Do pediatric and adult disaster victims differ? A descriptive analysis of clinical encounters from four natural disaster DMAT deployments.

OBJECTIVES: The differences between pediatric (< or = 17 years of age) and adult clinical field encounters were analyzed from four deployments of Disaster Medical Assistance Teams (DMATs). METHODS: A retrospective cohort review of all patients who presented to DMAT field clinics during two hurricanes, one earthquake, and one flood was conducted. Descriptive statistics were used to analyze: (1) age; (2) gender; (3) severity category level; (4) chief complaint; (5) treatments provided; (6) discharge diagnosis; and (7) disposition. Five subsets of pediatric patients were analyzed further. RESULTS: Of the 2,196 patient encounters reviewed, 643 (29.5%) encounters were pediatric patients. Pediatric patients had a greater number of blank severity category levels than adults. Pediatric patients also were: (1) more likely to present with chief complaints of upper respiratory infections or wounds; (2) less likely to present with musculoskeletal pain or abdominal pain; and (3) equally likely to present with rashes. Pediatric patients were more likely to receive antibiotics, pain medication, and antihistamines, but were equally likely to need treatment for wounds. Dispositions to the hospital were less frequent for pediatric patients than for adults. CONCLUSIONS: Pediatric patients represent a substantial proportion of disaster victims at DMAT field clinics. They often necessitate special care requirements different from their adult counterparts. Pediatric-specific severity category criteria, treatment guidelines, equipment/medication stocks, and provider training are warranted for future DMAT response preparations.

The influence of collection site and methods on postmortem morphine concentrations in a porcine model.

This study was to determine the relationship of antemortem to postmortem morphine concentrations in heart and femoral blood in a porcine model following acute intravenous opiate overdose. The study involved 20 swine; each was sacrificed 10 min after injection of 2 mg/kg body weight of morphine. Drug concentrations were assayed from vitreous humor and blood isolated from the femoral vein and artery and left and right ventricles at various times postmortem. Comparisons were made between antemortem and postmortem values to determine agreement and reliability. Both free and total postmortem values varied significantly among animals, sampling sites, and over time. Free postmortem values were generally higher in comparison with antemortem values, whereas postmortem total morphine values were similar to or slightly lower than antemortem values. The effect of time on postmortem values was small. These results demonstrate a significant amount of variability in free and total morphine measurements both over time and within and between sites. Furthermore, a comparison of antemortem to postmortem values demonstrates a lack of consistency relative to the dose of morphine administered. Concentrations of morphine in the femoral vein were typically the lowest observed. This observation is not surprising given the transformation that occurs prior to the drug reaching the femoral vein. Values associated with diffuse tissues, relative to femoral veins, demonstrate more stochastic variation.

The influence of site of collection on postmortem morphine concentrations in heroin overdose victims.

When assaying for postmortem morphine concentration, significant site sampling variability exists between central and peripheral sampling sites and even within sampling regions of the body. To study the variation, 76 suspected heroin overdoses were identified. Each had femoral artery (FA) and vein (FV), left and right ventricle and pooled heart blood samples obtained at autopsy. Forty-four tested positive for morphine. Morphine concentrations were determined by gas chromatography/mass spectrometry, with sampling site differences reported as log-transformed ratios and compared by signed rank test. The mean FA to FV ratio for total morphine was 1.2 (range 0-4.5). The ratio for left heart to right heart total morphine was 1.1 (range 0.4-3.2). Left ventricular to FV total morphine ratio was 2.0 (range 0.6-6.9). In these opioid overdose deaths, FA and FV morphine concentrations are usually similar, although up to 4.5-fold differences were noted. Centrally obtained morphine concentrations are on average twice as high compared with peripheral morphine concentrations. Left and right ventricular morphine concentrations were usually similar, although up to 3.2-fold differences were noted (left side higher).

Subsequent suicide mortality among emergency department patients seen for suicidal behavior.

OBJECTIVES: To determine whether suicide mortality rates for a cohort of patients seen and subsequently discharged from the ED for a suicide-related complaint were higher than for ED comparison groups. METHODS: This was a nonconcurrent cohort study set at a university-affiliated urban ED and Level 1 trauma center. All ED patients 10 years and older, with at least one ED visit between February 1994 and November 2004, were eligible. ED visit characteristics defined the cohort exposure. Patients with visits for suicide attempt or ideation, self-harm, or overdose (exposed) were compared with patients without these visits (unexposed). Exposure classification was determined from billing diagnoses, E-codes (E950-E959), and free-text searching of the ED tracking system data for suicide, overdose, and spelling variants. Emergency department patient data were probabilistically linked to state mortality records. The principal outcome was suicide death. Suicide mortality rates were calculated by using person-year (py) analyses. Relative rates (RR) and 95% confidence intervals (95% CIs) were calculated from Cox proportional hazards models. RESULTS: Among the 218,304 patients, the average follow-up was 6.0 years; there were 408 suicide deaths (incidence rate [IR]: 31.2 per 100,000 py). Males (IR: 48.3) had a higher rate than females (IR: 13.5; RR: 3.6; 95% CI = 2.8 to 4.6). A single ED visit for overdose (RR: 5.7; 95% CI = 4.5 to 7.4), suicidal ideation (RR: 6.7; 95% CI = 5.0 to 9.1), or self-harm (RR: 5.8; 95% CI = 5.1 to 10.6) was strongly associated with increased suicide risk, relative to other patients. CONCLUSIONS: The suicide rate among these ED patients is higher than population-based estimates. Rates among patients with suicidal ideation, overdose, or self-harm are especially high, supporting policies that mandate psychiatric interventions in all cases.

Rural and urban fatal pedestrian crashes among United States American Indians and Alaskan Natives.

The Fatality Analysis Reporting System (FARS) and the Web-based Injury Statistics Query and Reporting System (WISQARS) were used to compare fatal pedestrian crashes in American Indians and Alaskan Natives (AI/AN) between urban and rural locations for 2000-2001. There were significant differences between urban and rural crashes for driver, pedestrian, environmental, and engineering factors. Rural pedestrian crashes more often occurred on highways (p<0.0001) lacking traffic control devices (p<0.0001) and artificial lighting (p<0.0001). Alcohol was a significant cofactor in both environments (40% urban vs. 55% rural; p=0.0239). Prevention of AI/AN deaths should include engineering countermeasures specific to the needs of rural (lighting) and urban (medians with barriers) environments and address drinking behavior in both populations.