (air dense) organs. Bone and cartilage are more rigid and have greater density

Falls
In the United States, falls are the most common cause of non-fatal injuries. In 2014, 9.2
million non-fatal unintentional falls were reported. In the same year, 33,018 patients
17:52:19, subject to the Cambridge Core
.002