Might not it be helpful if, coincidentally, the Council on Injury, Violence, and Poison Prevention for the American Academy of Pediatrics had just updated their policy statement regarding firearm-related injuries? Indeed, just two months ago, the AAP published an update, featuring a mere 66 citations worth of evidence, rather than politicized talking points.
A couple interesting statistics from their summary:
– The firearm-associated death rate among youth ages 15 to 19 has fallen from its peak of 27.8 deaths per 100 000 in 1994 to 11.4 per 100 000 in 2009.
– However, of all injury deaths of individuals younger than 20 years, still 1 in 5 were firearm related.
– For youth 15 to 24 years of age, firearm homicide rates were 35.7 times higher than in other high-income countries.
– For children 5 to 14 years of age, firearm suicide rates were 8 times higher, and death rates from unintentional firearm injuries were 10 times higher in the United States than other high-income countries.
– The difference in rates is postulated to the ease of availability of guns in the United States compared with other high-income countries.
Their recommendations section seems quite straightforward:
– The most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.
– Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them.
– Trigger locks, lock boxes, gun safes, and safe storage legislation are encouraged by the AAP.
– Other measures aimed at regulating access of guns should include legislative actions, such as mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks.
– The AAP recommends restoration of the ban on the sale of assault weapons to the general public.
Any chance policymakers might listen to the society of physicians “Dedicated to the health and well-being of infants, children, adolescents and young adults”?
“Firearm-Related Injuries Affecting the Pediatric Population”
www.ncbi.nlm.nih.gov/pubmed/10742344
Category: Trauma
Pain Control on the Wrong Track
Codeine, the oral narcotic analgesia that is long past its prime. Approximately 8% of the caucasian population cannot metabolize codeine into morphine – and then a small handful are rapid metabolizers that will overdose on an otherwise therapeutic dose. But, this didn’t stop these folks in Montreal from evaluating its efficacy for pediatric musculoskeletal limb pain.
Pediatric pain is a little odd. Overall, the Emergency Department does a poor job of treating pain. Studies in pediatric EDs show significant percentages of injured patients don’t receive any pain control. But, then, we all have the anecdotal experience in which a child is sitting on a stretcher watching TV with a fractured arm denying he’s in any pain at all – why are you bothering me again? Spongebob is on.
Long story short, this study randomized children to receive either ibuprofen alone or ibuprofen plus codeine. At each time point, the difference in pain scales was no different between groups. Pain scores weren’t that high to begin with, and had moderate improvement after either treatment.
For minor pain, acetaminophen and ibuprofen are adequate options. For more severe pain, intravenous narcotics, intranasal narcotics, or even intramuscular ketamine are probably better options.
“Efficacy of an Ibuprofen/Codeine Combination for Pain Management in Children Presenting to the Emergency Department With a Limb Injury: A Pilot Study”
www.ncbi.nlm.nih.gov/pubmed/23232154
More C-Spine “Doom and Gloom”
If you haven’t been paying attention to the literature, then you’re practicing completely unawares of an epidemic of missed spinal cord injuries. From the literature that suggests CT isn’t adequately sensitive and the final common pathway for c-spine clearance should be MRI, to this new article that says all of those studies in summary aren’t enough – and patients might also need “erect cervical spine radiographs”.
This is a case series – the authors bill it as a retrospective review, but the methods are laughably absent, at best – of four patients the authors identified as having cervical spine instability missed through traditional diagnostic methods. These patients, aged 61 through 87, received Emergency Department evaluation for cervical spine injury, were treated conservatively initially, and eventually needed operative intervention. The ED work-up of these patients can probably best be described as “interesting” – e.g., a 61 year-old female thrown from horse whose initial work-up involved only three-view radiographs of the cervical spine. Or, a seventy-five year old man with a cervical fracture on CT who was managed initially in a semi-rigid collar without other assessment for ligamentous injury.
Regardless, each of these patients had some combination of eventual CT or MRI that failed to adequately describe the extent of cervical spine instability, but a simple erect radiograph demonstrated subluxation. Interestingly, this is a little bit of full circle back to the days of flexion/extension films. While other studies have demonstrated MRI picks up signal abnormalities not detected on CT imaging, the clinical significance of this is debatable. Conversely, these dynamic/load-bearing plain radiographs offer a true functional test without precisely describing the injury – akin to the difference between cardiac stress testing and coronary angiograms.
These injuries are quite rare, and not every patient needs an MRI or dynamic testing for cervical stability. However, in the end, these tests have a role and should be utilized as necessary in the appropriate clinical situation.
