25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was diagnosed as such [ citation needed ]  compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society." [ 39 ]  A 2014 study published in the  European Journal of Psychotraumatology  was able to compare and contrast C-PTSD, PTSD, and borderline personality disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. [ 40 ]  BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to have PTSD or to have some history of trauma.


In  Trauma and Recovery , Herman expresses the additional concern that patients with C-PTSD frequently risk being misunderstood as inherently ' dependent ', ' masochistic ', or ' self-defeating ', comparing this attitude to the historical misdiagnosis of  female hysteria . [ 4 ]  However, those who develop C-PTSD do so as a result of the intensity of the  traumatic bond  — in which someone becomes tightly biochemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, embedded in their personality over the years of trauma — a normal reaction to an abnormal situation. [ 41 ]


While standard evidence-based treatments may be effective for treating  post-traumatic stress disorder , treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat.


The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Julian Ford and  Bessel van der Kolk  have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of  developmental trauma disorder  (DTD). [ 42 ] : 60   According to Courtois and Ford, for DTD to be diagnosed it requires a


history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses or other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational. [ 42 ]


Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.


A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field: [ 42 ] : 67


Judith Lewis Herman, in her book,  Trauma and Recovery , proposed a complex trauma recovery model that occurs in three stages:


Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the  therapeutic relationship . [ 4 ]  However, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. This stage might involve the need for major life changes for some patients. [ 43 ]


Securing a safe environment requires strategic attention to the patient's economic and social ecosystem. The patient must become aware of her own resources for practical and emotional support as well as the realistic dangers and vulnerabilities in her social situation. Many patients are unable to move forward in their recovery because of their present involvement in unsafe or oppressive relationships. In order to gain their autonomy and their peace of mind, survivors may have to make difficult and painful life choices. Battered women may lose their homes, their friends, and their livelihood. Survivors of childhood abuse may lose their families. Political refugees may lose their homes and their homeland. The social obstacles to recovery are not generally recognized, but they must be identified and adequately addressed in order for recovery to proceed. [ 43 ]


It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation,  dissociation , and interpersonal problems. [ 24 ]  Six suggested core components of complex trauma treatment include: [ 1 ]


The above components can be conceptualized as a model with three phases. Not every case will be the same, but the first phase will emphasize the acquisition and strengthening of adequate coping strategies as well as addressing safety issues and concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events. [ 44 ]


In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. [ 45 ]  Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. [ 46 ] [ 47 ]  Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. [ 46 ]  For example, it is well established that the development of  dissociative identity disorder  among women is often associated with early childhood sexual abuse. [ citation needed ]


Cognitive behavioral therapy ,  prolonged exposure therapy  and  dialectical behavioral therapy  are well established forms of evidence-based intervention. These treatments are approved and endorsed by the  American Psychiatric Association , the  American Psychological Association  and the Veteran's Administration. There is a question as to whether these PTSD treatments can also treat CPTSD. Given that the ICD-11 CPTSD diagnosis is relatively young, it will be years before this is adequately studied. However, some preliminary studies have examined whether PTSD treatments work equally well in those with PTSD or CPTSD. [ 48 ]  Two different studies of phase-based PTSD treatment found that both standard PTSD treatment and phased treatment worked equally well whether participants had a diagnosis of PTSD or CPTSD (per the ITQ). [ 49 ] [ 50 ] [ 51 ]  Another study of an existing European intensive trauma treatment combining Prolonged Exposure and EMDR found that people with PTSD and CPTSD and comparable decreases in PTSD and CPTSD (though they had more severe PTSD at baseline). [ 52 ]


One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of  therapy  or  intervention  are reimbursed by insurance companies who use  evidence-based practice  as a criterion for reimbursement.


It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. [ citation needed ]  There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories.


Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners.


Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including  Bessel van der Kolk  and  Bruce D. Perry ) who argue:


Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing." [ 53 ]


Complex post-traumatic stress disorder is a long term mental health condition which often requires treatment by highly skilled mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition. [ 54 ]


There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy [ 55 ] ) there are many therapeutic interventions used by mental health professionals to treat PTSD. As of February 2017 [update] , the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD: [ 56 ]


The American Psychological Association also conditionally recommends [ 57 ]


While these treatments have been recommended, there is still a lack of research on the best and most efficacious treatments for complex PTSD. Psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and reprocessing therapy are effective in treating C-PTSD symptoms like PTSD, depression and anxiety. [ 63 ] [ 64 ]  For example, in a 2016, meta-analysis, four out of eight EMDR studies resulted in statistical significance, indicating the potential effectiveness of EMDR in treating certain conditions. Additionally, subjects from two of the studies continued to benefit from the treatment months later. Seven of the studies that employed psychometric tests showed that EMDR led to a reduction in depression symptoms compared to those in the placebo group. [ 65 ]   Mindfulness  and  relaxation  is effective for PTSD symptoms, emotion regulation and interpersonal problems for people whose complex trauma is related to sexual abuse. [ 63 ] [ 64 ]


Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include:


Judith Lewis Herman  of Harvard University was the first psychiatrist and scholar to conceptualise complex post-traumatic stress disorder (C-PTSD) as a (new) mental health condition in 1992, within her book  Trauma & Recovery  and an accompanying article. [ 4 ] [ 17 ]  In 1988, Herman suggested that a new diagnosis of complex post-traumatic stress disorder (C-PTSD) was needed to describe the symptoms and psychological and emotional effects of long-term trauma. Over the years, the definition of CPTSD has shifted (including a proposal for DESNOS in DSM-IV and a diagnosis of EPCACE in ICD-10), with a different definition in the ICD-11 than per Dr. Herman's initial conceptualization. [ 74 ]  The ICD-11 definition of CPTSD overlaps more with DSM-5 PTSD than earlier definitions of PTSD. [ 11 ]


Though acceptance of the idea of complex PTSD has increased with mental health professionals, the research required for the proper validation of a new disorder was considered insufficient to include CPTSD as a separate disorder in the DSM-IV and DSM-5. [ 75 ] [ 11 ]  The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the  DSM-IV  but was rejected by members of the  Diagnostic and Statistical Manual of Mental Disorders  (DSM) committee of the  American Psychiatric Association  for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder. [ 19 ]


Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder. [ 76 ]  Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of  DSM-5  refused to include DTD due to a perceived lack of sufficient research.


One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. [ 17 ]  Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders. [ 77 ]  Conversely, an article published in  BioMed Central  has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders. [ 78 ]


Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences. [ 78 ]  In the diagnosis of PTSD, the definition of the stressor event is limited to life-threatening or sexually violent events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. [ 5 ]  By broadening the stressor criterion, an article published by the  Child and Youth Care Forum  claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM. [ 79 ]


Direct therapeutic exposure  ( DTE ) is a  behavior therapy  technique pioneered by Patrick A. Boudewyns, where  stressors  are vividly and safely confronted to help combat  veterans , and patients with  posttraumatic stress disorder  (PTSD),  panic disorder , or  phobias .  Exposure therapy  has supporting evidence with both simple and complex traumas. [ 1 ]  A similar therapy is  Eye Movement Desensitization and Reprocessing  (EMDR).  First known publication in book form is  Flooding and Implosive Therapy: Direct Therapeutic Exposure in Clinical Practice  by Patrick A. Boudewyns, Robert H. Shipley.  1983.  ISBN   0-306-41155-5 .


It is not uncommon to combine DTE treatment with other therapies.


Direct exposure has been used with a variety of populations including agoraphobia [ 2 ]  and chronic PTSD [ 3 ]  It involves as the name applies placing the client either real or imaginally in the feared situation.


