Mortality peaks after trauma

MORTALITY PEAKSIn general, the only effective interventions for this primary peak in injury-induced mortality are aggressive prevention strategies, either devices, such as automobile restraints and bicycle helmets, that prevent or lessen injury, or laws, such as drinking and driving penalties and motorcycle helmet laws, that limit certain risk-enhancing behavior patterns.

The second mortality peak occurs within hours of injury, accounts for approximately 30% of deaths, about half of which result from hemorrhage and half from central nervous system (CNS) injuries. Important reductions in mortality rates during this period (“the golden hour”) have resulted from the development of trauma, emergency medical services with rapid transport systems. Overall, preventable trauma mortality rates, as defined by expert panels, have been reduced from approximately 25% to 30% to 2% to 3% where well-organized trauma care systems exist. Currently, an estimated 85% of U.S. residents have potential access to level 1/2 trauma centers within 60 minutes, but for 28% this is by helicopter only. The nearly 50 million Americans who do not have access to organized trauma care within an hour live mostly in rural areas. Further development of trauma systems and evidence-based care protocols and expansion of these systems to rural areas will undoubtedly result in further reductions in mortality rates during this early postinjury period.

The third mortality peak includes deaths that occur from day 1 to 2 after trauma resuscitation and acute care to weeks later. This late mortality generally is attributed to infection, multiple organ failure (MOF). Of all trauma deaths, 10% to 20% occur during this period. The development of efficient evidence-based trauma care, however, is changing the epidemiology of these deaths. During the first week after trauma, refractory intracranial hypertension complicating severe traumatic brain injury (TBI) now accounts for a significant number of these deaths. The incidence of sepsis and MOF-related deaths following trauma has continued to diminish as a result of aggressive early resuscitation with improved goal-directed endpoints along with advanced organ support and ongoing critical care. Sepsis and MOF now account for approximately 5% of overall mortality and only 30% of later mortality where organized trauma systems and sophisticated intensive care unit care exist. In addition to severe TBI, fatal pulmonary embolism also now accounts for a significant number of these late deaths. Lastly, the aging of America has created an ever-increasing population of fragile elders with significant comorbidities, decreased organ reserve, and minimal ability to recover from the primary trauma insult. As a result, increasing challenges are the ethics of end-of-life, palliative care decision making. In the severely injured very elderly patient, just because “it can be done” does not necessarily justify that “it should be done.” From both unnecessary patient suffering and consumption of limited critical resources viewpoints, thoughtful, ethical, and appropriate intervention or lack of intervention must be applied.

Optimal efforts to reduce the morbidity, mortality of trauma must include specific programs for each of the three separate mortality peaks. Early deaths can best be reduced with injury prevention programs and educational outreach or legislated use of protective devices and control of dangerous behavior. Focus on the regional planning and fiscal support of trauma system development will affect the number of avoid- able deaths during the second “golden hour” mortality peak. Finally, late deaths will be diminished as research generates better understanding of the extensive physiologic processes and cell biology related to inflammation, immune dysfunction, sepsis, coagulopathy, multiple organ failure, and CNS injury and development of proven evidence-based care.

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