Introduction
When man was basking in the glory of conquering killer diseases like tuberculosis, smallpox, polio, typhoid, plague and other infective diseases that threatened to wipe out the human race in the past, cutting short the euphoria are certain modern causes of death and morbidity like injuries, HIV, etc. There is, however, one difference that these modern problems are man made and thus offers a greatest hope of conquering these. It is said that 99 percent of the accidents are man made and only 1 percent is providential.
Injuries due to trauma are on an unprecedented high across the globe more so in developing nations like India. The reasons are not far to seek. Road traffic accidents are on the rise, so are the industrial and agricultural accidents. Intolerance, hatred, and unrest have caused escalation in terrorist activities across the world leading to increased mortality and bizarre injuries that could maim and make one disabled for life. Add to this instances of assaults, falls, train, air and other accidents not to forget natural calamities like floods, quakes, etc. and war, all this lead to a plethora of injuries that could be a burden to the entire mankind. With sports and games gaining worldwide popularity, injuries due to these events are also on the rise. Suddenly injuries have gained the tag of a modern international epidemic that is ravaging young lives like never before.
Epidemiology
Injuries due to various causes could be either fatal or nonfatal. A look at the injury epidemiology could help you to understand the enormity of the situation.
Fatal Injuries
- Injuries are the 4th leading cause of death over all ages (6%).
- Between 1–44 years of age, it is the leading cause of death.
- Between 15–24 years, 8 out of every 10 deaths in young are due to injuries.
- Injuries account for more premature deaths than cancer, heart disease, or HIV.
- Fifty percent of deaths occur at the scene within minutes or en route to the hospital.
- Twenty to thirty percent dies of neurological dysfunction within several hours to 2 days post-injury.
- Ten to twenty percent dies of infection or multiple organ failure within days or weeks.
- Every year 1.9 million are hospitalized due to injury.
- Twenty seven million are treated in the emergency department.
- Injuries account for an estimated 8 percent of all hospital discharges, 37 percent of emergency department visits, and 35 percent of all emergency medical services transport.
- Nonfatal injures lead to reduced quality of life and high costs accrued to the health care system, employers and society in general.
- Persons less than 45 years account for 60 percent of all injury fatalities and hospitalization and 78 percent of all causality department visits.
- Persons more than 65 years account for 25 percent of all injury deaths and 30 percent of injury related hospitalization.
- Seventy percent of injury deaths and more than 50 percent of nonfatal injuries occur among males.
- Rate of injury deaths in male and female is 2:1.
- Rate of nonfatal injury in male: female is 1.3:1.
- But over 65 year’s male: female is 1:1.3.
The above statistics are frightening and calls for immediate attention to rein the deleterious effects of injuries on the mankind.4
Mechanism of Injury Leading to Death
Various mechanisms of injuries lead to death or nonfatal injuries. Let us try and analyze the figures.
- Twenty nine percent — are due to motor vehicle accidents.
- Eighteen percent — are due to firearm injuries.
- Eleven percent — is due to falls.
- Poisonings lead to 17 percent of all deaths.
- Thirty percent of all injury deaths are intentional.
After having identified various mechanisms of injury deaths, a look at the causes of death shows that CNS injuries and hypovolemic shock are the prime causes of deaths in fatal injuries.
Possible Causes of Death
- CNS injuries account for 40–50 percent deaths.
- Hemorrhage — 30–35 percent.
- Multiple organ failure — 5–10 percent.
Mechanism of Trauma
The three leading mechanisms of trauma are motor vehicle accidents, firearm injuries, and falls. Now let us analyze each one in detail.
Motor Vehicle Accidents (WHO Statistics)
Increased movements, crazy driving, alcohol, technology, and recklessness all have led to an increase in the motor vehicle accidents across the world. People tend to forget that motor vehicles are meant for commuting and are for their convenience and not for adventure and thus end up with increased instances of accidents (Fig. 1.1). Let us have a look at the Global and Indian scenario.
Global Scenario
- Leading cause of injury deaths.
- Second leading cause of nonfatal injury.
- Male:Female ratio in injury deaths is 2:1.
- For males aged 15–44, RTA’s rank 2nd (behind HIV and AIDS) as the leading cause of premature death worldwide.
- Causes of accidents include speed, alcohol, and poor vehicle and road conditions.
- More than 1.2 million people are killed every year in accidents.
- Three to four percent of gross national product is lost is RTA’s.
- One child is killed every 3 minutes in the world.
- Total worldwide death toll of Tsunami in 2004 is about 2,30,000.
- So, the annual death toll due to RTA’s is 5 times more than Tsunami.
- Three thousand deaths/day.
- Five hundred children/day.
- Fifty million people worldwide are injured in RTA’s every year and 15 million seriously.
- Low- and middle-income countries account for more than 85 percent of global deaths.
- Global financial cost of RTA injuries is 518 billion USD/year.
Indian Scenario
- One person dies from injury every 6–10 minutes.
- Presently more than 86,000 people die annually.
- Financial loss due to RTA’s is 12,000 crores/year.
- There are 406,730 accidents each year.
- Social cost due to road accidents is 550 crores annually.
- India accounts for 10 percent of the 1.2 million fatal accidents in the world.
- By 2050, India will have the greatest number of automobiles on the planet overtaking USA.
Now let us analyze the other mechanism of injuries.
Firearms
Liberal laws and misuse are leading to increased shoot-out deaths particularly in the Western countries. While most of them are suicides, homicides are also equally high.
Here are a few chilling statistics related to firearm injuries:
- They are responsible for 18 percent of all injury deaths and are the 2nd leading cause.
- Fifty six percent were suicides and 39 percent were homicides.
