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Injury and Violence
Jonathan R. Ballard, MD, MPH, MPhil
image BASICS
  • Injury, intentional or not, is considered predictable and preventable (1).
  • Unintentional injuries are no longer considered “accidents” given that injuries are preventable (1).
  • Unintentional injury is the fifth leading cause of death and intentional self-harm is the 10th leading cause of death in 2010 in the United States (2).
  • 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 (1).
  • Violence-related deaths account for 54,103 deaths in the United States in 2009 (3) with 61% suicide, 25% homicide, and 14% deaths of undetermined intent (4).

Leading Cause of Death by Age Group, United States, 2011 (5)


Most Common

Number of Deaths


Congenital anomalies



Unintentional injury



Malignant neoplasm



Heart disease


  • Children mostly die of unintentional injuries: (in order) motor vehicle accidents (MVAs), fire/burn, drowning, and suffocation (6)
  • MVAs are the most common type of unintentional injury in adolescents, followed by firearm-associated injuries (7).
  • Suicide is the second leading cause of death for adolescents and young adults age 15 to 34 years (5).
  • Poisoning is particularly deadly for young adults ages 15 to 59 years for whom it is the leading cause of unintentional home injury deaths (6).
  • Unintentional death by firearm is fourth common cause of death in children ages 5 to 14 years, third common cause for adolescents and adults ages 15 to 29 years (6).
  • Homicide is the third leading cause of death in 2011 for persons between ages 1 to 4 and 15 to 34 in the United States (5).
  • Watch for homicide as cause of unexplained death in young children.
  • MVAs:
    • MVAs account for 35,303 deaths in 2010 in the United States, with an age-adjusted rate of 11 deaths per 100,000 persons (3).
    • More than 2.3 million adult drivers and passengers were treated in emergency departments from MVAs in 2009 (8).
    • Young adults (18 to 24 years old) have the highest crash-related injury rates of all adults (8).
    • Motorcyclists are found to be 37 times more likely to die in a motor vehicle crash than passenger car occupants and 9 times more likely to be injured (9).
    • Risk factors for involvement in an MVA include high speed, teenage drivers, alcohol consumption, distracted driving including hand-held mobile phones and inadequate visibility (10).
    • Risk of death by an MVA increases with male driver, inexperience, nighttime driving, speeding, tailgating, driving with other teenagers, cell phones, unrestrained occupants, use of older cars, nonuse of crash helmets, alcohol, and drug use. In elderly—poor vision, medical conditions, and comorbidities increases risk of death by an MVA (8,10).
  • Pedestrians:
    • 4,280 pedestrians were killed by motor vehicles in 2010 and about 70,000 were injured in 2010 (8).
    • Pedestrians are 1.5 more times likely than passenger vehicle occupants to be killed in a car crash on each trip (8).
  • Bicycles:
    • Risk of death increased from crash with motor vehicle if speed >30 km/hr (˜18 mph) and cyclist impact with front of vehicle (10).
    • 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 (10).
  • Suffocation: increased risk for children <1 year, unsafe sleeping environments (11)
  • Drowning: increased risk for African American children, unattended children in bathtubs, access to swimming pools, and recreational water activities (11)
  • Homicide:
    • Third leading cause of death for children 1 to 4 years and adolescents and young adults ages 15 to 34 years (5).
    • Lack of access to social capital, community organization, and economic resources; familial instability; community and family violence; access to firearms (4)
    • 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 (4)
  • Adolescent violence:
    • 33% of students are involved in fights annually; 13% of students participated in ≥1 fights at school in the last year (11).
    • 17% of students have carried a weapon in the last 30 days; 6.1% of students have carried a weapon to school; 9% of students have been injured by a weapon at school (11).
  • Injury (sports-related):
    • High school athletes are at increased risk (12).
    • High school students sustained 1.2 million injuries during the 2008 to 2009 school year (12).
  • Bullying:
    • Prevalence is 30% for children either bullying and/or being bullied in 6th to 10th graders (13)
    • Bullying associated with low self-esteem, social isolation, and depression (13)
    • 1:9 middle school students report being cyberbullied (via the Internet or cell phones); ˜50% of victims don't know perpetrator's identity (13).
  • Interpersonal violence (IPV):
    • 40-70% of female homicides killed by boyfriends or husbands (14)
    • Nearly 31% of women and 26% of men report having some form of IPV in their lifetime (14).
    • Dating violence: Prevalence has been reported to range from 9% to 46% (14).
    • Female, young (33% of rapes occur prior to 12 years of age; 50% by 18 years), history of IPV or sexual assault or child abuse, drugs, marital difficulties, unemployment, depression, minority status, income or educational disparity, poverty, weak legal sanctions (14)
  • Falls: poor vision, psychotropic medications and diuretics, arthritis, impaired mobility, inappropriate footwear and walking aids, cognitive impairment, gait imbalance, environmental risk factors (9)
  • Poisonings:
    • Poisonings are the second leading cause of unintentional home injury deaths for ages 15 to 59 years (6).
    • Prescription drug overdose is a leading cause of accidental death in adults (6).
    • A significant increase in opioid-associated deaths has occurred from 2000 to 2008 (6).
    • Combined use of other sedating drugs (6)
    • Watch for opioid-induced poisonings in unexplained altered mental status.
  • Prevention: The primary focus for reducing injury and violence is specific individually tailored preventive measures based on risk factors and populationlevel prevention (1). Prevention efforts have been framed as “the 5 E's”: enhanced education, engineering strategies, economic incentives, and enforcement/enactment of laws (1,9)[C].
  • Prevention by level of intervention: primary (i.e., prevent crash), secondary (i.e., prevent injury upon crash), and tertiary (i.e., prevent poor outcomes upon injury) (1,9)[C]
  • Acute setting: Follow Basic Life Support (BLS), Advanced Trauma Life Support (ATLS), Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS) guidelines (1,16)[A].
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  • Motor vehicle injuries:
    • Infants, toddlers, and children: age-appropriate child safety seats and passenger restraints with 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 (9)[A]
    • 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 (9)[B].
    • Older adults: alternative transportation programs, screening for high-risk drivers, gradual curtailment of driving privileges, more frequent license renewal process (9)[B]
    • Bicycle helmets can reduce risk of head injury by 63-88%. Canadian helmet legislation decreased mortality by 52% (9)[B].
    • Pedestrian injury: pedestrian safety education, reflective clothing, use of crosswalks, limit mobile phone use while crossing roads (9)[B]. Street lighting for pedestrians (9)[A]. Fluorescent clothing for pedestrians and cyclists (9)[A]
    • Cyclists injury: flashing lights and reflectors at night (9)[B]. Helmet use (9)[A]. Cyclists separation to motor vehicles (9)[B]
  • Falls:
    • Home safety assessments, installation of handrails and grab bars, removal of tripping hazards, nonslip mats, exercise programs such as Tai Chi to improve strength and balance, night lights, cataract surgery, gradual withdrawal of psychotropic medication (9)[B]
    • In May 2012, USPSTF recommended exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls (15)[B].
    • The USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small (15)[C].
  • Drowning:
    • Improved supervision of young children, especially for those with epilepsy. Swimming lessons in those >4 years old, trained lifeguard supervision, fencing, locked gates and pool alarms, no use of alcohol in recreation aquatic activities, personal floatation devices, and boating safety awareness; parental and caregiver certification in CPR (9)[B]
  • Violence (homicide, suicide, assaults):
    • Primary prevention: Most effective strategies focus on younger age groups to change individual attitudes and risk-taking behaviors (9)[C].
    • Secondary prevention: Detect and identify violence in early stages (9)[B]. The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services (15)[B].
    • Tertiary prevention: IPV reduced by alcoholism treatment for partner, intense advocacy interventions of >12 hours (9)[A]
    • Suicide: access to mental health services, improved family and community support, development of healthy coping and problem-solving skills
    • USPSTF recommends screening adults for depression when depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up (15)[B].
    • Dating violence: self-reported dating violence reduced by school and community-based programs for prevention of dating violence (9)[A]
  • Sports-related injuries:
    • Proper equipment. Helmets can prevent bicyclist head injuries and mortality (9)[A].
    • Plan of action for dealing with concussion and head injury in young athletes, with guidelines regarding if or when it is safe to return to play (17)[B].
  • Poisonings:
    • Follow acute care guidelines. Contact Poison Control Center hotline immediately after discovered ingestion of toxin for recommendations (18)[A].
1. Sleet DA, Dahlberg LL, Basavaraju SV, et al. Injury prevention, violence prevention, and trauma care: building the scientific base. MMWR Surveill Summ. 2011;60(Suppl 4):78-85.
2. Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61(4):1-117.
3. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Webbased Injury Statistics Query and Reporting System (WISQARS). http://www.cdc.gov/injury/wisqars.
4. Centers for Disease Control and Prevention. Division of Violence Prevention Annual Report 2011. http://www.cdc.gov/violenceprevention/pdf/dvp_annualreport_2011.pdf.
5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Leading Causes of Death 2011. http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2011-a.pdf.
6. Mack KA, Rudd RA, Mickalide AD, et al. Fatal unintentional injuries in the home in the U.S., 2000-2008. Am J Prev Med. 2013;44(3):239-246.
7. Centers for Disease Control and Prevention. National Suicide Statistics at a Glance. www.cdc.gov/ViolencePrevention/suicide/statistics/index.html.
8. Centers for Disease Control and Prevention. Injury Prevention and Control: Motor Vehicle Safety. http://www.cdc.gov/Motorvehiclesafety.
9. Curry P, Ramaiah R, Vavilala MS. Current trends and update on injury prevention. Int J Crit Illn Inj Sci. 2011;1(1):57-65.
10. World Health Organization. World Report on Road Traffic Injury and Prevention. Geneva, Switzerland: World Health Organization; 2004. http://whqlibdoc.who.int/publications/2004/9241562609.pdf?ua=1.
11. Committee on Injury, Violence, and Poison Prevention. Policy statement—role of the pediatrician in youth violence prevention. Pediatrics. 2009;124(1):393-402.
12. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. National Action Plan for Child Injury Prevention. Atlanta, GA: CDC, NICP; 2012. www.cdc.gov/safechild/pdf/National_Action_Plan_for_Child_Injury_Prevention.pdf
13. Donnerstein E. Internet bullying. Pediatr Clin North Am. 2012;59(3):623-633.
14. Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478-486.
15. U.S. Preventive Services Task Force. Recommendations. www.uspreventiveservicestaskforce.org/Page/Name/recommendations.
16. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18)(Suppl 3):S640-S656.
17. Armstrong C. Evaluation and management of concussion in athletes: recommendations from the AAN. Am Fam Physician. 2014;89(7):585-587.
18. Mowry JB, Spyker DA, Cantilena LR Jr, et al. 2012 annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol. 2013;51(10):949-1229.
  • T14.90 Injury, unspecified
  • T14.8 Other injury of unspecified body region
  • R29.6 Repeated falls
Clinical Pearls
  • Injury and violence are predictable and preventable.
  • Unintentional injury is the fifth leading cause of death.
  • Injury is the primary source of lost years of productive life for individuals younger than age 44 years.
  • MVAs cause most deaths in children and adolescents.
  • Children die of unintentional injuries (in order): MVA, drowning, fire/burn, and suffocation
  • Nearly 31% of women and 26% of men report having some form of IPV in their lifetime.