The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters.

OBJECTIVE: Sports-related concussion has received increasing attention as a cause of short- and long-term neurologic symptoms among athletes. The King-Devick (K-D) test is based on measurement of the speed of rapid number naming (reading aloud single-digit numbers from 3 test cards), and captures impairment of eye movements, attention, language, and other correlates of suboptimal brain function. We investigated the K-D test as a potential rapid sideline screening for concussion in a cohort of boxers and mixed martial arts fighters. METHODS: The K-D test was administered prefight and postfight. The Military Acute Concussion Evaluation (MACE) was administered as a more comprehensive but longer test for concussion. Differences in postfight K-D scores and changes in scores from prefight to postfight were compared for athletes with head trauma during the fight vs those without. RESULTS: Postfight K-D scores (n = 39 participants) were significantly higher (worse) for those with head trauma during the match (59.1 ± 7.4 vs 41.0 ± 6.7 seconds, p < 0.0001, Wilcoxon rank sum test). Those with loss of consciousness showed the greatest worsening from prefight to postfight. Worse postfight K-D scores (r(s) = -0.79, p = 0.0001) and greater worsening of scores (r(s) = 0.90, p < 0.0001) correlated well with postfight MACE scores. Worsening of K-D scores by ≥5 seconds was a distinguishing characteristic noted only among participants with head trauma. High levels of test-retest reliability were observed (intraclass correlation coefficient 0.97 [95% confidence interval 0.90-1.0]). CONCLUSIONS: The K-D test is an accurate and reliable method for identifying athletes with head trauma, and is a strong candidate rapid sideline screening test for concussion.

A randomised controlled feasibility trial of alcohol consumption and the ability to appropriately use a firearm.

OBJECTIVE: To show the feasibility of using a controlled trial to investigate the effect of alcohol on firearm use. METHODS: Randomised, blinded, placebo-controlled trial in the Firearm Usage and Safety Experiments (FUSE) Lab. Treatment subjects (male, 21-40-year-old, non-habitual drinkers, with no professional firearms training) received alcohol; control subjects received placebo alcohol. The AIS PRISim Firearm Simulator, including real pistols retrofitted to discharge compressed air cartridges that simulate firearm recoil and sound, was used to measure firearm performance. Accuracy and speed for target shooting, reaction time scenarios, and scenarios requiring judgement about when to use a gun were measured. RESULTS: 12 subjects enrolled in the trial, completing 160 training scenarios. All subjects in the alcohol arm reached target alcohol level. 33% of placebo subjects reported alcohol consumption. Mechanical malfunction of the simulator occurred in 9 of 160 (5.6%) scenarios. Intoxicated subjects were less accurate, slower to fire in reaction time scenarios, and quicker to fire in scenarios requiring judgement relative to controls. CONCLUSIONS: The feasibility of a randomised, controlled trial exploring the relationship between alcohol consumption and firearm use was shown. The hypothesis that alcohol consumption worsens accuracy and retards judgement about when to use a gun should be tested. Larger trials could inform policies regarding firearm use while intoxicated.

Determining objective injury prevention priorities.

BACKGROUND AND OBJECTIVE: Finite injury prevention resources make the establishment of prevention priorities essential. Toward this end, the US National Trauma Data Bank (NTDB) for 2000 to 2004 was accessed and four injury prevention priority scores (one previously defined and three new scores) were computed. METHODS: An injury prevention priority score (IPPS) was calculated based on the frequency of an injury mechanism and the median injury severity score. In addition, a mortality priority score (Mort-PS), a hospital charge priority score (Charge-PS), and a years of potential life lost (YPLL-PS) priority score were calculated for the 13 most common injury mechanisms. RESULTS: There was variability across the four scores, but motor vehicle traffic, firearm related, and fall injuries ranked high on all four of the priority criteria. Multiple criteria should be considered when assessing injury burden. CONCLUSIONS: The methods presented here can help prioritize injuries and support more objective public policies.

Racial segregation and county level intentional injury in Pennsylvania: analysis of hospital discharge data for 1997-1999.

