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1~ Herr 1 ~ A Continuing Public Heath Prob~rn Committee on Trauma Research Co~Tunission on life Sciences Nabonal Research Council and the InsHtute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1985

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National Academy Press 2101 Constitution Avenue, NW Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineenng, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to Drocedures aDDroved bv a Recort Review Committee consisting of members of the r ~ ~ r ~ r ~ -- - ~ National Academy of Sciences, the National Academy of Engineenng, and the institute of Medicine. The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of advising the federal government. The Council operates in accordance with general policies determined by the Academy under the authority of its congressional charter of 1863, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Council has become the pnnapal operating agency of both the National Academy of Sciences and the National Academy of Engineenog in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the lostitute of Mediane. The National Academy of Engineenng and the institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. The institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of medical and other professions for the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 Congressional charter responsibility to be an advisor to the federal government and its own irubative in ident~ng issues of medical care, research, and education. This report was prepared under Contract No. DINH22-84 C~781 with the National Academy of Sciences and the Deparunent of Transportation. Library of Congress Catalog Card Number 85~0999 international Standard Book Number 0-309~354~7 Printed in the United States of America First Pnndug, Mby 1985 Second Printing, October 1985 Third Printing, April 1986 Fourth Pnnting, March 1987 Finds Pnnting, March 1988 Sixth Pnnung, May 1989 Seventh Printing, August 1989 Eighth Pnnung, November 1989 Ninth Printing, February 1991 Tends Printing, January 1992

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Committee on Trauma Research WILLIAM H. FORGE, Chairman, Centers for Disease Control, Atlanta, G. eorgla SUSAN P. BAKER, Vice-Chairman, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland JOHN H. DAVIS, The University of Vermont College of Medicine, Burlington, Vermont PARK E. DIED, Schools of Law and Medicine, University of Virginia, Charlottesville, Virginia DONALD 5. GANN, Brown University, Rhode Island Hospital, Providence, Rhode Island ALBERT I. DING, Bioengineenng Center, Wayne State University, Detroit, Michigan ROBERT R. McMEEK~N, Armed Forces Institute of Pathology, Washington, D.C. JOHN F. MULLAN', University of Chicago Medical Center, Chicago, Illinois BRIAN ON, Insurance Institute for Highway Safety, Washington, D.C. JAMES B. RESWICK, Veterans' Administration Medical Center, Washington, D.C. LEON S. ROBERTSON, Yale University School of Medicine, New Haven, Connecticut RICHARD G. SNYDER, University of Michigan, Ann Arbor, Michigan WILLIAM A. SPENCER,. The Institute for Rehabilitation and Research, Houston, Texas C. THOMAS THOMPSON, Surgical Associates, Tulsa, Oklahoma DAVID C. VIANO, General Motors Research Laboratories, Warren, Michigan JULLAN A. WAILER, The University of Vermont College of Medicine, Burlington, Vermont Staff RICHARD D. THOMAS, Project Director ANDREW M. POPE, Staff Officer LESI`{E GIESE, Associate Staff Officer NORMAN GROSSBLArr, Editor . . . 111

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Preface Throughout history, the two major causes of early death have been infectious disease and injury. For most of the world, they continue to be the major determinants of longevity. In the developed countnes, inroads have been made in the battle against infectious disease, but injury continues to take its toll relentless, unexpected by those in- volved, and yet often avoidable and unnecessary. Injury is the principal public health problem in America today; it affects primarily the young and will touch one of every three A~ner- icans this year. B'ut injury is a problem that can be diminished con- siderably if adequate attention and support are directed to it. Exciting opportunities to understand and prevent injures and to reduce their effects are at hand. The alternative is the continued loss of health and life to predictable, preventable, and modifiable injures. In 1966, a landmark National Research Council report, Accidental Death and Disability: The Neglected Disease of Modern Society, documented how little progress had been made in either explicating the scientific aspects of injury control or applying what was known. More than 2.5 million Americans have died from injures since that report was issued. In 1983, Congress enacted a law authorizing the secretary of the Department of Transportation to request a study on trauma (injury) by the National Academy of Sciences, to deternune what is known about injurer, what research should be done to learn more, and what arrange- ments the federal government could use to increase and improve the knowledge of injury. In response to that authorization, the Committee on Trauma Research, in the National Research Council's Commission on Life Sciences, was established in collaboration with the Institute of Medicine. This report, the result of the committee's deliberations, reviews the progress that has been made in injury control in recent years and id'endfies future research needs. The committee believes that injury is a public health problem whose toll is unacceptable. The time has come for the nation to address this problem a problem that affects ah Americans and one on which an investment in research could yield an unprecedented public health return. WILLIAM H. FOEGE Chairman v

