Injury and Violence– Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Falls, motor vehicle accidents (MVA), homicide, suicide, domestic violence, child abuse, and poisonings are some of the common avoidable causes of death in society. In industrialized countries, injury is the 5th leading cause of death overall and the leading cause of death for persons 1–14 years, accounting for 40% of all child death. In the US yearly, 50 million are injured severely enough to require medical care, which may account for 10% of total US health care costs. Regardless of whether intentional or unintentional, injury is both predictable and preventable (1).
- Older adults and children are most susceptible to injuries. In the young as many as 75% of all deaths are caused by injuries and violence. Yearly, 1 in 3 adults aged >65 have falls. In women from 2004–2007, 54% of injuries occurred inside or near the home compared to 41% in men. Men acquired injuries more frequently in recreational environments and occupational settings.
- Injury classification schemes (1)[C]
- Body location (presenting to ED): Upper extremity 11.3%, lower extremity 4.3%, and face 4.1%
- Severity: High case fatality rates with firearm violence
- Mechanism/intentionality: 63% unintentional, 34% intentional injury deaths in the US each year
- Most common injuries (CDC data, 2007) (2)[A]:
- Falling is the most common injury in the young (43% of injuries) and elderly (64%) with blunt trauma coming in second, while blunt trauma (20%) and overexertion (13%) are the most common injuries in adolescents and adults respectively. Bites/stings (4.8%), bicycle accidents (4.7%), and poisonings (1.8%) are uniquely common to children while MVA become a consideration in adolescents and adults (10%; 3rd most common) as well as elderly (5%; 4th most common). The incidence of penetrating injury (8.1%) and blunt trauma/assault (4.9%) peaks as an adult, although the absolute numbers have decreased since 2006.
- Most common fatal injuries (CDC data, 2006) (2)[A]:
- MVA cause the most deaths of any injury in children, adolescents, and adults, coming in a close second in infants and the elderly superseded by unintentional suffocation and falls, respectively. Children die mostly of unintentional accidents; in order: MVA, drowning, fire/burn, and suffocation. Aside from MVA, most deaths in adolescents result from firearms, both homicide (2nd, 4th in adults) and suicide (3rd, 3rd in adults). Suicide by suffocation is also pervasive in both adolescence (4th) and adulthood (5th). Poisoning is particularly deadly in adults with both unintentional (2nd) and suicidal (6th) combined causing more deaths than MVA. Homicide from firearm is 4th in children, 2nd in adolescents, 4th in adults, while suicide by firearm is 3rd in adolescents and adults, 4th in the elderly. It should be noted: Watch for homicide in infants (3rd) and adverse drug effects in the elderly. Most firearm deaths are homicides in children and adolescents, suicides in adults and the elderly. Other common forms of suicide are suffocation, poisoning. Other common forms of homicide in adolescence (4th) and adults (5th) are penetrating injuries.
- Firearms (1)[C]
- In 2001, 35% of adults reported living in a home with at least 1 firearm
- Gun violence accounts for $100 billion of which $15 billion represented firearm injuries to children
- There has been recent decline in violent deaths and firearm injuries.
- Child violence (1)
- Homicide death rate for children are highest in US as compared to other industrialized nations.
- 33% of rapes occur prior to 12 years of age; 50% by 18 years.
- Adolescent violence (3)[B]:
- 33% of students are involved in fights annually; 12.8% of students participated in 1 or more fights at school in the last year.
- 17.1% of students have carried a weapon in the last 30 days; 6.1% of students have carried a weapon to school.
- 9.2% of students have been injured by a weapon at school.
- 5,674 aged 10–24 were murdered, or 16 per day, in 2007.
- 5.4% of students have missed 1 or more days of school due to fear of harm from violence.
- 16–19-year-olds are at highest risk for motor vehicle crashes, boys twice that of girls (1)[C].
- Dating violence: Prevalence of teen dating violence has been reported to range from 9%–46% (4)[C].
- Homicide (4)[C]
- 2nd leading cause of death for children 1–19 years of age
- Leading cause of death amongst black 15–24-year-olds
- 3% of direct medical expenses are related to assault.
- Bullying (4)[C]
- Prevalence 30% for children either bullying and/or being bullied in 6th- to 10th-graders
- Bullying is associated with low self-esteem, social isolation, and depression.
- 1 in 9 middle school students report being cyber-bullied (via the Internet). As many as 1/2 of victims don’t know the perpetrator’s identity.
- Interpersonal violence (IPV) (5)[C]
- 1 in 4 women and 1 in 7 men report a lifetime threatened or completed physical or sexual IPV.
- 1.4% of women and 0.7% of men reported such victimization within the past year.