STUDY OBJECTIVE: This study examined whether high levels of racial segregation are associated with high county level intentional injury rates. DESIGN: Multiple linear regression was used to assess the association between county racial segregation (measured by the Gini coefficient) and intentional injury rates. Multicollinearity was assessed with Eigenvalues and condition indices. SETTING: State of Pennsylvania. PATIENTS: County level intentional injury rates for 1995 to 1997 were calculated from hospital discharge data. MAIN RESULTS: After controlling for other known county level risk factors, higher levels of racial segregation in a county were significantly related to higher intentional injury rates. Multicollinearity was not a problem. Population size and density, family stability and median income, together with the percentage male, unemployed, in poverty, divorced men, and high school graduates of the county were controlled. CONCLUSIONS: Racial segregation is an important factor in the rate of intentional injury in a community. These results may be important for municipal and state agencies when developing public policies to prevent violence and promote racial integration.

Helmet laws and motorcycle rider death rates.

We investigated motorcycle rider death rates between states with full motorcycle helmet laws and those without. This was done using both unadjusted bivariate analyses and multivariate random-effects generalized least squares regression models of rider death rates. Multivariate models were adjusted for the competing influences of several explanatory variables, including the existence of a motorcycle helmet law. From 1994 to 1996, states with helmet laws experienced a median death rate of 6.20 riders per 10000 registered motorcycles and states without helmet laws experienced a median death rate of 5.07 riders per 10000 registered motorcycles (P = 0.008). After controlling for other factors that affect motorcycle rider fatalities (most notably population density and temperature), death rates in states with full helmet laws were shown to be lower on average than deaths rates in states without full helmet laws (P = 0.740). Our study weakens the claim that rider death rates are significantly lower in states without full motorcycle helmet laws.

Predicting survival in pediatric trauma patients receiving cardiopulmonary resuscitation in the prehospital setting.

OBJECTIVES: To determine survival in pediatric trauma patients receiving cardiopulmonary resuscitation (CPR) in the prehospital setting and to identify subgroups of patients who may have increased survival rates. METHODS: Records were obtained from the National Pediatric Trauma Registry on all pediatric trauma patients (age <19 years) over an 82-month period who received CPR at the scene of the injury. Data were recorded as to type of injury, need for additional CPR at the receiving hospital, and intubation in the field. Patient outcome was defined as: dead on arrival, dead at trauma center discharge, or alive at trauma center discharge. Univariate and logistic regression analyses were performed to identify statistical differences in survivors compared with nonsurvivors. RESULTS: Seven hundred twenty-nine patients were identified. The median age was 7.0 years, with a mean of 7.9 years; 62% were male, 37% were female, and 1% had no gender recorded. Age and gender distributions were not statistically different for the three outcomes. Eighty-seven patients (12%) were dead on arrival and an additional 458 (63%) were dead at trauma center discharge, while 184 (25%) were alive at trauma center discharge. Motor vehicle crashes accounted for 27% of admissions, and pedestrians struck by vehicle accounted for 23%. Intentional violence accounted for 18% of the accrued patients. Predictors of death in the patients who were alive at admission were penetrating injury (p = 0.001) and requirement of additional CPR at the trauma center (p = 0.001). Prehospital intubation was associated with decreased survival. Of the 641 patients who arrived at the hospital alive, 29% lived to trauma center discharge, but of the 534/641 who received prehospital intubation, only 19% lived. The mean Functional Independence Measure (FIM) scores were 38.9 (range 18 to 126). CONCLUSIONS: Survival of pediatric trauma patients after receiving CPR in the prehospital setting is significantly higher than expected in adult patients. Penetrating trauma, the need for additional CPR at the trauma center, and prehospital intubation are all predictors of a worse outcome.

State helmet laws and motorcycle rider death rates.

Motorcycles are the most dangerous form of motorized transportation. Per vehicle miles traveled, motorcyclists are about 3 times as likely as passenger car occupants to be injured in a crash, and 16 times as likely to die. Because the majority of these deaths are caused by head injury, safety advocates have recommended mandatory use of motorcycle helmets. Others contend that state laws mandating helmet use infringe on motorcyclists' rights, and question whether such laws really reduce motorcycle deaths and injury. Scientific evidence cannot address the appropriate balance between personal freedom and public safety, but it can address the effectiveness of mandatory helmet laws. This Issue Brief summarizes a new analysis of the effects of motorcycle helmet laws on death rates, and points out the need to account for other potential factors when comparing death rates across states.