Falls
These are mainly accidental and rarely intentional. Increased construction activities, sports, and playful children and fragile elders are all more prone for injuries due to falls.
- Accounts for 11 percent of injury deaths.
- Greater than 1/3 of all injury related hospitalization.
- Under less than 5 years, falls are the leading cause of nonfatal injury, 50 percent at home (less than 4 years) and 50 percent at school (More than 4 years).
- Death from falls is less (0.6–4.7%).
- In the elderly, falls is important cause of death. Thirty four percent in greater than 65 years and 46 percent greater than 85 years.
- It accounts for 80 percent of all injury related hospitalization greater than 65 years.
Overall
Now after analyzing each mechanism of injury in greater detail, the overall global scenario due to injuries is as follows:
- Worldwide injuries account for 1 in every 10 deaths.
- Eleven percent of the global burden of disease.
- By 2020, RTA’s will rise from 9th place to 3rd place by 2020.
- Violence will rise from 19th place to the 12th place.
- Self-inflicted injuries from 17th to the 14th place.
Nonfatal Injuries
In injury-related events those who are fortunate to survive deaths or near deaths, may have to face an equally disturbing events in the form of nonfatal injuries. These could range from simple fracture, sprain, strain to major and multisystem injuries. Any possibility of single or combination injuries are possible depending upon the type and severity of accidents. Nonfatal injuries are more morbid and could prove to be an enormous burden in terms of cost and time to the patient, relative, society, country and the world at large.
Among the fatal injuries leading to deaths, motor vehicle accidents rank first. However, a study of nonfatal injuries shows a different scenario.
Mechanism of Injury
- Falls — leading cause and accounts for 1/3 cases.
- RTA’s — account for 18 percent of the hospitalizations.
- Firearm injuries — account for less than 1 percent.
- Thirty percent of all injury deaths are intentional.
- Five to fifteen percent injury hospitalizations are intentional.
Interesting Statistics of Nonfatal Injuries
- Upper and lower limb injuries leading cause of hospitalization—50 percent.
- Moderately severe and severe injuries of the extremities account for 33 percent of hospitalization.
- Primary mechanism of injury accounting for hospitalization is falls accounting for 30 percent of all upper extremity injuries and 50–60 percent of all lower limb injuries.
- RTA’s are leading to increased hospitalizations due to lower limb injuries.
- Twenty percent of all hospitalizations due to upper limb injuries are due to accidents following machinery and tools.
- Head injury hospitalization accounts for 10–15 percent and is the 2nd leading cause.
- Other leading causes are spinal cord injuries and musculoskeletal injury of the back.
- Work-related back injury accounts for 1/5th to 1/4th of all workers compensation claims.
Sports Injuries
These are the important contributors of nonfatal injuries. Due to increased popularity of major sporting events like football, tennis, cricket, basketball, swimming, etc. injuries following sport activities are on the rise (Fig. 1.2). However, deaths due to sports are far and few and are not of concern.
PREHOSPITAL CARE
To have the best choice of survival, grievously injured victims should receive top quality care from the earliest moments of the accident from the emergency medical services system. Pick and dump attitude by these personnel 6could spell disaster. Proper first aid, skillful CPR and intelligent handling and shifting of the injured victims by the paramedics or general public can make a world of difference between a certain death and a possible good recovery (Fig. 1.3). Management during the golden hour (first hour post injury) is critical. Thus, prehospital care assumes extreme importance in these backdrops. A good prehospital trauma care system can decrease the mortality due to accidents by 33 percent.
Emergency Management and Research Institute (EMRI): is the first emergency call number and organized trauma care system in India. It has well-equipped ambulances, paramedic training and care on arrival at the hospital. It is responsible for administering proper prehospital care for the injured at the scene of accident and shifting them safely and quickly to the nearest well-equipped center meant for managing these victims (Fig. 1.4).
Once the patient is stabilized by these proper prehospital trauma life support (PHTLS) program effort is made to execute definitive treatment for individual bone and joint injuries.
However, not all well with the prehospital care of the accident or injured victims. The problems being faced by the trauma care systems in India are:
- Lack of human resources
- Lack of physical resources
- Lack of organizational resources
- Lack of trauma care system.
For effective management of the injured, all the above problems need to be tackled in a war footing by the government and the public.
Prevention of Injury
Now that injury is considered a major public health problem, the adage prevention is better than cure applies to it also. However, earlier it was thought that there is no role of prevention in the case of injury-related deaths or morbidities. But now fortunately people have started realizing that preventive measures have a very important role to play in reducing the incidence of injuries due to trauma and needs to be emphasized more. The following preventive steps are suggested:
Fig. 1.4: Shifting an injured victim to the nearest well-equipped hospital is the prime responsibility of trauma care systems (EMRI in India)
- Preventive measures should be done like for any other disease.
- Requires an organized and scientific approach.
- It requires a multidisciplinary approach.
- Surgeons need to provide health education to patients (Helmet wear, Alcohol prevention).
- Research into the preventive and treatment aspects of tackling injuries also helps.
Conclusion
There is no running away from the fact that injuries have arrived in a big way in terms of deaths and nonfatal injuries across the world. It has all the features of an epidemic and needs to be tackled as such. Here are certain injury related vital issues:
- Trauma is a major public health problem.
- Primary prevention should be emphasized.
- Effective and better treatment plan is required.
- Trauma is called the neglected disease of the modern society.
- It is now the costliest medical problem in the world.
You had a brief overview of the enormity of the problem posed by injuries. Various combinations of nonfatal musculoskeletal injuries could occur. The general principles and individual treatment of these injuries will now be dealt in the ensuing chapters.