Other techniques for treating PTSD:


Endovascular and hybrid trauma and bleeding management   is a new and rapidly evolving concept within medical healthcare and endovascular  resuscitation . It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. [ 1 ] [ 2 ] [ 3 ]  It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients. [ 4 ]


The fundamental principles of  trauma care  are built around  advanced trauma life support  (ATLS) guidelines using the mnemonic  ABCDE  for early assessment of the patient and detection of airway and circulatory problems. This way, life-threatening conditions are identified and resuscitation may be initiated, despite the lack of definitive diagnosis. [ 5 ]  The EVTM concept of acute trauma care incorporates modern endovascular techniques and procedures as additional adjuncts to this well-established protocol. [ 1 ] [ 2 ] [ 3 ] [ 4 ]  The new suggested algorithm of  A ABCDE has emerged for EVTM enabled providers. The additional “A” stands for  A ccess, indicating the importance of gaining early vascular access to the  femoral artery  (and  vein ), and is fundamental to this concept of trauma care. [ 6 ]  As with traditional trauma care, vascular access in the peripheral or central veins allows for blood sampling and administration of drugs or fluids. However, for EVTM enabled providers, early femoral arterial access provides the possibility to use potentially lifesaving endovascular diagnostic and therapeutic tools for temporary management and bridge to definitive endovascular or open surgical treatment, in addition to arterial blood sampling and invasive blood pressure monitoring. [ 1 ] [ 7 ]


One of the major elements of EVTM is the multidisciplinary team approach. By combining the expertise present allows for optimal treatment not just at the time of patient arrival but also in the pre-hospital setting and later in the operating suite. It is all about teamwork with a common goal, to save the patient. It allows for the hybrid use of open surgery and endovascular methods for hemorrhage control and definitive treatment. In a hemodynamically unstable bleeding patient, traditional treatment is  laparotomy  with abdominal packing, but an EVTM team might simultaneously gain vascular access and perform REBOA for proximal control or embolization as a part in definitive treatment. An EVTM multidisciplinary approach requires complete transparency, good communication and leadership. It is however also important to remember that just because you can, doesn't mean that you should use an EVTM approach. EVTM should always be considered but only used in the optimally selected patient at the right time if the expertise and equipment is present to do it safely. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 8 ]


In the acute setting, the femoral artery is most often the easiest to identify and access thanks to its typically reasonable size. This is however obviously relative to individual anatomical differences and hemodynamic state of the patient. It is in general beneficial to gain early vascular access as the inguinal area is seldom occupied and, if possible, attempt to do this on the contralateral side to a major lower extremity injury. Access may be attempted by ultrasound-guided or blind puncture and surgical cut-down, where ultrasound-guided is the safest and most reasonable alternative for the less experienced. Vascular access is based on the  Seldinger technique . After puncturing the vessel with a needle and confirmation of arterial access a wire is advanced, the needle removed and a vascular sheath is introduced. The access is then ready to use. [ 6 ]


The use of endovascular modalities for bleeding control and treatment on hemodynamically unstable trauma patients is increasing. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for hemorrhage control, angioembolization and stent grafts are highly established tools used for both arterial and venous hemorrhage in both traumatic and non-traumatic patients. [ 4 ] [ 9 ] [ 10 ] [ 11 ]  To be able to provide an endovascular opportunity for resuscitation requires good organization and a well-established endovascular team. [ 2 ] [ 3 ]


Acute care of a hemodynamically unstable trauma patient is never an ideal task. [ 12 ] [ 13 ]  The emphasis is on stopping blood extravasation and hemodynamic stabilisation without delay, despite if it is pre-hospital, in the emergency department or in a hybrid operating suite. REBOA, also called Aortic Balloon Occlusion (ABO), is a powerful endovascular tool that inflates an intra-aortic balloon occluding the lumen of the vessel and decreased or completely prevents blood flow to the more distal parts. If inflated in the aorta proximal to the identified source of bleeding it may help to diminish or stop blood extravasation, also potentially aiding to increase cardiac afterload. This should increase the central pressure and secure adequate myocardial and cerebral perfusion, hopefully rendering the patient, at least temporarily, more hemodynamically stable. REBOA is used as an endovascular tool for hemodynamic control and as a resuscitation adjunct that may prolong the life of the critical patient. REBOA is not only used from an endovascular resuscitation aspect, but may also to help by allowing more time for definitive treatment. [ 6 ] [ 9 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ excessive citations ]


Embolization  is a minimally invasive technique used in EVTM of selected hemodynamically unstable patients with both  traumatic  and non-traumatic injuries. It is the artificial creation of a thrombus by the introduction of various substances to intentionally occlude a vessel with the aim to stop or diminish blood extravasation and is a critical part of the modern management of arterial injuries. [ 6 ] [ 19 ]


Stent grafts , or endo-grafts, are a more permanent solution in the hemodynamically unstable patient and are an important part of the tool kit for EVTM. They are self-expanding artificial reconstructions of vessels with fabric coating deployed inside the original vessel and help to gain temporary control, stop the hemorrhage and repair the damaged vessel wall. They can be used and positioned, by an experienced surgeon, in every major vessel in the body. [ 6 ] [ 11 ] [ 20 ] [ 21 ] [ 22 ]


The  Journal of Endovascular Resuscitation and Trauma Management  (JEVTM) is an open access platform for publishing  peer-reviewed research  regarding endovascular hybrid hemorrhage control. The first issue was published August 2017 with continued publications quarterly. The editorial board is made up by clinicians and scientists who are experts within the field. [ 7 ]


Focused assessment with sonography in trauma  (commonly  abbreviated  as  FAST )  is a rapid bedside  ultrasound  examination performed by surgeons, emergency physicians, and paramedics as a  screening test  for blood around the heart ( pericardial effusion ) or abdominal organs ( hemoperitoneum ) after  trauma . [ 1 ] [ 2 ]  There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax. [ 3 ] [ 4 ]


The four classic areas that are examined for free fluid are the perihepatic space (including Morison's pouch or the  hepatorenal recess ), peri splenic  space,  pericardium , and the  pelvis .  With this technique it is possible to identify the presence of intraperitoneal or pericardial free fluid. In the context of traumatic injury, this fluid will usually be due to  bleeding .


Reasons a FAST or eFAST would be performed would be:


Since the FAST/eFAST is performed with ultrasound, there is very little risk to the patient as ultrasounds only emit sound waves and record the echo to create a picture. [ 5 ]  The most common contraindication would be delay of definitive care such as surgical intervention in the setting of obvious trauma or resuscitative efforts in an extreme scenario. [ 3 ]


The eFAST allows for the examination of both  lungs  by adding bilateral anterior thoracic  sonography  to the FAST exam. This allows for the detection of a  pneumothorax  with the absence of normal ‘lung-sliding’ and ‘comet-tail’ artifact (seen on the ultrasound screen). Compared with supine  chest radiography , with  CT  or clinical course as the gold standard, bedside sonography has superior  sensitivity  (49–99% versus 27–75%), similar  specificity  (95–100%), and can be performed in under a minute. [ 6 ]  Several recent prospective studies have validated its use in the setting of trauma resuscitation, and have also shown that ultrasound can provide an accurate estimation of pneumothorax size. [ 7 ] [ 8 ]  Although radiography or CT scanning is generally feasible, immediate bedside detection of a pneumothorax confirms what are often ambiguous physical findings in unstable patients, and guides immediate  chest decompression . In addition, in the patient undergoing  positive-pressure ventilation , the detection of an otherwise ‘occult’ pneumothorax prior to CT scanning may hasten treatment and subsequently prevent development of a  tension pneumothorax , a deadly complication if not treated immediately, and deterioration in the  radiology  suite (in the CT scanner). [ 9 ]


There are five components to the eFAST exam:


eFAST (extended focused assessment with sonography for trauma) allows an emergency physician or a surgeon the ability to determine whether a patient has  pneumothorax ,  hemothorax ,  pleural effusion , mass/tumor, or a lodged foreign body. The exam allows for visualization of the echogenic tissue, ribs, and lung tissue. Few radiographic signs are important in any trauma and they include the  stratosphere sign , the  sliding or seashore sign , and the  sinusoid sign.


Stratosphere sign  is a clinical medical  ultrasound  finding usually in an eFAST examination that can prove presence of a  pneumothorax . The sign is an imaging finding using a 3.5–7.5  MHz  ultrasound probe in the fourth and fifth intercostal spaces in the anterior clavicular line using the M-Mode of the machine. This finding is seen in the M-mode tracing as pleura and lung being indistinguishable as linear hyperechogenic lines and is fairly reliable for diagnosis of a pneumothorax. Even though the stratospheric sign can be an indication of pneumothorax its absence is not at all reliable to rule out pneumothorax as definitive diagnosis usually requires X-ray or  CT  of thorax. [ 11 ] [ 12 ] [ 13 ]


Seashore sign  is another eFAST finding usually in the lungs in the M-mode that depicts the glandular echogenicity of the lung abutted by the linear appearance of the visceral pleura. This sign is a normal finding. In absence of a seashore sign or presence of a stratosphere sign, pneumothorax is likely.  B-lines  or "comet trails" are echogenic bright linear reflections beneath the pleura that are usually lost with any air between the probe and the lung tissue and therefore whose presence with seashore sign indicates absence of a pneumothorax. [ 11 ] [ 13 ]


Sinusoid sign  is another  M-mode  finding indicating presence of pleural effusion. Due to the cyclical movement of the lung in inspiration and expiration, the motion-time tracing (M-mode) ultrasound shows a sinusoid appearance between the fluid and the line tissue. This finding indicates a possible  pleural effusion ,  empyema , blood in pleural space (hemothorax). [ 11 ] [ 12 ]


FAST is less invasive than  diagnostic peritoneal lavage , involves no exposure to radiation and is cheaper compared to  computed tomography , but achieves a similar accuracy. [ 14 ]


Numerous studies have shown FAST is useful in evaluating trauma patients. [ 15 ] [ 16 ] [ 17 ] [ 18 ]  It also appears to make  emergency department  care faster and better. [ 19 ] [ 20 ]


FAST is most useful in trauma patients who are hemodynamically unstable. A positive FAST result is defined as the appearance of a dark ("anechoic") strip in the dependent areas of the  peritoneum . In the right upper quadrant this typically appears in  Morison's Pouch  (between the  liver  and  kidney ). This location is most useful as it is the place where fluid will collect with a supine patient. In the left upper quadrant, blood may collect anywhere around the  spleen  (perisplenic space). In the  pelvis , blood generally pools behind the  bladder  (in the rectovesicular space). A positive result suggests hemoperitoneum; often  CT scan  will be performed if the patient is stable [ 22 ]  or a  laparotomy  if unstable. In those with a negative FAST result, a search for extra-abdominal sources of bleeding may still need to be performed.


Geriatric trauma  refers to a  traumatic injury  that occurs to an  elderly  person. People around the world are living longer than ever. In developed and underdeveloped countries, the pace of  population aging  is increasing. By 2050, the world's population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. [ 1 ]  While this trend presents opportunities for productivity and additional experiences, it also comes with its own set of challenges for health systems. More so than ever, elderly populations are presenting to the  Emergency Department  following traumatic injury. [ 2 ]  In addition, given advances in the management of chronic illnesses, more elderly adults are living active lifestyles and are at risk of traumatic injury. In the United States, this population accounts for 14% of all traumatic injuries, of which a majority are just mainly from falls. [ 3 ]


Trauma is a leading cause of  morbidity  and mortality across all age groups, however, geriatric populations are unique compared to younger counterparts in the amount of existing health issues and inherent risk of  disability  and  death . [ 4 ]  As a whole, older populations are more vulnerable to trauma from minor mechanisms of injury and less able to recover following injury. [ 5 ]  At the same time,  medications  to manage existing  chronic conditions  and co-morbidities may negatively affect older adults’ physiological responses to traumatic injuries and increase the risk for complications later on. [ 6 ]


A progressive decline in  central nervous system  function leads to a loss of  proprioception ,  balance  and overall  motor coordination , as well as a reduction in  eye–hand coordination ,  reaction time  and an unsteady  gait . [ 7 ]  These degenerative changes are often accompanied by  osteoarthritis  (degenerative joint disease), which leads to a reduction in the  range of motion  of the head, neck and extremities. Furthermore, elderly people frequently take multiple  medications  for control of various diseases and conditions. The side effects of some of these medications may either predispose to injury, or may cause a minor trauma to result in a much more severe condition. For example, a person taking  warfarin  (Coumadin) and/or  clopidogrel  (Plavix) may experience a life-threatening  intracranial hemorrhage  after sustaining a relatively minor  closed head injury , as a result of the defect in the  hemostatic mechanism  caused by such medications. The combined effects of these changes greatly predisposes elderly people to traumatic injury. Both the incidence of falls and the severity of associated complications increase with advancing age. [ 7 ]


Virtually all organ systems experience a progressive decline in function as a result of the  aging  process. [ 8 ] [ 9 ]  One example is a decline in  circulatory system  function caused in part by thickening of the  cardiac muscle . This can lead to  congestive heart failure  or  pulmonary edema . [ 10 ] [ 11 ]  Another example is the decline in muscle mass, which although highly variable among individuals, rapidly speeds up in older age and can decreases up to 50% when compared to the weight of the individual. [ 12 ]  This loss of muscle mass can compromise the elderly adult's ability to maintain a straight posture. [ 13 ]


Atrophy  of the brain begins to accelerate at around seventy years of age, [ 11 ]  which leads to a significant reduction in brain mass. Since the skull does not decrease in size with the brain, there is significant space between the two when this occurs which puts the elderly at a higher risk of a  subdural hematoma  after sustaining a closed head injury. [ 9 ]  The reduction of brain size can lead to issues with  eyesight ,  cognition  and  hearing . [ 11 ]


Because  falls  are the most common mechanism of injury in severely injured geriatric patients, [ 14 ]  the risk factors for geriatric trauma overlap significantly with those that predispose older adults to falls. Falls may often be described as “mechanical” or “non-mechanical.” A “mechanical fall” implies that an object or force in the patient's external environment caused the fall to occur. However, the use of this term may result in a failure to conduct a thorough evaluation of intrinsic factors related to the fall. Even in cases of community-dwelling older adults experiencing falls related to slipping, tripping, or stumbling, the patients’ co-morbidities and health status are often involved. In addition, a proportion of patients with reported “non-mechanical falls” have been shown to have environmental factors. [ 15 ]  For this reason, it is crucial to consider the interactions between environmental hazards and increased individual susceptibility from the accumulated effects of intrinsic risk factors when evaluating why a fall occurred in an older adult.


From a meta-analysis examining risk factors for falls in both community-dwelling and institutionalized populations, the most common intrinsic determinants of falls risks include: [ 16 ]


Other important intrinsic risk factors for falls indicated by other studies include peripheral nerve dysfunction with postural instability, [ 17 ]  use of  sedatives ,  hypnotics ,  antidepressants ,  benzodiazepines , [ 18 ]  and  vasodilators , [ 19 ]  and  history of problem drinking . [ 20 ]


Lastly, in one study, home modifications like adding handrails for outside and inside stairs, grab rails for bathrooms, outdoor lighting, and slip-resistant floors was shown to cause a 26% reduction in the rate of injuries caused by falls at home per year compared to a control group without these interventions. This demonstrates the value in creating a more accommodating and safe home environment for a community-dwelling elder, especially if they have several intrinsic risk factors for falls. [ 21 ]  Another study found a lower risk of falls associated with wearing athletic shoes and canvas shoes compared to other types of footwear including slippers, sandals, and high heels. [ 22 ]


Motor vehicle crashes are the second most frequent mechanism of injury to explain trauma in older adults. [ 23 ]  Risk factors that affect driving performance in older adults include:


Although the survivability of  burn  injuries continues to improve across all age groups, this improvement may be less for older burn victims. This observation may be attributable to a greater degree of co-morbidities and slow wound healing that result in an increased length of stay and higher mortality in the elderly compared to patients less than 60 years. [ 31 ]  Therefore, it is important to recognize and address risk factors that predispose older adults to burns.


Factors that increase the risk of incurring burn injury in older adults include:


Geriatric trauma may be caused by  elder physical, emotional, or sexual abuse , resulting in an increased risk of death at the end of a 13-year follow-up period in one study. [ 35 ]  According to a published uniform definition from the National Center for Injury Prevention and Control, Division of Violence Prevention, elder abuse is “an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.” [ 36 ]


To prevent or identify patients who may experience elder abuse, it is crucial to identify which older adults are at an increased risk. Some findings correlated with risk of elder mistreatment are presented below:


Falls and motor vehicle crashes are the most common types of injuries among geriatric adults. As a whole, older populations are more vulnerable to mortality from all causes of trauma given that they are less able to compensate following injury. [ 5 ]


Falls  account for three-quarters of all trauma in this population. [ 14 ]  In one review, the estimated probability of falling at least once in any given year for individuals 65 years and older was 27%. [ 41 ]  One out of five falls causes a serious injury such as broken bones or a head injury. [ 42 ]  In the United States, over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture. [ 43 ]


Motor vehicle crashes  are the second most common mechanism of injury among geriatric adults, and the most common cause of traumatic mortality. [ 44 ]  Of the possible injuries, older adults are especially at risk of chest injuries (such as rib fractures) which may negatively interact with existing cardiopulmonary comorbidities—increasing the risk of complications like pneumonia and respiratory failure. [ 45 ]  In addition, the highest mortality rate in geriatric trauma is among older pedestrians struck by a vehicle.


Burns  are also especially dangerous in geriatric populations. Relating back to physiology, comorbidities and slow wound healing can result in an increase length of stay, and higher mortality in the elderly compared to patients less than 60 yr of age. [ 46 ]


Falls  are the most common cause of injury in older adults. According to the Behavior Risk Factor Surveillance System in 2018, approximately 28 percent of individuals aver 65 years old reported a fall within the last year. This would account for approximately 36 million falls, of which approximately 8.4 million resulted in injuries. [ 47 ]  These falls are often underreported and can significantly threaten the individual's independence.