A case series analysis of mass casualty incidents.

INTRODUCTION: Mass casualty incidents (MCIs) are infrequent but potentially overwhelming events that can stress the capabilities of even the most organized emergency medical services (EMS) system. The Maryland EMS system has been identified as a pioneer and leader in the field of prehospital emergency care and, as with many states, Maryland's regional preparation for MCIs has been integrated into its overall EMS systems planning. OBJECTIVE: To determine how successful this integration has been by examining a three-year history of response to MCIs in Maryland. METHODS: A three-year case series of MCIs in Maryland was obtained from a Nexis national news publications search. These MCIs were cross-referenced with U.S. postal ZIP codes and the U.S. Census Bureau's ZIP code files. They were then mapped and summary statistics were prepared for analysis. Data obtained through the Maryland Health Services Cost Review Commission for all severely injured patients discharged from Maryland hospitals were obtained over the same three-year period for comparison. RESULTS: Eight MCIs occurred over a three-year period, resulting in a total of 203 injuries. An average of 25.4 +/- 10.7 injuries occurred per MCI. A total of 158 (77.8%) of injuries necessitated ambulance transportation. An average of 3.1 +/- 1.1 hospitals were involved per MCI. CONCLUSIONS: The Maryland EMS system was effective in responding to MCIs ranging in size from 10 to nearly 40 injuries. Analyzing MCIs that reoccur on a year-to-year basis should figure into the planning process for EMS systems.

A trauma resource allocation model for ambulances and hospitals.

OBJECTIVE: To develop a mathematical model for the location of trauma care resources. DATA SOURCES/STUDY SETTING: Severely injured patients queried from Maryland hospital discharge and vital statistics data. A spatial injury profile was created by parsing these patients into ZIP codes. STUDY DESIGN: The Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) was formulated using integer and heuristic programming. To maximize coverage of severely injured patients, trauma centers and aeromedical depots were simultaneously sited using TRAMAH. A severe injury was considered covered if at least one trauma center was sited within a time standard by ground, or if an aeromedical depot-trauma center pair was sited in such a way that the sum of the flying time from the aeromedical depot to the scene of injury plus the flying time from the scene of injury to the trauma center was within the same time standard. PRINCIPAL FINDINGS: From 1992 to 1994, 26,774 severe injuries were considered for coverage. Across Maryland, 94.8 percent of severely injured residents had access to trauma system resources within 30 minutes and 70.3 percent had access within 15 minutes. For the same number of resources as the existing Maryland Trauma System, TRAMAH achieved a coverage objective of 99.97 percent within 30 minutes. This translated into an additional 461 severely injured people covered each year. Holding in place the trauma centers of the existing system, approximately the same percentage of coverage as that of the existing system was achieved within 15 minutes by optimally locating six fewer aeromedical depots. CONCLUSIONS: TRAMAH will allow trauma systems planners to better locate their resources with respect to spatial needs and response times.

To the rescue: optimally locating trauma hospitals and helicopters.

Injury (trauma) is the leading cause of death in the United States for people younger than 45 years of age. Each day, more than 170,000 men, women, and children are injured severely enough to seek medical care. About 400 of these people will die and another 200 will sustain a long-term disability as a result of their injuries. An estimated 20-40% of trauma-related deaths could be prevented if all Americans lived in communities that were served by a well-organized system of trauma care. This Issue Brief describes a new computer model that can help State and regional policymakers decide where to place designated trauma hospitals and helicopter depots to maximize their residents' access to trauma care.

Fatal nontraffic injuries involving alcohol: A metaanalysis.

STUDY OBJECTIVE: Estimates of alcohol involvement in fatal injuries vary widely. For injuries other than those involving motor vehicles, no national data exist and the quality of regional data is limited. This study synthesizes US medical examiner studies of nontraffic fatalities for the purpose of estimating alcohol involvement by injury mechanism and intent. METHODS: We reviewed 331 medical examiner studies published between 1975 and 1995 that reported nontraffic injury fatalities. These studies were identified from computerized bibliographic databases and by hand searching of reference lists from 26 review publications and the subject indices of 7 prominent journals. A final total of 65 articles (19.6%) met our inclusion criteria for analysis. National data on motor vehicle fatalities were used for comparison. RESULTS: A total of 7,459 unintentional injury deaths, 28,696 homicide cases, and 19,347 suicide cases were aggregated. The aggregate percentage tested for blood alcohol concentration (BAC) was highest among homicide cases (88.2%), followed by unintentional injury deaths (84.0%) and suicide cases (81.7%). The aggregate percentage determined to be intoxicated (BAC, >/=100 mg/dL) was highest among homicide cases (31.5%), followed by unintentional injury deaths (31.0%) and suicide cases (22.7%). Mean and median comparisons produced comparable findings. Fewer than one quarter of the 65 articles reported gender- and age-specific rates. Inconsistent reporting of gender and age-specific rates in fatal nontraffic injuries prevented their analysis by cause of death. Fatally injured motor vehicle drivers, however, demonstrated distinct variation in alcohol involvement by age and gender. CONCLUSION: This metaanalysis is the first systematic attempt to estimate alcohol involvement in fatal nontraffic injuries at the national level. It demonstrates that alcohol is an important factor in many fatal injuries and that its importance varies by cause of injury.

A population-based study of trauma recidivism.

BACKGROUND: Patients with repeat presentations to acute care hospitals for new injuries are trauma recidivists. Prospective identification of those patients at greatest risk will permit focusing of limited hospital prevention resources. METHODS: A population-based analysis of patients with recurrent trauma presenting to all hospitals in Nevada during a 5-year period was conducted. Records of 10,355 presentations representing 10,137 patients were analyzed. RESULTS: Recidivist trauma patients were younger than non-recidivists, with patients aged 20 to 24 years having significantly higher rates of recidivism. Males were 1.53 times more likely than females to become recidivists. Cutting/piercing and machinery-related injuries were most frequently associated with recidivism. Cutting/piercing wound survivors were 7.06 times more likely to be recidivists than were gunshot wound survivors. Recidivists in motor vehicles crashes were 1.92 times less likely to wear seat belts than nonrecidivists. Recidivism was also significantly associated with positive blood alcohol levels and longer initial hospital stays. CONCLUSION: The rate of trauma recidivism in this study was 2.0%. Population-based data can be used to identify cohorts at risk of recidivism.

Geographic variation in serious nonfatal firearm injuries in Pennsylvania.

OBJECTIVE: The purpose of this study was to characterize the geographic epidemiology of serious nonfatal firearm injuries (NFFI) within Pennsylvania during a 6-year period. METHODS: A historical review of data from the Pennsylvania Trauma System Foundation trauma registry was completed using county-level data. Based on a format adapted from the United States Department of Agriculture, NFFI in Pennsylvania were classified by their county of occurrence: central city counties, metropolitan counties, nonmetropolitan counties, or rural counties. Population-based rates of NFFI were then calculated, as were NFFI as a proportion of the number of injuries within each region. These rates were stratified by intent of injury, scene of injury, and type of firearm. RESULTS: A total of 100,703 trauma cases were reported to the Pennsylvania Trauma System Foundation from 1988 through 1993, of which 5,847 were serious NFFI. Nonfatal firearm assaults increased from rural counties to central city counties, whereas unintentional NFFI decreased (p < 0.05). A 225% increase in the number of NFFI, from 445 cases in 1988 to 1,004 cases in 1993, was noted in the central city counties. Comparatively, the increase in the noncity regions was 145%, from 182 cases in 1988 to 263 in 1993. Nonfatal firearm injuries occurred most often at home in noncity counties (rural, nonmetropolitan, and metropolitan counties) (47.9%). This is in contrast to central city counties, where NFFI occurred significantly more often in the street (53.5%) (p < 0.05). Handgun NFFI increased, whereas rifle NFFI decreased, from rural counties to central city counties (p < 0.05). Relative to population size, the risk of shotgun injuries was greatest in central city counties and lowest in rural counties. Shotgun injuries also accounted for a significantly longer hospital stay (15.06 days) compared with handgun injuries (10.38 days) and rifle injuries (11.81 days) (p < 0.05). CONCLUSION: Significant variation in NFFI was observed across population-based regions in Pennsylvania. Rural areas demonstrated relatively high risks of NFFI committed unintentionally, in the home, and with rifles. As regional populations increase, relatively high risks of NFFI, committed as assaults, in the street, and by handguns, are highlighted. Although handguns were the most prominent firearm associated with NFFI, nonfatal shotgun injuries produced substantially longer hospital stays and may be an underappreciated cause of nonfatal firearm assaults in the urban setting.