“Erect Radiographs to Assess Clinical Instability in Patients with Blunt Cervical Spine Trauma”
jbjs.org/article.aspx?articleID=1392339
End-Tidal to Predict Operative Intervention in Trauma
In penetrating trauma, sometimes it’s very simple to predict operative intervention. However, sometimes, the perfusion states of our patients are less easy predict – vital signs frequently obfuscate the underlying clinical picture as the body compensates.
This is a prospective study that indirectly aims to validate end-tidal CO2 as a predictor of operative intervention in penetrating trauma by correlating it to serum lactate levels. And, as their primary outcome, these investigators observed a strong correlation between ETCO2 and lactate levels (R^2 = 0.74). For secondary endpoints – unsurprisingly, considering it was correlated with lactate – ETCO2 was also predictive of operative intervention. In fact, the authors report ETCO2 was more predictive of intervention than lactate, although it seems a little odd to significantly outperform lactate, given the strength of their linear correlation.
Compared with systolic blood pressure, the test performance characteristics essentially tell us what we already know: normal blood pressure isn’t helpful, low blood pressure is obviously helpful (98% specificity). Lactate and ETCO2 are more sensitive to hypoperfusion states not reflected in vital signs, although, in this small study, even elevated ETCO2 would miss 1 in 5 operative interventions (sensitivity 82%) and would incorrectly predict 1 operative intervention for every 4 correct predictions (specificity 82%).
If prospective study confirms that ETCO2 outperforms lactate levels as an indicator of hypoperfusion, perhaps it adds something to the trauma bay evaluation. Otherwise, it seems the most useful function might be to add to prehospital triage protocols – an environment where lactate wouldn’t be available.
“Nasal cannula end-tidal CO2 correlates with serum lactate levels and odds of operative intervention in penetrating trauma patients: A prospective cohort study”
http://www.ncbi.nlm.nih.gov/pubmed/23117381
More About ABIs Than You Ever Needed
These American Heart Association scientific statements are really quite lovely. Although much of the scientific discussion in this article pertains to the diagnosis of chronic vascular disease in the outpatient setting, measuring the ankle-brachial index has a place the the Emergency Department as well.
While most of the studies included in their mini-systematic review report AUCs for chronic peripheral vascular disease, the same principles apply for determination of acute peripheral vascular disease – relevant after lower-extremity penetrating trauma or fracture. And, if you’re going to use a test, sometimes it’s fun to know all the gritty details underpinning the evidence, how the cut-offs were determined, the difference between doppler and oscillometric devices, how discrepancies between legs should be handled, etc.
In any event, an interesting piece of literature to skim and save as a reference.
“Measurement and Interpretation of the Ankle-Brachial Index : A Scientific Statement From the American Heart Association”
The Hazards of Love
“Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system.”
Indeed!
According to this retrospective review of 11 years of electronic health records from University Hospital Bern, Switzerland, they identified 445 patients seeking emergency care secondary to sexual intercourse. The majority of emergency department visits were secondary to suspected infectious etiologies (62%), but neurologic complaints, trauma, and cardiovascular incidents comprised the remaining portion.
The trauma portion probably speaks for itself without need for additional detail. There was one myocardial infarction and one aortic dissection. Among the “various complaints”, two patients were diagnosed with “eczema”. However, among the neurologic emergencies, there were 12 cases of subarachnoid hemorrhage and 11 cases of – ah – “transient global amnesia”.
All things being equal, at least, sexual activity was only associated with 0.1% of emergency department visits – hardly the most dangerous of potential choices of recreation.
“Sexual activity-related emergency department admissions: eleven years of experience at a Swiss university hospital”
http://www.ncbi.nlm.nih.gov/pubmed/23100321
More Probably Unnecessary Head CTs/Admissions
I work at one of only two trauma centers in a city of four million potential patients, and I have firsthand experience with this issue. The issue is to determine the best management strategy for patients with mild traumatic brain injury and bleeding. We already know what to do with major bleeding – but patients with minor bleeding are a little more of a dilemma. They almost universally do well, but we observe them and repeat tests on nearly all of them.
This is a retrospective review of 36 months of trauma admissions to a level one trauma center in New Jersey, trying to describe the natural progression of mild traumatic intracranial bleeding. Historically, 1/3rd of these patients have bleeding that progresses, but only 1-3% will require neurosurgical intervention. This review found 341 patients with mild injuries and bleeding, and noted that 69% of these patients had no interval change in head CT results when repeated at 24 hours. Of the remaining patients, either no CT was performed (25 patients) because the injury was too insignificant or there was interval progression – including 11 patients who received neurosurgical intervention. But, the point of the article is generally supposed to be shown in Figure 2 – estimating the number of ongoing hemorrhages at each time point in the first 24 hours. Essentially, >80% of the bleeding ceases to expand within the first few hours from injury.