Every year, about 5 percent of falls result in hospitalizations in the geriatric population. These injuries lead to an increase in morbidity and a greater likelihood that they will be admitted to a nursing home. [ 48 ]  Approximately 95 percent of all hip fractures reported are due to an unforeseen fall and 25-75 percent of those do not recover fully to the mobility they had prior to the fall. [ 49 ]  Of those older adults who fall, only about half are able to stand back up on their own, the other half experience a “long lie” which makes them more likely to experience a steeper decline on their activities of daily living than those who are able to stand back up on their own. [ 50 ]  Furthermore, the medical complications arising from these falls make it so that they become the leading cause of death from injury in populations over 65 years old and fifth overall cause of death.


As a result of a fall, older adults can also experience post-fall anxiety syndrome. This fear of falling was present in 60 percent of community dwelling geriatric populations, and was demonstrated by their reduction in levels of activity; 15 percent of which severely restricted their mobility out of fear of having another fall. [ 51 ]  This further contributes to morbidity because it can contribute to cognitive impairment, depression, isolation, increase in rates of obesity, and further mobility impairment.


Source: [ 52 ]


The geriatric population is at increased risk for burn injury. While geriatric burns account for less than 5% of burns in developing countries, nearly 20% of burns in developed countries are experienced by the geriatric population. These burn injuries tend to occur at home—particularly in the kitchen or the bathroom—and most commonly consist of flame and scald burns.


Importantly, geriatric patients are at increased risk for downstream complications. This is in part due to limited mobility, decreased ability to react rapidly to threats, and pre-existing medical problems such as vision impairment and medication side effects. Additionally, due to the natural processes of aging, the skin of geriatric patients has impaired mechanisms to protect against burns, including impaired neurosensory sensitivity, skin permeability, and regeneration capacity. These impairments lead to deeper wounds, prolonged wound healing, and lower potential for complete recovery.


Fluid resuscitation  and  pain control  are key components of burn treatment. In the geriatric population, extra care must be paid to provide appropriate fluids, as age is significantly associated with increased volume requirement in the first 48 hours post-injury. Additionally, geriatric patients are often not provided with adequate pain control management, in part due to a misconception that pain decreases with age (there is no evidence to support this claim). Appropriate pain management is critical for recovery, and must consider patients' co-morbidities, organ functions, and current medications.


Skin-grafting  is another important form of treatment for burns. However, age is a risk factor for unsuccessful grafting due to the natural thinning of the skin that occurs with age. Other risk factors for failed skin relevant to the geriatric population for unsuccessful skin grafting include being over age 55, peripheral vascular disease, diabetes mellitus, and related problems of limb ischemia.


Studies suggest that few geriatric patients return to their previous state of health following burn injury. Long-term consequences in this population include exacerbation of pre-existing conditions, decreased mobility, loss of independence, worsened nutrition, pain, and psychological sequelae including depression.


One significant problem in the acute assessment of geriatric trauma patients is under- triage .  Trauma team activation  (TTA) must be done liberally due to limited costs and resources. Therefore, the criteria for TTA is established by the  American College of Surgeons  and individual  trauma centers . The criteria used to identify patients with a greater need for high level care include  vital signs  ( systolic blood pressure  below 90 mmHg or  heart rate  above 120 bpm),  level of consciousness , and mechanism of injury. However, elderly patients with severe trauma often do not meet the standard TTA criteria due to normal age-related changes and reduced physiologic capacities. For example, older adults have a less profound  tachycardic  response to  hemorrhage ,  pain , or  anxiety  following trauma. This explains why mortality increases in the elderly above a heart rate of 90 bpm, an association not observed until heart rate of 130 bpm in younger patients. Similarly, in older adults,  systemic vascular resistance  is increased, which may result in baseline  hypertension . In the setting of  shock , expected declines in blood pressure may not occur, leading to misinterpretation of the geriatric patient's condition. This supports why mortality significantly increases with systolic blood pressure below 110 mmHg in older adults but not until 95 mmHg in younger patients. [ 53 ] [ 54 ]  This is why several centers and studies support using older age as a TTA criterion as a means to reduce mortality in this population, regardless of the mechanism of injury. [ 55 ]


An  injury  is any  physiological  damage to living tissue [ 1 ]  caused by immediate physical stress. Injuries to humans can occur  intentionally  or  unintentionally  and may be caused by  blunt trauma ,  penetrating trauma ,  burning ,  toxic exposure ,  asphyxiation , or  overexertion . Injuries can occur in any part of the body, and different symptoms are associated with different injuries.


Treatment of a major injury is typically carried out by a  health professional  and varies greatly depending on the nature of the injury.  Traffic collisions  are the most common cause of accidental injury and injury-related death among humans. Injuries are distinct from  chronic conditions ,  psychological trauma ,  infections , or  medical procedures , though injury can be a contributing factor to any of these.


Several major health organizations have established systems for the classification and description of human injuries.


Injuries may be intentional or unintentional. Intentional injuries may be acts of violence against others or  self-inflicted  against one's own person. Accidental injuries may be unforeseeable, or they may be caused by  negligence . In order, the most common types of unintentional injuries are traffic accidents, falls,  drowning , burns, and accidental poisoning. Certain types of injuries are more common in  developed countries  or  developing countries . Traffic injuries are more likely to kill pedestrians than drivers in developing countries. Scalding burns are more common in developed countries, while open-flame injuries are more common in developing countries. [ clarification needed ] [ 2 ]


As of 2021, approximately 4.4 million people are killed due to injuries each year worldwide, constituting nearly 8% of all deaths. 3.16 million of these injuries are unintentional, and 1.25 million are intentional. Traffic accidents are the most common form of deadly injury, causing about one-third of injury-related deaths. One-sixth are caused by suicide, and one-tenth are caused by homicide. Tens of millions of individuals require medical treatment for nonfatal injuries each year, and injuries are responsible for about 10% of all years lived with disability. Men are twice as likely to be killed through injury than women. [ 3 ]  In 2013, 367,000 children under the age of five died from injuries, down from 766,000 in 1990. [ 4 ]


The  World Health Organization  (WHO) developed the  International Classification of External Causes of Injury  (ICECI). Under this system, injuries are classified by mechanism of injury, objects/substances producing injury, place of occurrence, activity when injured, the role of human intent, and additional modules. These codes allow the identification of distributions of injuries in specific populations and case identification for more detailed research on causes and preventive efforts. [ 5 ]


The United States  Bureau of Labor Statistics  developed the Occupational Injury and Illness Classification System (OIICS). Under this system injuries are classified by nature, part of body affected, source and secondary source, and event or exposure. The OIICS was first published in 1992 and has been updated several times since. [ 6 ]   The Orchard Sports Injury and Illness Classification System (OSIICS) , previously OSICS, is used to classify injuries to enable research into specific  sports injuries . [ 7 ] [ 8 ]


The  injury severity score  (ISS) is a medical score to assess trauma severity. [ 9 ] [ 10 ]  It correlates with mortality, morbidity, and hospitalization time after trauma. It is used to define the term  major trauma  ( polytrauma ), recognized when the ISS is greater than 15. [ 10 ]  The AIS Committee of the  Association for the Advancement of Automotive Medicine  designed and updates the scale.


Traumatic injury is caused by an external object making forceful contact with the body, resulting in a  wound .  Major trauma  is a severe traumatic injury that has the potential to cause  disability  or  death . Serious traumatic injury most often occurs as a result of traffic collisions. [ 11 ]  Traumatic injury is the leading cause of death in people under the age of 45. [ 12 ]


Blunt trauma injuries are caused by the forceful impact of an external object. Injuries from blunt trauma may cause  internal bleeding  and  bruising  from ruptured  capillaries  beneath the skin, abrasion from scraping against the superficial  epidermis , lacerated tears on the skin or internal organs, or  bone fractures .  Crush injuries  are a severe form of blunt trauma damage that apply large force to a large area over a longer period of time. [ 11 ]  Penetrating trauma injuries are caused by external objects entering the  tissue  of the body through the  skin . Low-velocity penetration injuries are caused by sharp objects, such as  stab wounds , while high-velocity penetration injuries are caused by ballistic projectiles, such as  gunshot wounds  or injuries caused by  shell fragments . [ 13 ]  Perforated injuries result in an entry wound and an exit wound, while puncture wounds result only in an entry wound. Puncture injuries result in a cavity in the tissue. [ 14 ]


Burn injury is caused by contact with extreme temperature, chemicals, or radiation. The effects of burns vary depending on the depth and size. Superficial or first-degree burns only affect the  epidermis , causing pain for a short period of time. Superficial partial-thickness burns cause weeping  blisters  and require dressing. Deep partial-thickness burns are dry and less painful due to the burning away of the skin and require surgery. Full-thickness or third-degree burns affect the entire  dermis  and is susceptible to  infection . Fourth-degree burns reach deep tissues such as muscles and bones, causing loss of the affected area. [ 15 ]


Thermal burns  are the most common type of burn, caused by contact with excessive heat, including contact with flame, contact with hot surfaces, or  scalding  burns caused by contact with hot water or steam.  Frostbite  is a type of burn caused by contact with excessive cold, causing cellular injury and deep tissue damage through the crystallization of water in the tissue.  Friction burns  are caused by  friction  with external objects, resulting in a burn and abrasion. [ 15 ]   Radiation burns  are caused by exposure to  ionizing radiation . Most radiation burns are  sunburns  caused by  ultraviolet  radiation or high exposure to radiation through medical treatments such as repeated  radiography  or  radiation therapy . [ 16 ]


Electrical burns  are caused by contact with  electricity  as it enters and passes through the body. They are often deeper than other burns, affecting lower tissues as electricity penetrates the skin, and the full extent of electrical burns are often obscured. They will also cause extensive destruction of tissue at the entry and exit points. Electrical injuries in the home are often minor, while high tension power cables cause serious electrical injuries in the workplace.  Lightning strikes  can also cause severe electrical injuries. Fatal electrical injuries are often caused by tetanic spasm inducing  respiratory arrest  or interference with the heart causing  cardiac arrest . [ 17 ]


Chemical burns  are caused by contact with  corrosive substances  such as  acid  or  alkali . Chemical burns are rarer than most other burns, though there are many chemicals that can damage tissue. The most common chemical-related injuries are those caused by  carbon monoxide ,  ammonia ,  chlorine ,  hydrochloric acid , and  sulfuric acid . Some  chemical weapons  induce chemical burns, such as  white phosphorus . Most chemical burns are treated with extensive application of water to remove the chemical contaminant, though some burn-inducing chemicals react with water to create more severe injuries. [ 18 ]  The ingestion of corrosive substances can cause chemical burns to the larynx and stomach. [ 19 ]


Toxic injury  is caused by the ingestion, inhalation, injection, or absorption of a  toxin . This may occur through an interaction caused by a  drug  or the ingestion of a  poison . Different toxins may cause different types of injuries, and many will cause injury to specific organs. [ 20 ]  Toxins in gases, dusts, aerosols, and smoke can be inhaled, potentially causing respiratory failure. Respiratory toxins can be released by structural fires, industrial accidents, domestic mishaps, or through chemical weapons. Some toxicants may affect other parts of the body after inhalation, such as carbon monoxide. [ 21 ]


Asphyxia causes injury to the body from a lack of oxygen. It can be caused by  drowning ,  inhalation  of certain substances,  strangulation ,  blockage of the airway , traumatic injury to the airway,  apnea , and other means. The most immediate injury caused by asphyxia is  hypoxia , which can in turn cause acute lung injury or  acute respiratory distress syndrome  as well as damage to the circulatory system. The most severe injury associated with asphyxiation is cerebral  hypoxia  and  ischemia , in which the brain receives insufficient oxygen or blood, resulting in neurological damage or death. Specific injuries are associated with water inhalation, including alveolar collapse,  atelectasis ,  intrapulmonary shunting , and  ventilation perfusion mismatch . [ 22 ]  Simple asphyxia is caused by a lack of external oxygen supply. Systemic asphyxia is caused by exposure to a compound that prevents oxygen from being transported or used by the body. This can be caused by  azides , carbon monoxide,  cyanide ,  smoke inhalation ,  hydrogen sulfide ,  methemoglobinemia -inducing substances,  opioids , or other systemic asphyxiants. Ventilation and oxygenation are necessary for treatment of asphyxiation, and some asphyxiants can be treated with antidotes. [ 23 ]


Injuries of overuse or overexertion can occur when the body is strained through use, affecting the bones, muscles, ligaments, or tendons.  Sports injuries  are often overuse injuries such as  tendinopathy . [ 24 ]  Over-extension of the ligaments and tendons can result in  sprains  and  strains , respectively. [ 25 ]  Repetitive sedentary behaviors such as extended use of a computer or a physically repetitive occupation may cause a  repetitive strain injury . [ 26 ]  Extended use of brightly lit screens may also cause  eye strain . [ 27 ]


Abdominal trauma  includes injuries to the  stomach ,  intestines ,  liver ,  pancreas ,  kidneys ,  gallbladder , and  spleen . Abdominal injuries are typically caused by traffic accidents, assaults, falls, and work-related injuries, and physical examination is often unreliable in diagnosing blunt abdominal trauma.  Splenic injury  can cause  low blood volume  or  blood in the peritoneal cavity . The treatment and prognosis of splenic injuries are dependent on cardiovascular stability. [ 28 ]  The gallbladder is rarely injured in blunt trauma, occurring in about 2% of blunt abdominal trauma cases. Injuries to the gallbladder are typically associated with injuries to other abdominal organs. [ 29 ]  The intestines are susceptible to injury following blunt abdominal trauma. [ 30 ]  The kidneys are protected by other structures in the abdomen, and most injuries to the kidney are a result of blunt trauma. [ 31 ]  Kidney injuries typically cause blood in the urine. [ 32 ]


Due to its location in the body,  pancreatic injury  is relatively uncommon but more difficult to diagnose. Most injuries to the pancreas are caused by penetrative trauma, such as gunshot wounds and stab wounds. Pancreatic injuries occur in under 5% of blunt abdominal trauma cases. The severity of pancreatic injury depends primarily on the amount of harm caused to the  pancreatic duct . [ 33 ]  The stomach is also well protected from injury due to its heavy layering, its extensive blood supply, and its position relative to the  rib cage . As with pancreatic injuries, most traumatic stomach injuries are caused by penetrative trauma, and most civilian weapons do not cause long-term tissue damage to the stomach. Blunt trauma injuries to the stomach are typically caused by traffic accidents. [ 34 ]  Ingestion of corrosive substances can cause chemical burns to the stomach. [ 19 ]   Liver injury  is the most common type of organ damage in cases of abdominal trauma. [ 35 ]  The liver's size and location in the body makes injury relatively common compared to other abdominal organs, and blunt trauma injury to the liver is typically treated with nonoperative management. [ 36 ]  Liver injuries are rarely serious, though most injuries to the liver are concomitant with other injuries, particularly to the spleen, ribs, pelvis, or spinal cord. [ 35 ]  The liver is also susceptible to toxic injury, with overdose of  paracetamol  being a common cause of liver failure. [ 37 ]


Facial trauma  may affect the  eyes ,  nose ,  ears , or  mouth . Nasal trauma is a common injury and the most common type of facial injury. [ 38 ]  Oral injuries are typically caused by traffic accidents or alcohol-related violence, though falls are a more common cause in young children. The primary concerns regarding oral injuries are that the airway is clear and that there are no concurrent injuries to other parts of the head or neck. Oral injuries may occur in the soft tissue of the face, the hard tissue of the mandible, or as  dental trauma . [ 39 ]


The ear is susceptible to trauma in head injuries due to its prominent location and exposed structure. Ear injuries may be internal or external. Injuries of the external ear are typically lacerations of the cartilage or the formation of a hematoma. Injuries of the middle and internal ear may include a  perforated eardrum  or trauma caused by extreme pressure changes. The ear is also highly sensitive to  blast injury . The bones of the ear are connected to facial nerves, and ear injuries can cause paralysis of the face. Trauma to the ear can cause  hearing loss . [ 40 ]


Eye injuries  often take place in the  cornea , and they have the potential to permanently damage vision.  Corneal abrasions  are a common injury caused by contact with foreign objects. The eye can also be injured by a foreign object remaining in the cornea. Radiation damage can be caused by exposure to excessive light, often caused by  welding  without eye protection or being exposed to excessive ultraviolet radiation, such as  sunlight . Exposure to corrosive chemicals can permanently damage the eyes, causing  blindness  if not sufficiently irrigated. The eye is protected from most blunt injuries by the  infraorbital margin , but in some cases blunt force may cause an eye to hemorrhage or tear. [ 41 ]  Overuse of the eyes can cause eye strain, particularly when looking at brightly lit screens for an extended period. [ 27 ]