- When IPV is defined more broadly, estimates approach 1 in 5 adults.
- Youth are affected disproportionately accounting for ∼30% of potential life years lost before age 65 (more than cancer and heart disease combined) (1)[C].
- 37.3% of all ED visits are injury-related (1)[C].
- Motor vehicle crashes: (3)[C]
- 3 in 10 people are involved in an alcohol-related motor vehicle crash in their lifetime. 1 in 4 teens killed in a motor vehicle crashes (2008) had a blood alcohol level >0.08 g/dl.
- 18% of high school students do not wear seatbelts. Teens are more likely to speed and to underestimate driving risks.
- 86% of youth under the age of 14 wear seatbelts; yet, 65% of these wear restraints that are inappropriate for their age or weight.
- Contribution of motor vehicle crashes and falls to lifetime medical costs of injury: 40%
- 86% of individuals who died from drowning were not wearing personal flotation devices.
- Injuries and risk factors that contribute vary at different stages of life and development (3):
- Infants, toddlers, and children (ages 0–9):
- MVA: Unrestrained or improperly restrained. Only 37% of children are restrained in age-appropriate devices; of children killed in MVA, 68% are killed while riding with a driver under the influence of alcohol.
- All-terrain vehicle (ATV): Age, weight of the child vs weight of ATV, nonhelmeted rider, lack of legislation and enforcement
- Suffocation (children <1 year old): Loose bedding, wedging, cosleeping, entrapment, hanging, sleeping in environments not intended for infants (couches, adult bed)
- Drowning: Males, inadequate supervision, residential swimming pools
- Falls: Walkers, open windows, open stairways, inadequate supervision, hazardous playground equipment
- Homicides: Lack of access to social capital, community organization, and economic resources, familial instability, community and family violence, access to firearms
- Adolescents (ages 10–24):
- MVA: Male driver, inexperience, nighttime driving, speeding, tailgating, driving with other teenagers, cell phones, unrestrained occupants, alcohol and drug use
- Homicide and suicide: Access to firearms, mental health, alcohol and drug use, exposure to suicidal behavior, history of aggressive behavior, cognitive deficits, poor supervision, exposure to violence, parental drug and alcohol use, poor peer-to-peer interaction, academic failure, poverty, lower socioeconomic class
- Sports-related injuries
- Adults (ages 25–64):
- MVA: Alcohol and drug use, speeding, distractions (e.g., other passengers, cell phones)
- Prescription drug overdose is leading cause of accidental death in adults.
- Homicide and suicide: See adolescent risk factors
- Infants, toddlers, and children (ages 0–9):
- IPV (5)[C]:
- Risk factors: Female, young, history of IPV or sexual assault or child abuse, drugs, unemployment, depression, minority status, income or educational disparity, poverty, weak legal sanctions
- Older adults (≥65):
- MVA: Poor vision, medical condition, and comorbidities
- Falls: Poor vision, medications, weakness, gait imbalance, environmental risk factors (loose rugs, poor lighting, lack of stair railings)
- In addition, individuals from low-income and racial and ethnic minority groups are at a greater risk for injury. Factors contributing to the increased risk in this population include (6):
- Lower income and education, hazardous and overcrowded living environments, children lack safe recreational facilities and play areas, increased drug activity and violence, access to firearms, limited organized athletics or extracurricular activities, less access to affordable childcare, proximity of housing to busy streets, increased exposure to physical hazards
Multifactorial. Popular model used in the field of injury prevention was designed by Dr. William Haddon. Defines 3 phases of an event: pre, during, and post. Events are then charted against the contributing factors: host, agent (e.g., motor vehicle), and the physical environment to illustrate how they are interrelated. Information is then used to identify specific risk factors and develop injury prevention strategies.
- Mechanism, timing, and location of injury:
- Blunt vs. penetrating; intentional vs. unintentional; others injured vs. isolated injury; circumstances (weather, substance use, restrained vs. unrestrained)
- Does history correlate with level of injury (i.e., level of suspicion for abuse [elderly, child, or partner])?
- Level of prehospital care, preexisting medical conditions, medications
- Prevention: Experts agree that most injuries are preventable. Prevention efforts have been framed as “the 5 E’s”: enhanced Education, Engineering strategies, Economic incentives, Enactment of legislation, and Enforcement of laws.
- Prevention by level of intervention: Primary (i.e., prevent crash–listed below by etiology), Secondary (i.e., prevent injury upon crash), and Tertiary (i.e., prevent poor outcomes upon injury).
