Injury and Violence

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  • Injury, intentional or not, is often predictable and preventable.
  • Unintentional injuries are no longer considered “accidents” given that most injuries are preventable.
  • As of 2016, unintentional injury is the 4th leading cause of death, and intentional self-harm is the 10th leading cause of death in the United States.
  • Injury is the leading cause of death of people aged 1 to 44 years and a leading cause of disability for people of all ages, regardless of sex, race/ethnicity, or socioeconomic status.
  • Violence-related deaths accounted for 55,693 deaths in the United States in 2016 (74% suicide, 26% homicide).


Leading Cause of Death by Age Group, United States, 2016

AgeMost CommonNumber of Deaths
<1 yCongenital anomalies4,816
1–44 yUnintentional injury61,749
45–64 yMalignant neoplasm157,655
≥65 yHeart disease507,118

Source: Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS)
  • Children mostly die of unintentional injuries: motor vehicle accidents (MVAs), drowning, fire/burn, and suffocation.
  • MVAs are the most common type of unintentional injury deaths in adolescents, followed by poisoning deaths.

    Poisoning, which includes drug overdose, has been the leading cause of injury deaths in the United States overall since 2011 and is particularly deadly for persons ages 15 to 64 years, as the leading cause of injury deaths among 25 to 64 years and the second leading cause of unintentional injury deaths for 15 to 24 years.

  • Approximately 5.8 million people worldwide die yearly secondary to injuries, of which all forms of violence combine to cause nearly 1/3 of these deaths (World Health Organization [WHO]).
  • Unintentional motor vehicle traffic deaths rank second in the United States for overall injury deaths, first in those aged 5 to 24 years and second in those aged 1 to 4 years and 25 to >65 years.
  • Among leading causes of injury deaths in the United States, firearms (related suicide and homicide deaths combined) rank third overall.
  • Homicide is the third leading cause of death in 2016 for persons 15 to 34 years in the United States.

    Consider homicide as cause of unexplained death in young children.

Etiology and Pathophysiology


Risk Factors

  • MVAs:
    • MVAs accounted for 40,528 deaths in 2016 with an age-adjusted rate of 12.2 deaths per 100,000 persons.
    • >2.5 million adult drivers and passengers were treated in emergency departments (EDs) in 2015.
    • Young adults (20 to 24 years old) have the highest crash-related injury rates.
    • In the United States, 1 in 3 deaths involved drunk driving and almost 1 in 3 deaths involved implicated speeding.
    • Motorcyclists are more likely to die in a motor vehicle crash than car occupants. The risk of death is reduced by 37% with helmets.
    • Risk factors for involvement in an MVA include high speed, teenage drivers, consumption of alcohol or drugs affecting the central nervous system, fatigue, and distracted driving (handheld mobile phones and inadequate visibility).
    • Increased risk of death by MVA: male driver, inexperience, nighttime driving, speeding, tailgating, driving with other teenagers, cell phone use, unrestrained occupants, use of older cars, nonuse of crash helmets, alcohol, and drug use. In elderly, poor vision, medical conditions, and comorbidities increase risk of death by an MVA (CDC, National Center for Injury Prevention and Control [NCIPC], and WHO).
  • Pedestrians:
    • 5,376 pedestrians were killed by motor vehicles and nearly 129,000 were treated in EDs for nonfatal injuries (2015; CDC, NCIPC).
  • Bicycles (WHO):
    • Risk of death from crash with motor vehicle increases if speed >30 km/hr (~18 mph) and if there is impact with front of vehicle.
    • Risk factors for cyclist injury include alcohol consumption, shared use motorways, poor visibility, lack of understanding of road safety, and design/type of impacting vehicle.
  • Sports- and recreation-related injury (CDC):
    • >2.6 million children (0 to 19 years) treated in EDs each year; males, deconditioned adults, and athletes playing collision or contact sports are at also increased risk.
  • Drowning: a leading cause of unintentional injury death among all children, particularly 1 to 4 years of age; children at increased risk include African Americans and those unattended in bathtubs, swimming pools, and recreational water activities (CDC, NCIPC).
  • Suffocation: increased risk for children <1 year, unsafe sleeping environments (CDC)
  • Falls (CDC, NCIPC):
    • The leading cause of nonfatal injuries and most common cause of traumatic brain injuries (TBIs)
    • Poor vision, psychotropic medications and diuretics, arthritis, impaired mobility, inappropriate footwear and walking aids, cognitive impairment, gait imbalance, environmental risk factors (1)
  • Violence: risk factors: adverse childhood exposures (ACEs); lack of access to social capital, community organization, and economic resources; familial instability; community and family violence; access to firearms; mental health; personal or household member alcohol and drug use; exposure to suicidal behavior; history of aggressive behavior; cognitive deficits; poor supervision; poor peer-to-peer interaction; academic failure; poverty; lower socioeconomic class (CDC)
  • Homicide: third leading cause of death for persons aged 15 to 34 years in the United States (CDC). Most common victims are young males. Firearms are used in more than half of U.S. homicides.
  • Suicide: Females are more likely to have suicidal thoughts, but males are 4 times more likely to complete suicide. Most common methods are firearms for males and poisoning for females (CDC, NCIPC).
  • Adolescent violence (CDC):
    • In 2015, nearly 8% of students participated in ࣙ1 fights at school in the last year.
    • >5% of high schoolers reported not going to school on ≥1 day(s) in the last 30 days because they felt unsafe at school or on their way to school.
    • 4% of students have carried a weapon to school; 6% of students have been threatened or injured by a weapon at school.
  • Bullying (CDC):
    • 20% of 9th- to 12th-grade students bullied on school property in the last year
    • 15% of students report cyberbullying.
    • Bullying is associated with social, emotional, and academic difficulties.
  • Interpersonal and intimate partner violence (IPV):
    • WHO reports about 38% of female homicides were killed by partners, similar to CDC reports of 40% of female homicide victims.
    • In their lifetime, approximately 8.5 million women and >4 million men report physical violence, rape, or stalking from an intimate partner many before the age of 18 years (CDC).
    • Dating violence: Of high school students who dated in the previous 12 months, 12% of girls and 7% of boys experienced physical violence, and 16% of girls and 5% of boys experienced sexual violence (CDC).
    • Increased risk for female, history of IPV or sexual assault or child abuse, alcohol or drugs, marital difficulties, unemployment, emotional or mental health problems, income or educational disparity, poverty

      Poisonings (CDC):

  • The United States’ epidemic of drug overdoses (poisonings) includes more than half a million deaths from 2000 to 2015, mainly from opioids (>6 out of 10, ~91 deaths per day).
  • Since 1999, prescription opioids sold in the United States have almost quadrupled, and deaths from prescription opioids have more than quadrupled.
  • >33,000 people died from opioid overdoses in 2015; a 15% increase in opioid-death rates from 2014 to 2015 is likely due to illicit opioids, including synthetic opioids (72%) such as fentanyl and fentanyl analogs and heroin (20%).
  • Overlapping prescriptions of pain relievers or other sedating drugs; high doses, history of mental illness or substance abuse, uninsured or Medicaid, low income increase risk for overdose deaths.
  • Consider opioid-induced poisonings in unexplained altered mental status.

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