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:L Acknowledgments The following colleagues in both the public and pirate sectors generously shared information, resource material, and expertise: Eula gingham, Em~lie Black, Gregory Dahlberg, Ench Daub, Rolf Eppinger, James Fletcher, Michael Finkelstein, Charles Miller, Thomas Morris, Stephen Nelson, Gary Noble, Ayub Ommaya, David Rall, Lawrence Rose, Bernard Schriever, Gordon Smith, Michael Stoto, Stephen Teret, and Donald Trunkey. The committee notes with regret the passing of William Haddon, a pioneer in the field of injury control with long-time interest in the subject of this report. V1

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Contents EXECUTIVE SUMMARY 1 INJURY: MAGNITUDE AND CHARACTERISTICS OF THE PROBLEM ................................. 2 EPIDEMIOLOGY OF INJURIES: THE NEED FOR MORE A DE Q U ATE D ATA ........................ Human Factors in Injury Causation, 26 Product, Vehicle, and Environmental Factors, 28 Elements of an Injury Surveillance System, 29 Existing Injury Surveillance Systems and Their Limitations, 30 Epidemiologic Uses of Injury Data, 33 Recommendations, 36 PREVEbTrIO N OF INJURY .................. General Approaches to Injury Prevention, 37 Prevention of Specific Types of Injury, 41 Status of Injury-Prevention Programs and Research, 45 Recommendations, 46 4 INJURY BIOMECHANICS AND THE PREVENTION OF IMPACTr INJURY ~ em en State of Injury Biomechanics Research, 48 Mechanisms of Injury, 49 Research Needs, 53 Conclusions, 57 Recommendations, 62 TREATMENT .... Prehospital Care, 65 Hospital Care, 67 Charactenstics of Injuries That Require Treatment, 69 Conclusions, 72 Recommendations, 73 . . . . V11 .. 18 .. 25 37 48 . 65

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6 REHABILITATION.......... Research Issues and Needs, 84 Conclusions, 91 Recommendations, 92 7 CURRENT FEDERAL EXPENDITURES FOR INJURY-RELATED RESEARCH ....... 8 ADMINISTRATION OF INJURY RESEARCH Criteria for Organizing Injury Research, 110 Function of a Federal Center to Administer Injury Research, 111 Location of a Federal Center to Administer Injury Research, 112 Conclusions and Recommendations, 115 ....... 80 ...... 99 109 REFERENCES 119 APPENDIX A Recommendations for an Injury Research and Training Agenda APPENDIX B Committee Biographies INDEX Xtlll ..... 139 149 . 155

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List of Tables and Figures TABLES Major Categories of injury Deaths in 1982 in the United States. 23 Examples of Data Needs for Injury Surveillance. 30 4-1 Summary of Known and Needed Information Regarding Injurv Mechanisms. 58-60 5-1 Summary of Known and Needed Information Regarding Treatment for Injurv. 74-79 6-1 Status of and Deficits in Rehabilitation-Related Research. 94-98 7-1 Federal Support for Research on Injurv Epidemiology in Fiscal 1983. 101 7-2 Federal Support for Research on Injury Prevention in Fiscal 1983. 103 Federal Support for Research on Injurv Mechanisms and Biomechanics in Fiscal 1983. 104 7~ Federal Support for Research on Acute Care of the Injured in Fiscal 1983. 105 Federal Support for Research on Long-Term Care and Rehabilitation of the Injured in Fiscal 1983. 106 FIGURES 1-1 Percentages of deaths from injury and other causes in the United States in 1980, by age. 19 1-2 Percentages of years of potential life lost to injury, cancer, heart disease, and other diseases before age 65. 20 4-1 Three principal mechanisms of impact injury. 50 ~2 Stretch of vessel can tear tissue (partial tear shown) with loss or containment of blood. Opposing forces across vessel can cause shear injury (complete tear shown) with or without loss of blood. 51 Vessels beneath skin can be torn by stretch or shear without laceration of skin, resulting in bruise, or contusion. 53 7-1 Preretirement years of life lost annually and federal research expenditures for major causes of death in the United States. 108 ~1 Suggested location and organizational structure of proposed Center for Injury Control. 117 1X

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011 l U 11' or ~ 1 - . A Continuing Public Head Prob~rn