The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study

Since 1990, Florida has used a uniform set of eight triage criteria, known as the trauma scorecard, for triaging adult patients with trauma to state-approved trauma centers. If any one of the eight criteria are met, paramedics classify the patient as a "trauma alert" and transport to a state-approved trauma center. Widespread concern within the trauma care community that the scorecard was not providing an effective tool for adult trauma triage, particularly for older adults, was a motivating force for conducting an evaluation of the trauma scorecard's performance. Thus, the Florida Department of Health and Rehabilitative Services, Office of Emergency Medical Services initiated a research effort to assess the effectiveness of the state-adopted trauma triage criteria for adults, giving special attention to geriatric trauma. The results of the Florida Trauma Triage Study indicate that the eight triage criteria comprising the trauma scorecard produce unacceptable levels of undertriage in elderly patients (age 55 years or older) with life-threatening injuries.     

Latent infection with Epstein-Barr virus in odontogenic disorders: comparison among ameloblastoma, dentigerous cyst and odontogenic keratocyst

This pilot study was carried out to determine whether converting from a two-tier to a three-tier in-hospital trauma triage system improves the efficiency of emergency department (ED) care and minimizes inappropriate triage. Patients at an urban, Level 1 trauma centre were triaged using either a two-tier (months 1-3; n = 197) or three-tier (months 4-6; n = 240) trauma response system. Patients were assessed for triage type, age, sex, injury severity score, Glasgow coma score, post-ED disposition, total ED time, survival, complication rate, probability of survival and unexpected death. Comparisons were made by ANOVA table analysis; significance was assumed for p < 0.05. Two-tier (n = 197) and three-tier patients (n = 240) were matched with respect to mean age, sex, mean injury severity score, mean Glasgow coma score, post-ED disposition, survival and probability of survival. Two-tier patients were triaged to give 20% alerts [criteria = physiological derangement (PD) and/or injury mechanism (MOI)] and 80% consults; three-tier patients were triaged as 20% category I (criteria = PD), 18% category II (criteria = MOI) and 62% consults. Total ED time decreased from two-tier (3.98 +/- 2.81 h) to three-tier triage (3.53 +/- 2.14 h, p = 0.001). There was no difference between two-tier alert and three-tier category I times (2.09 +/- 1.64 vs. 1.95 +/- 1.75 h; p = 0.72). Category II patients (3.28 +/- 1.98 h; p = 0.009) spent less time in the ED than did two-tier consults (4.36 +/- 2.65 h). The mean ED three-tier consult time significantly decreased as well (3.95 +/- 2.42 h, p = 0.008 vs. two-tier consult). Complications per patient were unchanged from two-tier to three-tier triage (0.17 +/- 0.52 vs. 0.12 +/- 0.48; p = 0.15). Under-triage (5%) and over-triage (7.5%) were minimal under three-tier triage. It is concluded that using a three-tier triage system results in an increase in the early involvement of the trauma service while decreasing emergency department time and minimizing over-triage.     

Effects of lead exposure on licking and yawning behaviour in rats

Most studies on facial trauma in the pediatric age group focus on special subgroups. This investigation encompasses all traumatic facial injuries, minor and major, of children and adolescents. Epidemiological data of the type and pattern of injury of trauma patients less than 19 years of age, treated during a 3-year-period in a large metropolitan trauma centre were reevaluated. Of the 1385 patients, 68% had soft tissue injuries, 24% had dental trauma, and 8% fractures of facial bones. More than 90% suffered from minimal or minor trauma. The leading cause of injury was a fall, predominantly at the toddler stage. In adolescents an adult mechanism of trauma prevailed: over 60% of injuries were sequelae of an assault or altercation. The male sex predominated through all age groups and for all types of injuries. The bulk of soft tissue injuries are located within a small falling zone, extending from the nose to the mental area. There was a rising incidence of fractures of facial bones towards older age groups, mandibular fractures being the most common. Condylar fractures, with their potential impact on further growth of the mandible, are seen frequently in children and adolescents, making up 80% of the fractures of the lower jaw.     

