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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
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1 - .
A Continuing
Public Head Prob~rn