Cardiac injuries affect the  heart  and  blood vessels .  Blunt cardiac injury  in a common injury caused by blunt trauma to the heart. It can be difficult to diagnose, and it can have many effects on the heart, including contusions, ruptures, acute valvular disorders,  arrhythmia , or  heart failure . [ 42 ]  Penetrative trauma to the heart is typically caused by stab wounds or gunshot wounds. Accidental cardiac penetration can also occur in rare cases from a fractured sternum or rib. Stab wounds to the heart are typically survivable with medical attention, though gunshot wounds to the heart are not. The  right ventricle  is most susceptible to injury due to its prominent location. The two primary consequences of traumatic injury to the heart are severe hemorrhaging and  fluid buildup  around the heart. [ 43 ]


Musculoskeletal injuries  affect the  skeleton  and the  muscular system .  Soft tissue injuries  affect the  skeletal muscles ,  ligaments , and  tendons . Ligament and tendon injuries account for half of all musculoskeletal injuries. Ligament sprains and tendon strains are common injuries that do not require intervention, but the healing process is slow.  Physical therapy  can be used to assist reconstruction and use of injured ligaments and tendons. Torn ligaments or tendons typically require surgery. [ 25 ]  Skeletal muscles are abundant in the body and commonly injured when engaging in athletic activity. Muscle injuries trigger an inflammatory response to facilitate healing. Blunt trauma to the muscles can cause contusions and  hematomas . Excessive tensile strength can overstretch a muscle, causing a strain. Strains may present with torn muscle fibers, hemorrhaging, or  fluid in the muscles . Severe muscle injuries in which a tear extends across the muscle can cause total loss of function. Penetrative trauma can cause laceration to muscles, which may take an extended time to heal. Unlike contusions and strains, lacerations are uncommon in sports injuries. [ 44 ]


Traumatic injury may cause various  bone fractures  depending on the amount of force, direction of the force, and width of the area affected.  Pathologic fractures  occur when a previous condition weakens the bone until it can be easily fractured.  Stress fractures  occur when the bone is overused or suffers under excessive or traumatic pressure, often during athletic activity. Hematomas occur immediately following a bone fracture, and the healing process often takes from six weeks to three months to complete, though continued use of the fractured bone will prevent healing. [ 45 ]   Articular cartilage damage  may also affect function of the skeletal system, and it can cause posttraumatic  osteoarthritis . Unlike most bodily structures, cartilage cannot be healed once it is damaged. [ 46 ]


Injuries to the  nervous system  include  brain injury ,  spinal cord injury , and  nerve injury . Trauma to the  brain  causes  traumatic brain injury  (TBI), causing "long-term physical, emotional, behavioral, and cognitive consequences". Mild TBI, including  concussion , often occurs during athletic activity, military service, or as a result of untreated  epilepsy , and its effects are typically short-term. More severe injuries to the brain cause moderate TBI, which may cause confusion or lethargy, or severe TBI, which may result in a  coma  or a secondary brain injury. TBI is a leading cause of mortality. [ 47 ]  Approximately half of all trauma-related deaths involve TBI. [ 12 ]  Non-traumatic injuries to the brain cause  acquired brain injury  (ABI). This can be caused by  stroke , a  brain tumor , poison, infection, cerebral hypoxia, drug use, or the secondary effect of a TBI. [ 48 ]


Injury to the  spinal cord  is not immediately terminal, but it is associated with concomitant injuries, lifelong medical complications, and reduction in life expectancy. It may result in complications in several major organ systems and a significant reduction in mobility or paralysis.  Spinal shock  causes temporary paralysis and loss of reflexes. [ 49 ]  Unlike most other injuries, damage to the  peripheral nerves  is not healed through cellular proliferation. Following nerve injury, the nerves undergo degeneration before regenerating, and other pathways can be strengthened or reprogrammed to make up for lost function. The most common form of peripheral nerve injury is stretching, due to their inherent elasticity. Nerve injuries may also be caused by laceration or compression. [ 50 ]


Injuries to the  pelvic area  include injuries to the  bladder ,  rectum ,  colon , and  reproductive organs . Traumatic injury to the bladder is rare and often occurs with other injuries to the abdomen and pelvis. The bladder is protected by the  peritoneum , and most cases of bladder injury are concurrent with a fracture of the  pelvis . Bladder trauma typically causes  hematuria , or blood in the urine. Ingestion of alcohol may cause distension of the bladder, increasing the risk of injury. A  catheter  may be used to extract blood from the bladder in the case of hemorrhaging, though injuries that break the peritoneum typically require surgery. [ 51 ]  The colon is rarely injured by blunt trauma, with most cases occurring from penetrative trauma through the abdomen. Rectal injury is less common than injury to the colon, though the rectum is more susceptible to injury following blunt force trauma to the pelvis. [ 52 ]


Injuries to the  male reproductive system  are rarely fatal and typically treatable through grafts and reconstruction. The elastic nature of the  scrotum  makes it resistant to injury, accounting for 1% of traumatic injuries. Trauma to the scrotum may cause damage to the  testis  or the  spermatic cord . Trauma to the  penis  can cause  penile fracture , typically as a result of vigorous  intercourse . [ 53 ]  Injuries to the  female reproductive system  are often a result of  pregnancy  and  childbirth  or sexual activity. They are rarely fatal, but they can produce a variety of complications, such as chronic discomfort,  dyspareunia ,  infertility , or the formation of  fistulas . Age can greatly affect the nature of genital injuries in women due to changes in hormone composition. Childbirth is the most common cause of genital injury to women of reproductive age. Many cultures practice  female genital mutilation , which is estimated to affect over 125 million women and girls worldwide as of 2018. [ 54 ]  Tears and abrasions to the  vagina  are common during sexual intercourse, and these may be exacerbated in instances of non-consensual sexual activity. [ 55 ]


Injuries to the  respiratory tract  affect the  lungs ,  diaphragm ,  trachea ,  bronchus ,  pharynx , or  larynx .  Tracheobronchial injuries  are rare and often associated with other injuries.  Bronchoscopy  is necessary for an accurate diagnosis of tracheobronchial injury. [ 56 ]  The neck, including the pharynx and larynx, is highly vulnerable to injury due to its complex, compacted anatomy. Injuries to this area can cause  airway obstruction . [ 57 ]  Ingestion of corrosive chemicals can cause chemical burns to the larynx. [ 19 ]  Inhalation of toxic materials can also cause serious  injury  to the respiratory tract. [ 21 ]


Severe trauma to the chest can cause damage to the lungs, including  pulmonary contusions ,  accumulation of blood , or a  collapsed lung . The  inflammation  response to a lung injury can cause acute respiratory distress syndrome. Injuries to the lungs may cause symptoms ranging from  shortness of breath  to terminal  respiratory failure . Injuries to the lungs are often fatal, and survivors often have a reduced quality of life. [ 58 ]  Injuries to the diaphragm are uncommon and rarely serious, but blunt trauma to the diaphragm can result in the formation of a  hernia  over time. [ 59 ]  Injuries to the diaphragm may present in many ways, including abnormal blood pressure, cardiac arrest, gastroinetestinal obstruction, and respiratory insufficiency. Injuries to the diaphragm are often associated with other injuries in the chest or abdomen, and its position between two major cavities of the human body may complicate diagnosis. [ 60 ]


Most injuries to the skin are minor and do not require specialist treatment. Lacerations of the skin are typically repaired with  sutures ,  staples , or adhesives. The skin is susceptible to burns, and burns to the skin often cause blistering. Abrasive trauma scrapes or rubs off the skin, and severe abrasions require  skin grafting  to repair. Skin tears involve the removal of the epidermis or dermis through friction or shearing forces, often in vulnerable populations such as the elderly. Skin injuries are potentially complicated by foreign bodies such as glass, metal, or dirt that entered the wound, and skin wounds often require cleaning. [ 61 ]


Much of  medical practice  is dedicated to the treatment of injuries.  Traumatology  is the study of traumatic injuries and injury repair. Certain injuries may be treated by  specialists . Serious injuries sometimes require  trauma surgery . Following serious injuries, physical therapy and  occupational therapy  are sometimes used for rehabilitation.  Medication  is commonly used to treat injuries. [ citation needed ]


Emergency medicine  during major trauma prioritizes the immediate consideration of life-threatening injuries that can be quickly addressed. The airway is evaluated, clearing bodily fluids with suctioning or creating an artificial airway if necessary. Breathing is evaluated by evaluating motion of the chest wall and checking for  blood  or  air  in the  pleural cavity . Circulation is evaluated to resuscitate the patient, including the application of  intravenous therapy . Disability is evaluated by checking for responsiveness and reflexes. Exposure is then used to examine the patient for external injury. Following immediate life-saving procedures, a  CT scan  is used for a more thorough diagnosis. Further resuscitation may be required, including ongoing blood transfusion, mechanical ventilation and nutritional support. [ 12 ]