Paramedic judgment of the need for trauma team activation for pediatric patients

OBJECTIVE: To determine the value of paramedic judgment in determining the need for trauma team activation (TA) for pediatric blunt trauma patients. METHODS: A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28, 1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of >10 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. RESULTS: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric blunt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. CONCLUSION: Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly after injury. However, if a pediatric patient appears injured, transport from the scene and examination by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.     

Oral anticoagulation in dental surgery

STUDY OBJECTIVES: To evaluate whether pediatric or emergency medicine residents exhibit a bias when they select patients from triage based on the chief complaint, ie, medical versus surgical in the pediatric emergency department (PED). DESIGN: A retrospective chart review of a convenience sample of consecutive patients, excluding those seen during times when both pediatric and emergency medicine residents were not simultaneously present. SETTING: Urban Municipal PED with 25,000 visits annually. TYPE OF PARTICIPANTS: Pediatric residents, emergency medicine residents, and medical students rotating through the PED and their supervising attending physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred and ninety-nine charts were included in the study. On the basis of the triage complaint the initial diagnosis was classified as either surgical or medical. Surgical diagnoses were assigned to those patients who required a surgical procedure, involved a surgical subspecialty or were victims of trauma and represented 151 (25.2%) of the patients seen. Medical diagnoses were assigned to the nonsurgical patients and represented 448 (74.8%) of the patients seen. There are roughly three pediatric residents to each emergency resident working in our PED. Of the 367 patients seen by the pediatric residents, 73 (19.9%) had surgical diagnoses, and 294 (80.1%) had medical diagnoses. Of the 158 patients seen by the emergency residents, 59 (37.3%) had surgical diagnoses and 99 (62.7%) had medical diagnoses. chi2 analysis was used to compare categorical variables. The P value was considered significant at <0.05. DISCUSSION: Residents, both pediatric and emergency medicine, were instructed to see patients based upon the severity of the patient illness as judged by the triage nurse unless the patients' illnesses were of equal severity, in which case they were to be seen in the order in which they presented. The null hypothesis was that in the absence of physician bias, both pediatric and emergency medicine residents would see the same proportion of surgical and medical patients. The results showed that a bias exists. Emergency medicine residents saw a greater proportion of surgical patients, and pediatric residents saw a greater proportion of general medical patients. A limitation of this study may be the that the supervising attending physician selected residents to see certain patients to expedite PED flow. CONCLUSIONS: Recognizing that bias in the selection of patients seen exists is important in ensuring a balanced education experience.     

Vascularization of the humerus

OBJECTIVES: 1) To perform a statewide analysis of the frequency of major pediatric trauma cases and the use of resuscitation skills by paramedics (EMT-Ps). 2) To determine whether EMT-Ps use resuscitation skills less frequently for injured children than for older patients. METHODS: Study Design: Retrospective, database analysis of major trauma cases. Setting and Population: 1995 statewide trauma registry data for patients with EMT-P scene care. OBSERVATIONS: The database included patient demographics, field vital signs, field procedures [e.g., intravenous (i.v.) line placement, chest compressions, needle thoracostomy, endotracheal intubation], field medication, and vital signs at ED presentation. Data Analysis: Patients aged < or = 12 years ("pediatric") were compared with those aged > 12 years ("older"). Analyses of patients with tachycardia, hypotension, and obtundation were performed using chi 2 analysis (alpha = 0.05). RESULTS: Of 3,502 trauma patients managed by an EMT-P, only 297 (8%) were aged < or = 12 years. Fewer pediatric patients (18%) than adults (27%) had an injury severity scale score > or = 16, p < 0.005. The frequency of most resuscitation skills and the administration of medications were not statistically different between patient groups. However, i.v.s were four times more likely to be placed in adults (76%) than in pediatric patients (42%), p < 0.001. Subanalyses indicated fewer pediatric patients with tachycardia (p = 0.02) or hypotension (p = 0.02) received an i.v., compared with adults who had similar physiologic parameters. Obtunded patients were equally likely to receive endotracheal intubation, although the procedure was rarely used (20%). CONCLUSIONS: EMT-Ps infrequently manage seriously injured children. i.v.s are less frequently placed in pediatric trauma patients, even in the setting of physiologic abnormalities. The contributions of these field procedures to patient outcomes should be evaluated further.     

Pediatric all-terrain vehicle trauma: a 5-year statewide experience

BACKGROUND/PURPOSE: This is a retrospective review of the pediatric all-terrain vehicle trauma victims who presented to the five major trauma centers serving the state of West Virginia during the 5-year period from January 1991 to December 1995. The purpose of this research is to characterize the nature of the injuries and the individuals injured to better appreciate the magnitude of the problem of ATV-related injuries in the pediatric population. METHODS: This study is a retrospective review of these 218 consecutive pediatric patients from trauma registry data and their medical records. RESULTS: Two hundred eighteen patients between the ages of 2 years and 16 years presented during the study period. Boys outnumbered girls three to one. The average Injury Severity Score (ISS) was 8.76, the average Glasgow Coma Score (GCS) was 14.4, and the average Trauma Score (TS) was 15.2. The most common injuries were orthopedic followed by head and facial injuries. The majority of the children did not wear helmets, and their injuries resulted in an average hospital length of stay of 4.3 days. Thirty-eight percent of the children required surgery. There were a total of four deaths for a mortality rate of 1.8%. The estimated total hospitalization cost for the 218 patients was $1,918,400.00. CONCLUSIONS: All-terrain vehicle-related trauma remains an ongoing safety concern facing society today. Every physician who cares for children should address this important issue when talking to children and parents about safety issues and injury prevention.     

Profile of pediatric bicycle injuries

BACKGROUND: Bicycle injury data from local communities are important for developing injury prevention and control programs. This study represents the efforts of one community trauma center to describe bicycle injuries. METHODS: We conducted a retrospective analysis of bicycle injury data from hospital charts, emergency medical services reports, and medical examiner reports. The review encompassed a 4-year period. The study sample included 211 trauma alert patients, ages 1 through 15 years, who were treated for bicycle-related injuries at our level II pediatric trauma center. RESULTS: Bicycle injuries accounted for 18% of all pediatric trauma alert patients. The mean age of injured children was 10 years, and 79% were males. Bicycle-motor vehicle collisions caused 84% of injuries. Only 3 children (1.4%) wore bicycle helmets. Resulting injuries included external wounds (86%), head injuries (47%), fractures (29%), and internal organs (9%). Six children died. CONCLUSIONS: Bicycle injuries are a significant cause of mortality and morbidity for children in our community. Use of safety helmets by child bicyclists is inadequate. The data from this study can be used as a baseline in testing the effectiveness of local and state interventions, including new legislation mandating helmet use by children in our state.     

Which bacteria are found in Belgian women with uncomplicated urinary tract infections in primary health care, and what is their susceptibility pattern anno 95-96?

OBJECTIVE: The purpose of a curfew is to decrease the amount of crime inflicted on minors during the late hours of the night. On June 1, 1994, a city curfew was instituted in New Orleans, requiring all persons 17 years of age or younger to be off the streets from 9 PM to 6 AM Sunday through Thursday, and from 11 PM to 6 AM on Friday and Saturday. This study evaluated the effect of the curfew on emergency medical services (EMS) transports for patients who were 17 years old or younger (pediatric). METHODS: Data from all pediatric transports were included from the months before (5/94) and after (6/94) the institution of the curfew, and from the same two months one year earlier (5/93 and 6/93). A chi-square test was used to evaluate comparisons. RESULTS: The city EMS transports 48,000 patients per year in a one-tiered system (paramedic only) that acts as the sole provider of emergency EMS transport in the city. Approximately 10% of all transports are pediatric, and 40% of the pediatric transports are for trauma. A total of 1,642 transports were found that fit the inclusion criteria. In May 1993, there were 415 total pediatric transports; 234 were pediatric trauma. In June 1993, there were 406 total pediatric transports; 250 were pediatric trauma. In May 1994, there were 447 total pediatric runs; 243 were pediatric trauma. During the postcurfew month, June 1994, there were a significant decrease in pediatric transports to 370 (p < 0.01) and a significant decrease in pediatric trauma transport to 189 (p < 0.01). CONCLUSION: The institution of a curfew may lead to a drop in pediatric EMS runs during curfew hours. Another value of the curfew may be in the secondary effects of the curfew in preventing childhood injury during noncurfew hours.     

Role of anticardiolipin antibodies in young persons with migraine and transient focal neurologic events: a prospective study

OBJECTIVES: The aim of this study was to determine the relative risks of pediatric diagnostic, interventional and electrophysiologic catheterizations. BACKGROUND: The role of the pediatric catheterization laboratory has evolved in the last decade as a therapeutic modality, although remaining an important tool for anatomic and hemodynamic diagnosis. METHODS: A study of 4,952 consecutive pediatric catheterization procedures was undertaken. RESULTS: Patient ages ranged from 1 day to 20 years (median 2.9 years). One or more complications occurred in 436 studies (8.8%) and were classified as major in 102 and minor in 458, with vascular complications (n=189; 3.8% of procedures) the most common adverse event. Arrhythmic complications (n=24) were the most common major complication. Death occurred in seven cases (0.14%) as a direct complication of the procedure and was more common in infants (n=5). Independent risk factors for complications included a young patient age and undergoing an interventional procedure. CONCLUSIONS: Complications continue to be associated with pediatric cardiac catheterization. Efforts should be directed to improving equipment for flexibility and size, and finding alternative methods for vascular access. Patient age and interventional studies are risk factors for morbidity and mortality.     

Computed tomography in injuries to the respiratory system in children. The correlation with adults

INTRODUCTION: Diagnostic imaging in emergency rooms may be inadequate and delayed, which makes chest traumas in children more severe and difficult to treat. We carried out a retrospective study on adults and children who had survived major chest traumas involving the respiratory tract to assess the differences between the two age groups and the role of emergency CT. MATERIAL AND METHODS: Our series consisted of fourteen children admitted to the emergency department for various accidents. Home accidents prevailed (9/14 = 64.3%). On admission, chest radiography was performed in most cases (11/14 = 78.6%); CT was carried out in 21.4% (3/14 patients). RESULTS: Trauma involved more organs in pediatric patients (11/14 = 78.6%) and lung involvement was always associated with other types of injury, namely contusion (14/14 = 100%), pneumothorax (11/14 = 78.6%), hemothorax (10/14 = 71.4%), tear (4/14 = 28.6%). CT corrected or integrated the radiographic findings of contusion focus in 67% (8/14) and that of pneumothorax in 63.6%; both patterns cannot be demonstrated otherwise. DISCUSSION: Mixed and multiple posterior parenchymal injuries with no rib fractures prevail in young subjects because their bones and ligaments are more elastic, which may lead to trauma underestimation. Tracheobronchial ruptures and pneumomediastinum are much more severe in children than in adults. Chest plain film is often the only diagnostic tool used, despite its major technical and interpretative limitations, also because skull and abdomen are the most investigated regions. Executive limitations are stronger in childhood, increasing the margin of error and the risk of delayed treatment. CT is as cost-effective as radiography and shows even the injuries missed or poorly depicted on conventional images; CT also gives accurate information on damage severity and nature. CONCLUSIONS: Traumatic injuries are more severe in pediatric patients due to their build and to biomechanical, clinical and management factors. Spiral CT should be considered the examination of choice to be performed in the emergency department equipped also for pediatric re-animation.     

Results of treatment of multiple trauma in 130 children

Trauma remains the leading cause of death in the pediatric age group, despite recent advances in prevention and treatment. We retrospectively analyzed 130 cases of multiple trauma among 725 pediatric patients with injuries treated here during 1988-1989. Road accidents and falls from heights were the most common causes of injury. Mean age was 7 years (range 0.5-15) and the male to female ratio 2.7:1.0. Overall mortality was 9.2%. 57 patients (44%) did not get any prehospital medical care and 5 of them with injury severity scores (ISS) greater than 25 died. In contrast 11/18 (61%) of patients with ISS greater than 25 who were treated by medical teams survived. On arrival at the emergency room, 15% were hypothermic ( < 34 degrees C), and 6 were in hypovolemic shock--5 of whom died. Most common injuries were head trauma (91), limb injuries (69), abdominal trauma (34) and thoracic trauma (34). In 39 injury was severe, with pediatric trauma score (PTS) 6 or less, 12 of whom died. All deaths except 1 were associated with severe head injury and with ISS more than 25. There was no mortality in those with PTS more than 7 or ISS less than 25. Thus, the prehospital care of pediatric patients with head injury is associated with high mortality. Absence of mortality in patients with PTS of more than 7 emphasizes the importance of designated trauma centers for these patients.     