This is a useful jumping off point to perform the sort of work that isn’t featured in this article – characterizing the characteristics of patients and bleeding that progresses. If patients with bleeding unlikely to progress can be safely discharged rather than being observed for interval CT, this is a useful reduction in ED length of stay, observation admissions, or CT use.
“The temporal course of intracranial haemorrhage progression: How long is observation necessary?”
www.ncbi.nlm.nih.gov/pubmed/22658418
Trauma, the Hard Way
Anyone who has been to a surgery morbidity and mortality conference understands the cultural bias behind the desire to “pan-scan” all trauma patients. If an injury is missed, and the body part wasn’t scanned, someone is going to need to stand up and look foolish.
However, this article describes a trauma center in Boston that made a concerted effort to reduce CT scanning. They came up with fifteen evidence-based guidelines for various scans and made a consensus to use these decision instruments to assist in their assessment for need for CT. And, as you might expect, they identified significant reductions in CT scanning during their study period – 37% total reduction in number of CT scans. If 37% doesn’t sound like a big enough number, perhaps the $1.1M absolute difference in brain, chest, and abdomen/pelvis scan costs is enough to get your attention.
However, they have rather some weaknesses. They state there were “no missed injuries”, which is unusual because every study of CT in trauma patients fails to achieve 100% sensitivity – even in patients with liberal use of CT. Then, they do have twice as many “complications” in their evidence-based scan group, as well as three times as many 30-day readmissions. I’m not sure each complication follows from the scanning strategy, but it is an oddly significant difference.
Interestingly, they excluded patients who did not survive 24 hours. Perhaps it complicated their abstraction process, but it is of slightly greater clinical interest to evaluate for potential missed injuries that resulted in immediate demise, rather than the misses that resulted in slightly longer-term morbidity.
“Evidence-based guidelines are equivalent to a liberal computed tomography scan protocol for initial patient evaluation but are associated with decreased computed tomography scan use, cost, and radiation exposure”
www.ncbi.nlm.nih.gov/pubmed/22929486
It’s Too Hot To Fight & Other Fables
There’s a mythology regarding temperature and violent crime – both increase in tandem up until a certain point, at which it becomes “too warm”. This study, a retrospective analysis of violent crime from a six-year period in Dallas, TX, generally confirms the increase in violence as the temperature increases.
The authors additionally propose, however, a curvilinear relationship based on the data that interprets an inflection point at 80-89 degrees a bit aggressively, considering they only have one data point above 80-89 with which to define the further trend. The absolute differences between total numbers of violent assaults in each temperature bracket are small enough, it’s a little hard to confidently say there’s a point at which it becomes too hot for violent crime. It makes sense, of course, but that’s more editorializing.
Perhaps they could attempt to externally validate these findings in Iraq – which seems awfully hot and violent. They also note there is a strong correlation between temperature and hours of daylight – but it seems as though that’d be rather difficult to control for one or the other.
And, tying this entire issue into climate change is another unusual matter entirely….
“Temperature and Violent Crime in Dallas, Texas: Relationships and Implications of Climate Change”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415828/
Head to Head With Head CT Rules
The “headline” you’ll see from this article is that the Canadian Head CT Rule outperforms the New Orleans Criteria for radiographic imaging in minor head trauma. Specifically, it outperforms it in this prospective, observational cohort from several hospitals in Tunisia, consecutive patients with blunt trauma to the head and at least one symptom secondary to the head trauma.
The most striking thing about this article, however, remains the gruesome number of false positives generated by each of these head CT decision rules. While, obviously, the intent is to capture all the cases requiring neurosurgical intervention, the New Orleans Criteria could not rule out potential need for neurosurgical intervention in 1,180 out of 1,582. When the theoretical purpose of these rules is to prevent “scanning everyone”, we’re not getting much bang for our buck. The Canadian Head CT Rule was better – but still indicated a need for scan in 656 out of 1,582.
While the article focuses mostly on the need for neurosurgical intervention in GCS 15 patients, it’s interesting to see their “secondary outcomes” which did not need “intervention”. Only 34 total patients in their cohort required intervention – while they found 133 skull fractures, 41 subdurals, 45 epidurals, 69 subarachnoids/hemorrhagic contusions, and 1 case of pneumocephalus. The Canadian rule would have missed 11 of the 218 “clinically significant” findings, for a sensitivity of 95%. The article does not specific precisely which types of findings were missed, but, clearly, many of those may be argued to be not significant. Unfortunately, deriving a better rule based on a more liberal definition of “clinical significance” is likely to result in more missed interventions – but it’s still probably worth trying.
“Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study”
http://www.ncbi.nlm.nih.gov/pubmed/22251188