Shotgun wounds in children. Not just accidents.

OBJECTIVE: To characterize the demographic characteristics of shotgun wounds in children and adolescents across various regions within a state. DESIGN: Retrospective case study. SETTING: Accredited trauma centers in Pennsylvania. PATIENTS: All patients less than 18 years old who sustained shotgun wounds. DATA COLLECTION: Patient data were collected from the Pennsylvania Trauma Systems Foundation statewide trauma registry for January 1987 through December 1994. Data reviewed included age, race, sex, region, nature of injury, assailant, location of incident, length of stay in the hospital and intensive care unit, Injury Severity Score, organs injured, death, and discharge disposition. RESULTS: Over 8 years there were 95 shotgun wounds in patients with a mean +/- SD age of 14.0 +/- 3.7 years; the male-to-female ratio was 5.8:1. The incidence of shotgun wounds in urban areas increased threefold during the second half of the study; the incidence in nonurban regions was unchanged. Eighteen deaths (19%) occurred, 17 (94%) within 24 hours and 10 (56%) because of intracranial injury. Overall, unintentional shotgun wounds were most common (n = 46 [48%]), followed by assaults (n = 37 [39%]) and suicides (n = 8 [8%]). The highest per capita incidence of shotgun wounds occurred in urban areas, typically the result of an assault (n = 30 [73%]). In nonurban areas, shotgun wounds were usually unintentional (n = 36 [67%]); 34 (63%) occurred in the home. In contrast, in urban areas, 26 shotgun wounds (63%) occurred on the street. Overall, 14 fatal shotgun wounds (78%) occurred in the home. Operative intervention was required for 57 patients (60%). Ultimately, 67 patients (71%) were discharged to home. CONCLUSIONS: In urban areas, shotgun wounds are increasing in incidence, often occur on the street, and often result from assault. In nonurban areas, shotgun wounds are usually unintentional, often occur in the home, and are more often lethal than shotgun wounds in urban areas. Multiple-organ injury, surgery, and lengthy hospital stays are common.

A correlation of air plethysmography and color-flow-assisted duplex scanning in the quantification of chronic venous insufficiency.

PURPOSE: Air plethysmography has been useful in assessing patients who have chronic venous insufficiency. Limb reflux times determined by color-flow-assisted duplex scanning have been shown to correlate with the severity of chronic venous insufficiency. The purpose of this study was to compare air plethysmographic measurements with reflux times obtained by color-flow-assisted duplex scanning in patients with chronic venous insufficiency. METHODS: One hundred twenty-two limbs in 61 consecutive patients with various stages of chronic venous insufficiency were evaluated; air plethysmographic and color-flow-assisted duplex scans were performed at the same sitting. Fifty-nine of the patients had venous ulceration. Values obtained by air plethysmographic scans included venous filling index, ejection volume, residual volume, ejection fraction, and residual volume fraction. Color-flow-assisted duplex scan values included reflux times in the deep and superficial venous segments and total and mean limb reflux times. RESULTS: Using the Pearson correlation, the venous filling index was found to correlate significantly with total limb venous reflux times, mean total limb reflux times, and venous reflux times in the deep venous system, as determined by color-flow-assisted duplex scans (p < 0.001). CONCLUSIONS: Limb reflux time as determined by color-flow-assisted duplex scans correlated significantly with the air plethysmographic variable accepted as a measure of the severity of venous reflux, the venous filling index. This study confirms the validity of total limb reflux times in the quantification of chronic venous insufficiency.