Local anesthetics inhibit the G protein-mediated modulation of K+ and Ca++ currents in anterior pituitary cells

OBJECTIVES: To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome. METHODS: A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function. RESULTS: The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in 5 cases. Of 36 cases with follow-up, complications developed in 9 cases (25%), 7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome adversely were pediatric age (< or =12 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury. CONCLUSION: Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.     

A critical analysis of on-scene helicopter transport on survival in a statewide trauma system

BACKGROUND: Recently, questions have been raised regarding the effectiveness of helicopters in trauma care. We conducted a retrospective study to evaluate the effect of on-scene helicopter transport on survival after trauma in a statewide trauma system. METHODS: Data were obtained from a statewide trauma registry of 162,730 patients treated at 28 accredited trauma centers. Patients transported from the scene by helicopter (15,938) were compared with those transported by ground with advanced life support (ALS) (6,473). Interhospital transfers and transports without ALS were excluded. Statistical analysis was performed using one-way analysis of variance and logistic regression. RESULTS: Patients transported by helicopter were significantly (p < 0.01) younger, were more seriously injured, and had lower blood pressure. They were also more likely to be male and to have systolic blood pressure < 90 mm Hg. Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival. CONCLUSION: A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.     

Characteristics of pancreatic injury in children: a comparison with such injury in adults

A retrospective study of eight pediatric patients (under 15 years of age) who had pancreatic injuries was undertaken. Comparisons were made with 59 adult patients who sustained pancreatic injuries over the same 15-year period. All the pediatric injuries and 96.6% of the adult resulted from blunt abdominal trauma. Bicycle accidents (children, 75.0%; adults, 0%; P < .001) and automobile accidents (children, 0%; adults, 61.0%; P < .01) were the most common causes of pancreatic injury in the two groups. There was no significant difference in the incidence of abdominal pain or peritoneal irritation between the groups. However, abdominal pain in the adults was poorly localized. Isolated pancreatic injuries were noted in 62.5% of the pediatric patients and in 15.3% of the adult patients (P < .05). Associated intraabdominal injuries were present in 25.0% of the children and in 69.5% of the adults (P < .05). The duodenum was injured in two (25.0%) pediatric patients and in 10 (16.9%) adult patients. Whereas the duodenal injuries in pediatric patients were intramural hematomas without perforation in both cases, all but one of these injuries in adults were perforations or transections (P < .05). There was a significant difference in the type of pancreatic injury between the two groups (P < .05). Surgery was performed in 12.5% of the pediatric cases and in 78.0% of the adult cases (P < .01). There were no deaths among the pediatric patients, but 8.5% of the adults died in the hospital. The difference with respect to clinical course might be related to the differences in cause of injury.     

Evaluation of head injury in a pediatric emergency department: pretrauma and posttrauma system

OBJECTIVE: To determine if trauma center protocols affect the number of tests and consultations performed and the length of time spent in the emergency department or hospital. DESIGN: A retrospective review and comparison of treatment for children with isolated head injury admitted to the emergency department before trauma center designation (group 1, 1985), and 5 years after implementation of trauma center protocols (group 2, 1991). SETTING: Urban children's hospital, level I trauma center. RESULTS: One hundred sixty-five children met the enrollment criteria in 1985 and 162 met the criteria in 1991. Falls were the predominant mechanism of injury (55%) for both years. For patients with moderate injury (Glasgow Coma Scale score, 9-12) or severe injury (Glasgow Coma Scale score, <9), there was no difference in radiographic or laboratory evaluation. For patients with minimal head injury (Glasgow Coma Scale score, 15, no loss of consciousness, amnesia, seizure, focal neurologic findings, or persistent symptoms) and minor head injury (Glasgow Coma Scale score, >12, and loss of consciousness or amnesia), more radiologic and laboratory studies were done in 1991 that showed no clinically significant abnormalities. Patients with minimal head injury in group 2 were 14 times more likely to have cranial computed tomographic scans performed (95% confidence interval [CI], 3.4-67); 11 times more likely to have cervical spine radiographs (95% CI, 2.2-76.6); and 23 times more likely to have hepatic enzymes obtained (95% CI, 3-491). These differences persisted when analyzed by both the age of the patient and mechanism of injury. CONCLUSIONS: Application of trauma system protocols to isolated head injury patient evaluation results in increased use of laboratory and radiologic services. These practices have the potential to increase the cost of medical care without significantly improving outcome.     

