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Injury and Violence

Injury and Violence is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Injury, intentional or not, is often predictable and preventable.
  • Unintentional injuries are no longer considered “accidents” given that most injuries are preventable.
  • As of 2015, unintentional injury is the fourth 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 62,516 deaths in the United States in 2015 (71% suicide, 28% homicide, and 1% undetermined).

Epidemiology

Incidence
Leading Cause of Death by Age Group, United States, 2015

AgeMost CommonNumber of Deaths
<1Congenital anomalies4,825
1–44Unintentional injury52,880
45–64Malignant neoplasm159,176
65+Heart disease507,138

Source: Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS)
  • Children mostly die of unintentional injuries: (in rank order) motor vehicle accidents (MVAs), drowning, fire/burn, and suffocation.
  • MVAs are the most common type of unintentional injury deaths in adolescents, followed by firearm-associated injury deaths.
ALERT
Poisoning, which includes drug overdose, has been the leading cause of injury deaths 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.
  • All forms of violence combine to cause >1.3 million deaths worldwide, 2.5% of global mortality (World Health Organization [WHO]).
  • Since 2000, suicide has been increasing among those 10 to 74 years, especially in nonurban areas, and it is the second leading cause of death for 15 to 34 years.
  • Among leading causes of injury deaths, firearms (related suicide, homicide unintentional injury deaths combined) rank third overall, second in 10 to 44 years, third in 45 to 65+ years, and fourth in 5 to 9 years of age.
  • Homicide is the third leading cause of death in 2015 for persons between ages 1 to 4 years and 15 to 34 years in the United States.

Alert
Consider homicide as cause of unexplained death in young children.

Etiology and Pathophysiology

Multifactorial

Risk Factors

  • MVAs:
    • MVAs accounted for 36,161 deaths in 2015 with an age-adjusted rate of 10.3 deaths per 100,000 persons.
    • 2.5 million adult drivers and passengers were treated in emergency departments (EDs), and ~200,000 patients were hospitalized as a result of MVAs in 2012.
    • Young adults (20 to 24 years old) have the highest crash-related injury rates.
    • Motorcyclists are 29 times more likely to die in a motor vehicle crash than car occupants and 5 times more likely to be injured per mile traveled.
    • Risk factors for involvement in an MVA include high speed, teenage drivers, consumption of alcohol or drugs affecting the central nervous system, fatigue, distracted driving (hand-held 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 children 1 to 4 years and adolescents and young adults ages 15 to 34 years (CDC). Most common victims are young males. Firearms are used in 1 out of 2 homicides (WHO).
  • 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):
    • 23% of students are involved in fights annually; 8% of students participated in ≥1 fights at school in the last year.
    • 16% of students have carried a weapon in the last 30 days; 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 and 6% of male homicides were killed by partners.
    • Nearly 27% of women and 11% of men report having some form of IPV in their lifetime (CDC).
    • Dating violence: Of 9th- to 12th-grade students dating in the previous 12 months, 10% experienced physical violence and 11% experienced sexual violence (CDC).
    • Increased risk for female, young (12% of rapes occur prior to 12 years of age; 40% by 18 years), 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
ALERT
  • 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 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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Citation

Stephens, Mark B., et al., editors. "Injury and Violence." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116972/all/Injury_and_Violence.
Injury and Violence. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116972/all/Injury_and_Violence. Accessed March 19, 2019.
Injury and Violence. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116972/all/Injury_and_Violence
Injury and Violence [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116972/all/Injury_and_Violence.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Injury and Violence ID - 116972 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116972/all/Injury_and_Violence PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -