is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries. in general, however, giving lots of fluids appears to increase the risk of death. current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. targets include a mean arterial pressure of 60 mmhg, a systolic blood pressure of 70–90 mmhg, or the re-establishment of peripheral pulses and adequate ability to think. hypertonic saline has been studied and found to be of little difference from normal saline. as no intravenous fluids used for initial resuscitation have been shown to be superior, warmed lactated ringer's solution continues to be the solution of choice. if blood products are needed, a greater use of fresh frozen plasma and platelets instead of only packed red blood cells has been found to improve survival and lower overall blood product use; a ratio of 1:1:1 is recommended. the success of platelets has been attributed to the fact that they may prevent coagulopathy from developing. cell salvage and autotransfusion also may be used. blood substitutes such as hemoglobin-based oxygen carriers are in development; however, as of 2013 there are none available for commercial use in north america or europe. these products are only available for general use in south africa and russia. medications tranexamic acid decreases death in people who are having ongoing bleeding due to trauma, as well as those with mild to moderate traumatic brain injury and evidence of intracranial bleeding on ct scan. it only appears to be beneficial, however, if administered within the first three hours after trauma. for severe bleeding, for example from bleeding disorders, recombinant factor viia—a protein that assists blood clotting—may be appropriate. while it decreases blood use, it does not appear to decrease the mortality rate. in those without previous factor vii deficiency, its use is not recommended outside of trial situations. other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury. while positive inotropic medications such as norepinephrine sometimes are used in hemorrhagic shock as a result of trauma, there is a lack of evidence for their use. therefore, as of 2012 they have not been recommended. allowing a low blood pressure may be preferred in some situations. surgery the decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. bleeding must be controlled before definitive repair may occur. damage control surgery is used to manage severe trauma in which there is a cycle of metabolic acidosis, hypothermia, and hypotension that may lead to death, if not corrected. the main principle of the procedure involves performing the fewest procedures to save life and limb; less critical procedures are left until the victim is more stable. approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require exploratory surgery. the majority of preventable deaths from trauma result from unrecognised intra-abdominal bleeding. prognosis trauma deaths occur in immediate, early, or late stages. immediate deaths usually are due to apnea, severe brain or high spinal cord injury, or rupture of the heart or of large blood vessels. early deaths occur within minutes to hours and often are due to hemorrhages in the outer meningeal layer of the brain, torn arteries, blood around the lungs, air around the lungs, ruptured spleen, liver laceration, or pelvic fracture. immediate access to care may be crucial to prevent death in persons experiencing major trauma. late deaths occur days or weeks after the injury and often are related to infection. prognosis is better in countries with a dedicated trauma system where injured persons are provided quick and effective access to proper treatment facilities. long-term prognosis frequently is complicated by pain; more than half of trauma patients have moderate to severe pain one year after injury. many also experience a reduced quality of life years after an injury, with 20% of victims sustaining some form of disability. physical trauma may lead to development of post-traumatic stress disorder (ptsd). one study has found no correlation between the severity of trauma and the development of ptsd. epidemiology further information: list of preventable causes of death deaths from injuries per 100,000 inhabitants in 2004 no data < 25 25–50 50–75 75–100 100–125 125–150 150–175 175–200 200–225 225–250 250–275 > 275 incidence of accidents by activity in denmark trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually. it is the fifth leading cause of significant disability. about half of trauma deaths are in people aged between 15 and 45 years and trauma is the leading cause of death in this age group. injury affects more males; 68% of injuries occur in males and death from trauma is twice as common in males as it is in females, this is believed to be because males are much more willing to engage in risk-taking activities. teenagers and young adults are more likely to need hospitalization from injuries than other age groups. while elderly persons are less likely to be injured, they are more likely to die from injuries sustained due to various physiological differences that make it more difficult for the body to compensate for the injuries. the primary causes of traumatic death are central nervous system injuries and substantial blood loss. various classification scales exist for use with trauma to determine the severity of injuries, which are used to determine the resources used and, for statistical collection. history the human remains discovered at the site of nataruk in turkana, kenya, are claimed to show major trauma—both blunt and penetrating—caused by violent trauma to the head, neck, ribs, knees, and hands, which has been interpreted by some researchers as establishing the existence of warfare between two groups of hunter-gatherers 10,000 years ago. the evidence for blunt-force trauma at nataruk has been challenged, however, and the interpretation that the site represents an early example of warfare has been questioned. society and culture economics the financial cost of trauma includes both the amount of money spent on treatment and the loss of potential economic gain through absence from work. the average financial cost for the treatment of traumatic injury in the united states is approximately us$334,000 per person, making it costlier than the treatment of cancer and cardiovascular diseases. one reason for the high cost of the treatment for trauma is the increased possibility of complications, which leads to the need for more interventions. maintaining a trauma center is costly because they are open continuously and maintain a state of readiness to receive patients, even if there are none. in addition to the direct costs of the treatment, there also is a burden on the economy due to lost wages and productivity, which in 2009, accounted for approximately us$693.5 billion in the united states. low- and middle-income countries citizens of low- and middle-income countries (lmics) often have higher mortality rates from injury. these countries accounted for 89% of all deaths from injury worldwide. many of these countries do not have access to sufficient surgical care and many do not have a trauma system in place. in addition, most lmics do not have a pre-hospital care system that treats injured persons initially and transports them to hospital quickly, resulting in most casualty patients being transported by private vehicles. also, their hospitals lack the appropriate equipment, organizational resources, or trained staff. by 2020, the amount of trauma-related deaths is expected to decline in high-income countries, while in low- to middle-income countries it is expected to increase. special populations children main article: pediatric trauma cause deaths per year traffic collision 260,000 drowning 175,000 burns 96,000 falls 47,000 toxins 45,000 due to anatomical and physiological differences, injuries in children need to be approached differently from those in adults. accidents are the leading cause of death in children between 1 and 14 years old. in the united states, approximately sixteen million children go to an emergency department due to some form of injury every year, with boys being more frequently injured than girls by a ratio of 2:1. the world's five most common unintentional injuries in children as of 2008 are road crashes, drowning, burns, falls, and poisoning. weight estimation is an important part of managing trauma in children because the accurate dosing of medicine may be critical for resuscitative efforts. a number of methods to estimate weight, including the broselow tape, leffler formula, and theron formula exist. pregnancy trauma occurs in approximately 5% of all pregnancies, and is the leading cause of maternal death. additionally, pregnant women may experience placental abruption, pre-term labor, and uterine rupture. there are diagnostic issues during pregnancy; ionizing radiation has been shown to cause birth defects, although the doses used for typical exams generally are considered safe. due to normal physiological changes that occur during pregnancy, shock may be more difficult to diagnose. where the woman is more than 23 weeks pregnant, it is recommended that the fetus be monitored for at least four hours by cardiotocography. a number of treatments beyond typical trauma care may be needed when the patient is pregnant. because the weight of the uterus on the inferior vena cava may decrease blood return to the heart, it may be very beneficial to lay a woman in late pregnancy on her left side. also recommended are rho(d) immune globulin in those who are rh negative, corticosteroids in those who are 24 to 34 weeks and may need delivery or a caesarian section in the event of cardiac arrest. research