- Motor vehicle injuries (3)[C]:
- Infants, toddlers, and children: Age-appropriate child safety seats and passenger restraints, child safety seat distribution programs, education programs for parents and caregivers, safety seat checkpoints, harsh penalties for drivers transporting children under the influence of drugs and/or alcohol, legislation regarding restraint of motor vehicle occupants
- Adolescents and adults: Graduated driver licensing programs, blood alcohol concentration laws, minimum drinking age laws, sobriety checkpoints, programs for alcohol servers, zero alcohol tolerance laws for young drivers, school-based education programs on drinking and driving. Emergency medical services (EMS) response times, engineering cars for rapid extraction, organized trauma systems; collapsible automobile steering columns have been shown to decrease injury mortality and morbidity. With a motorcycle helmet: 29% decreased risk for death and 67% decreased risk for traumatic brain injury (1).
- Older adults: Alternative transportation programs, screening for high-risk drivers, gradual curtailment of driving privileges, more frequent license renewal process
- Falls (3)[C]:
- Infants and toddlers: Home safety assessments, window guards, and elimination of walker use
- Older adults: Home safety assessments, installation of handrails and grab bars, removal of tripping hazards, nonslip mats, exercise programs designed to improve strength and balance, night lights
- Drowning (3)[C]:
- Improved care provider supervision of young children; trained lifeguard supervision at public and open swimming locations; clearly demarcated swimming areas at open water locations; fencing, locked gates, and pool alarms for residential swimming pools; personal flotation devices and boating safety awareness; parental certification in cardiopulmonary resuscitation (CPR)
- Fire and burns (7)[C]:
- Reducing temperature of hot water heaters to <54.4°C (130.1°F)
- Smoke and carbon monoxide detectors
- Fire exit planning
- Educational campaigns directed toward populations and communities at highest risk for home fires (homes with children <4, adults >65, lower socioeconomic class, rural communities)
- Pedestrian injuries (3)[C]:
- Environmental modifications (sidewalks, lighted intersections and walkways), strict speed laws, reflective clothing
- Violence (homicide, suicide, assaults) (8)[C]:
- Most effective strategies are those focused on younger age groups that focus on key areas of youth development and adjustment, including positive sense of self; emotional and behavioral regulation; decision-making skills; moral system of belief; and presence of a positive connection with family, community, and environment.
- Limited access to firearms and/or firearm safety training
- Suicide: Access to mental health services, improved family and community support, development of healthy coping and problem-solving skills
- Dating violence: 1 RCT of a school program was shown to be effective in decreasing self-reported dating violence 4 years out from the intervention (4)
- Sports-related injuries (3)[C]:
- Toolkits providing educational material regarding sports-related injuries have been developed by the CDC for coaches, athletic directors, and parents.
- Proper use of sport gear and equipment. Helmets can prevent 85% of bicyclist head injuries. States without helmet laws have doubled fatality rate from head injuries (1).
- Plan of action for dealing with injuries such as concussion in young athletes, which include strict guidelines regarding if or when it is safe to return to play.
- Poisoning (1)[C]:
- High rates in children: Call poison center hotline immediately after ingestion of toxin (90% occur at home)
Financial and societal costs:
- Injury-related medical expenditures estimates in the US range from $224–$406 billion annually (1)
- Social burden of injury: Loss of productivity, emotional loss, nonmedical expenditures, reduced quality of life, litigation, rehabilitation, mental health costs, altered family and peer relationships, chronic pain, substance use and abuse, changes in lifestyle (2)
1. Betz M, Li G. Injury prevention and control. Emerg Med Clin N Am. 2007;25:901–914.
2. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed 09/20/2010 at:http://www.cdc.gov/ncipc/wisqars.
3. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. CDC Injury Fact Book. Atlanta: Author, 2006.
4. Committee on Injury, Violence, and Poison Prevention et al. Policy statement–Role of the pediatrician in youth violence prevention. Pediatrics. 2009;124:393–402.
5. Zolotor AJ, Denham AC, Weil A et al. Intimate partner violence. Obstet Gynecol Clin North Am. 2009;36:847–60, xi
6. Fallat ME, et al. The impact of disparities in pediatric trauma on injury prevention initiatives. J Trauma Injury Crit Care. 2006;60(2):452–4.
7. Schnitzer PG. Prevention of unintentional childhood injuries. Am Fam Physician. 2006;74:1864–9.
8. Sullivan TN, Farrell AD, Bettencourt AF, et al. Core competencies and the prevention of youth violence. New Dir Child Adolesc Dev. 2008;2008:33–46.
Guralnick S, Serwint JR. Firearms. Pediatr Rev. 2007;28:396–7.
- Injury is the number 1 source of years of productive life lost for individuals <44 years of age.
- Injuries are both predictable and preventable.