Pain management  is another aspect of injury treatment.  Pain  serves as an indicator to determine the nature and severity of an injury, but it can also worsen an injury, reduce mobility, and affect quality of life.  Analgesic  drugs are used to reduce the pain associated with injuries, depending on the person's age, the severity of the injury, and previous medical conditions that may affect pain relief.  NSAIDs  such as  aspirin  and  ibuprofen  are commonly used for acute pain. Opioid medications such as  fentanyl ,  methadone , and  morphine  are used to treat severe pain in major trauma, but their use is limited due to associated long-term risks such as addiction. [ 62 ]


Complications  may arise as a result of certain injuries, increasing the recovery time, further exasperating the symptoms, or potentially causing death. The extent of the injury and the age of the injured person may contribute to the likelihood of complications. Infection of wounds is a common complication in traumatic injury, resulting in diagnoses such as  pneumonia  or  sepsis . [ 63 ]  Wound infection prevents the healing process from taking place and can cause further damage to the body. A majority of wounds are contaminated with microbes from other parts of the body, and infection takes place when the immune system is unable to address this contamination. The surgical removing of devitalized tissue and the use of topical antimicrobial agents can prevent infection. [ 64 ]


Hemorrhaging of blood is a common result of injuries, and it can cause several complications. Pooling of blood under the skin can cause a  hematoma , particularly after blunt trauma or the suture of a laceration. Hematomas are susceptible to infection and are typically treated compression, though surgery is necessary in severe cases. [ 65 ]  Excessive blood loss can cause  hypovolemic shock  in which cellular oxygenation can no longer take place. This can cause  tachycardia ,  hypotension , coma, or  organ failure .  Fluid replacement  is often necessary to treat blood loss. [ 66 ]  Other complications of injuries include cavitation, development of fistulas, and organ failure.


Injuries often cause psychological harm in addition to physical harm. Traumatic injuries are associated with psychological trauma and distress, and some victims of traumatic injuries will display symptoms of  post-traumatic stress disorder  during and after the recovery of the injury. The specific symptoms and their  triggers  vary depending on the nature of the injury. [ 67 ]   Body image  and  self-esteem  can also be affected by injury. Injuries that cause permanent disabilities, such as spinal cord injuries, can have severe effects on self-esteem. [ 68 ] [ 69 ]  Disfiguring injuries can negatively affect body image, leading to a lower quality of life. Burn injuries in particular can cause dramatic changes in a person's appearance that may negatively affect body image. [ 70 ] [ 71 ] [ 72 ]


Severe injury can also cause social harm. Disfiguring injuries may also result in stigma due to scarring or other changes in appearance. [ 73 ] [ 74 ]  Certain injuries may necessitate a change in occupation or prevent employment entirely. Leisure activities are similarly limited, and athletic activities in particular may be impossible following severe injury. In some cases, the effects of injury may strain personal relationships, such as marriages. [ 75 ]  Psychological and social variables have been found to affect the likelihood of injuries among athletes. Increased life stress can cause an increase in the likelihood of athletic injury, while  social support  can decrease the likelihood of injury. [ 76 ] [ 77 ]  Social support also assists in the recovery process after athletic injuries occur. [ 78 ]


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. [ citation needed ]


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 ]


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 ]


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 ]


The initial assessment is critical in determining the extent of injuries and what will be needed to manage an injury, and for treating immediate life threats.


Primary  physical examination  is undertaken to identify any life-threatening problems, after which the secondary examination is carried out. This may occur during transportation or upon arrival at the hospital. The secondary examination consists of a systematic assessment of the  abdominal ,  pelvic , and  thoracic  areas, a complete inspection of the body surface to find all injuries, and a  neurological examination . Injuries that may manifest themselves later may be missed during the initial assessment, such as when a patient is brought into a hospital's emergency department. [ 23 ]  Generally, the physical examination is performed in a systematic way that first checks for any immediate life threats (primary survey), and then taking a more in-depth examination (secondary survey). [ 24 ]


Persons with major trauma commonly have chest and pelvic  x-rays  taken, [ 6 ]  and, depending on the mechanism of injury and presentation, a  focused assessment with sonography for trauma  (FAST) exam to check for internal bleeding. For those with relatively stable blood pressure, heart rate, and sufficient  oxygenation ,  CT scans  are useful. [ 6 ] [ 25 ]   Full-body CT scans , known as pan-scans, improve the survival rate of those who have suffered major trauma. [ 26 ] [ 27 ]  These scans use intravenous injections for the  radiocontrast  agent, but not oral administration. [ 28 ]  There are concerns that intravenous contrast administration in trauma situations without confirming adequate renal function may cause damage to kidneys, but this does not appear to be significant. [ 25 ]


In the U.S., CT or  MRI  scans are performed on 15% of those with trauma in  emergency departments . [ 29 ]  Where blood pressure is low or the heart rate is increased—likely from bleeding in the abdomen—immediate surgery bypassing a CT scan is recommended. [ 30 ]  Modern 64-slice CT scans are able to rule out, with a high degree of accuracy, significant injuries to the neck following blunt trauma. [ 31 ]


Surgical techniques, using a tube or catheter to  drain fluid from the peritoneum ,  chest , or the  pericardium around the heart , often are used in cases of severe blunt trauma to the chest or abdomen, especially when a person is experiencing early signs of  shock . In those with  low blood-pressure , likely because of bleeding in the abdominal cavity,  cutting through the abdominal wall surgically  is indicated. [ 6 ]


By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems may help to enhance the overall health of a population. [ 32 ]  Injury prevention strategies are commonly used to prevent injuries in children, who are a high risk population. [ 33 ]  Injury prevention strategies generally involve educating the general public about specific risk factors and developing strategies to avoid or reduce injuries. [ 34 ]  Legislation intended to prevent injury typically involves seatbelts, child car-seats, helmets, alcohol control, and increased enforcement of the legislation. [ citation needed ]  Other controllable factors, such as the use of drugs including  alcohol  or  cocaine , increases the risk of trauma by increasing the likelihood of traffic collisions, violence, and abuse occurring. [ 6 ]  Prescription drugs such as  benzodiazepines  may increase the risk of trauma in  elderly  people. [ 6 ]


The care of acutely injured people in a public health system requires the involvement of bystanders, community members, health care professionals, and health care systems. It encompasses  pre-hospital trauma assessment  and care by  emergency medical services  personnel, emergency department assessment, treatment, stabilization, and in-hospital care among all age groups. [ 35 ]  An established trauma system network is also an important component of community disaster preparedness, facilitating the care of people who have been involved in disasters that cause large numbers of casualties, such as earthquakes. [ 32 ]


The pre-hospital use of  stabilization  techniques improves the chances of a person surviving the journey to the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at a  trauma center  as well as provide primary stabilization by checking and treating  airway, breathing, and circulation  as well as assessing for disability and gaining exposure to check for other injuries. [ 23 ]


Spinal motion restriction  by securing the neck with a  cervical collar  and placing the person on a  long spine board  was of high importance in the pre-hospital setting, but due to lack of evidence to support its use, the practice is losing favor. Instead, it is recommended that more exclusive criteria be met such as age and neurological deficits to indicate the need of these adjuncts. [ 36 ] [ 37 ]  This may be accomplished with other medical transport devices, such as a   Kendrick extrication device , before moving the person. [ 38 ]  It is important to quickly control severe bleeding with direct pressure to the wound and consider the use of  hemostatic agents  or  tourniquets  if the bleeding continues. [ 39 ]  Conditions such as impending airway obstruction, enlargening neck hematoma, or unconsciousness require intubation. It is unclear, however, if this is best performed before reaching hospital or in the hospital. [ 40 ]


Rapid transportation of severely injured patients improves the outcome in trauma. [ 6 ] [ 23 ]  Helicopter EMS transport reduces mortality compared to ground-based transport in adult trauma patients. [ 41 ]  Before arrival at the hospital, the availability of  advanced life support  does not greatly improve the outcome for major trauma when compared to the administration of  basic life support . [ 42 ] [ 43 ]  Evidence is inconclusive in determining support for pre-hospital  intravenous fluid resuscitation  while some evidence has found it may be harmful. [ 44 ]  Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them, [ 6 ]  and outcomes may improve when persons who have experienced trauma are transferred directly to a trauma center. [ 45 ]


Improvements in pre-hospital care have led to "unexpected survivors", where patients survive trauma when they would have previously been expected to die. [ 46 ]  However these patients may struggle to rehabilitate. [ 47 ]


Management of those with trauma often requires the help of many healthcare specialists including physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. Generally, the first step of managing trauma is to perform a primary survey that evaluates a person's airway, breathing, circulation, and neurologic status. [ 48 ]  These steps may happen simultaneously or depend on the most pressing concern such as a  tension pneumothorax  or major arterial bleed. The primary survey generally includes assessment of the cervical spine, though  clearing  it is often not possible until after imaging, or the person has improved. After immediate life threats are controlled, a person is either moved into an operating room for immediate surgical correction of the injuries, or a secondary survey is performed that is a more detailed head-to-toe assessment of the person. [ 49 ]


Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure. [ 50 ]  Examples of these indications include penetrating neck trauma, expanding neck hematoma, and being unconscious. In general, the method of intubation used is  rapid sequence intubation  followed by ventilation, though intubating in shock due to bleeding can lead to arrest, and should be done after some resuscitation whenever possible. Trauma resuscitation includes control of active bleeding. When a person is first brought in, vital signs are checked, an  ECG  is performed, and, if needed, vascular access is obtained. Other tests should be performed to get a baseline measurement of their current blood chemistry, such as an  arterial blood gas  or  thromboelastography . [ 51 ]  In those with  cardiac arrest  due to trauma chest compressions are considered futile, but still recommended. [ 52 ]  Correcting the underlying cause such as a  pneumothorax  or  pericardial tamponade , if present, may help. [ 52 ]


A  FAST  exam may help assess for internal bleeding. In certain traumas, such as  maxillofacial  trauma, it may be beneficial to have a highly trained health care provider available to maintain airway, breathing, and circulation. [ 53 ]


Traditionally, high-volume  intravenous fluids  were given to people who had poor perfusion due to trauma. [ 54 ]  This is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries. [ 55 ]  In general, however, giving lots of fluids appears to increase the risk of death. [ 56 ]  Current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. [ 4 ] [ 55 ]  Targets include a  mean arterial pressure  of 60 mmHg, a  systolic blood pressure  of 70–90 mmHg, [ 54 ] [ 57 ]  or the re-establishment of peripheral pulses and adequate ability to think. [ 54 ]   Hypertonic saline  has been studied and found to be of little difference from normal saline. [ 58 ]


As no intravenous fluids used for initial resuscitation have been shown to be superior, warmed  Lactated Ringer's solution  continues to be the solution of choice. [ 54 ]  If blood products are needed, a greater use of  fresh frozen plasma  and  platelets  instead of only  packed red blood cells  has been found to improve survival and lower overall blood product use; [ 59 ]  a ratio of 1:1:1 is recommended. [ 57 ]  The success of platelets has been attributed to the fact that they may prevent  coagulopathy  from developing. [ 60 ]   Cell salvage and autotransfusion  also may be used. [ 54 ]


Blood substitutes  such as  hemoglobin-based oxygen carriers  are in development; however, as of 2013 there are none available for commercial use in North America or Europe. [ 54 ] [ 61 ] [ 62 ]  These products are only available for general use in South Africa and Russia. [ 61 ]


Tranexamic acid  decreases death in people who are having ongoing bleeding due to trauma, as well as those with mild to moderate traumatic brain injury and evidence of intracranial bleeding on CT scan. [ 63 ] [ 64 ] [ 65 ]  It  only appears to be beneficial, however, if administered within the first three hours after trauma. [ 66 ]  For severe bleeding, for example from  bleeding disorders ,  recombinant factor VIIa —a protein that assists blood clotting—may be appropriate. [ 6 ] [ 55 ]  While it decreases blood use, it does not appear to decrease the mortality rate. [ 67 ]  In those without previous factor VII deficiency, its use is not recommended outside of trial situations. [ 68 ]


Other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury. [ 4 ]  While positive  inotropic medications  such as  norepinephrine  sometimes are used in hemorrhagic shock as a result of trauma, there is a lack of evidence for their use. [ 69 ]  Therefore, as of 2012 they have not been recommended. [ 58 ]  Allowing a low blood pressure may be preferred in some situations. [ 70 ]


The decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. Bleeding must be controlled before definitive repair may occur. [ 71 ]   Damage control surgery  is used to manage severe trauma in which there is a  cycle  of  metabolic acidosis ,  hypothermia , and  hypotension  that may lead to death, if not corrected. [ 6 ]  The main principle of the procedure involves performing the fewest procedures to save life and limb; less critical procedures are left until the victim is more stable. [ 6 ]  Approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require exploratory surgery. The majority of preventable deaths from trauma result from unrecognised intra-abdominal bleeding. [ 72 ]


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 ]


Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually. [ 80 ] [ 81 ]  It is the fifth leading cause of significant disability. [ 80 ]  About half of trauma deaths are in people aged between 15 and 45 years and trauma is the leading cause of death in this age group. [ 81 ]  Injury affects more males; 68% of injuries occur in males [ 82 ]  and death from trauma is twice as common in males as it is in females, this is believed to be because males are much more willing to engage in risk-taking activities. [ 81 ]  Teenagers and young adults are more likely to need hospitalization from injuries than other age groups. [ 83 ]  While elderly persons are less likely to be injured, they are more likely to die from injuries sustained due to various physiological differences that make it more difficult for the body to compensate for the injuries. [ 83 ]  The primary causes of traumatic death are central nervous system injuries and  substantial blood loss . [ 80 ]  Various classification scales exist for use with trauma to determine the severity of injuries, which are used to determine the resources used and, for statistical collection.


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 ]


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 ]


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. [ citation needed ]


Due to anatomical and physiological differences, injuries in children need to be approached differently from those in adults. [ 92 ]  Accidents are the leading cause of death in children between 1 and 14 years old. [ 76 ]  In the United States, approximately sixteen million children go to an emergency department due to some form of injury every year, [ 76 ]  with boys being more frequently injured than girls by a ratio of 2:1. [ 76 ]  The world's five most common unintentional injuries in children as of 2008 are road crashes, drowning, burns, falls, and poisoning. [ 93 ]


Weight estimation  is an important part of managing trauma in children because the accurate dosing of medicine may be critical for resuscitative efforts. [ 94 ]  A number of methods to estimate weight, including the  Broselow tape ,  Leffler formula , and  Theron formula  exist. [ 95 ]


Trauma occurs in approximately 5% of all pregnancies, [ 96 ]  and is the leading cause of maternal death. Additionally, pregnant women may experience  placental abruption ,  pre-term labor , and  uterine rupture . [ 96 ]  There are diagnostic issues during pregnancy;  ionizing radiation  has been shown to cause birth defects, [ 4 ]  although the doses used for typical exams generally are considered safe. [ 96 ]  Due to normal  physiological changes that occur during pregnancy , shock may be more difficult to diagnose. [ 4 ] [ 97 ]  Where the woman is more than 23 weeks pregnant, it is recommended that the fetus be monitored for at least four hours by  cardiotocography . [ 96 ]


A number of treatments beyond typical trauma care may be needed when the patient is pregnant. Because the weight of the uterus on the  inferior vena cava  may decrease blood return to the heart, it may be very beneficial to lay a woman in late pregnancy on her left side. [ 96 ]  also recommended are  Rho(D) immune globulin  in those who are rh negative,  corticosteroids  in those who are 24 to 34 weeks and may need delivery or a  caesarean section  in the event of cardiac arrest. [ 96 ]


Most research on trauma occurs during war and military conflicts as militaries will increase trauma research spending in order to prevent combat related deaths. [ 98 ]  Some research is being conducted on patients who were admitted into an  intensive care unit  or trauma center, and received a trauma diagnosis that caused a negative change in their health-related quality of life, with a potential to create anxiety and symptoms of depression. [ 99 ]  New preserved blood products also are being researched for use in pre-hospital care; it is impractical to use the currently available blood products in a timely fashion in remote, rural settings or in theaters of war. [ 100 ]


A  medical surge  occurs when "patient volumes challenge or exceed a hospital's servicing capacity"—often but not always tied to high volume of patients in a hospital's  emergency room . [ 1 ]  Medical surges can occur after a  mass casualty incident . [ 2 ]  In a poll by the  American College of Emergency Physicians  (ACEP) in May 2018, 93% of doctors said their US emergency rooms were not fully prepared for medical surges. 6% said their emergency departments were fully prepared. [ 3 ]