The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs

OBJECTIVE: To describe the incidence and causes of pediatric head, spinal cord, and peripheral nerve injuries in an urban setting and to assess the implications of these data for injury prevention programs. METHODS: Pediatric deaths and hospital admissions secondary to neurological trauma included in the Northern Manhattan Injury Surveillance System from 1983 to 1992 were linked to census counts to compute incidence rates. Rates before the implementation of a nonspecific injury prevention program were compared with rates after the implementation, and rates for the target population were compared to rates for the control population. Rates were analyzed on the basis of the cause of injury as well as the age, gender, and neighborhood income level of the injured. RESULTS: The incidence of neurological injuries resulting in hospitalization or death was 155 incidents per 100,000 population per year; the mortality rate was 6 people per 100,000 population per year. Neurological injuries represented 18% of all pediatric injuries and accounted for 23% of all traumatic deaths. Spinal cord and peripheral nerve injuries were relatively rare (5%) compared to head injuries (95%). Minor head injuries, including isolated cranial fractures, minor concussions (<1 h loss of consciousness), and unspecified minor head injuries, accounted for the majority of neurological injuries (76%), whereas severe head injuries, including severe concussion (>1 h loss of consciousness), cerebral laceration/contusion, intracerebral hemorrhage, and unspecified major injuries, were less common (18% of all neurological injuries). Boys were more often affected than girls at every age, and this preference increased with age. Children younger than 1 year showed the highest incidence of both major and minor injuries. One- to 4-year olds showed the lowest rates, with steady increases thereafter. Traffic accidents and falls were the leading causes (38 and 34%, respectively), and assaults were the next leading causes (12%). Among children admitted to surveillance system hospitals, falls were most common in children younger than 4 years, pedestrian motor vehicle accidents were most common in late childhood, and assaults were most common in early adolescence. Case:fatality rates were 5 to 7% for all age groups except 5- to 12-year-olds, for whom the case:fatality rate was 1.9%. Residence in a low-income neighborhood was associated with an increased risk of injury (rate ratio, 1.71; confidence interval, 95%, 1.54, 1.89). The average hospitalization cost per injury was $8502. Medicaid (54%) and other government sources (5%) covered the majority of expenses, including indirect reimbursement of usually uncollected self-pay billing (19%). Although injury incidence rates fell in both the control and intervention cohorts during implementation of a nonspecific injury prevention program, targeted age and population groups demonstrated greater relative reductions in injuries than nontargeted ones, suggesting a positive effect. CONCLUSIONS: Deaths and hospital admissions secondary to pediatric neurological trauma represent a significant public health problem, with the majority of the direct cost being born by government agencies. Future efforts to prevent neurological trauma in children who live in inner cities should focus on families with low incomes and provide novel education programs regarding infant abuse, infant neglect, and infant injury avoidance. Age-appropriate school-based programs should also be developed to address traffic safety and conflict resolution.     

The feasibility of organ salvage from non-heart-beating trauma donors

BACKGROUND: Blunt trauma patients without vital signs on admission are potential non-heart-beating donors. OBJECTIVE: To review the feasibility of postmortem visceral perfusion and organ donation in blunt trauma patients without vital signs. DESIGN: A retrospective case series of blunt trauma victims who were declared dead in the emergency department. SETTING: A level I trauma center. MAIN OUTCOME MEASURES: Factors potentially precluding donation and potential donor yield. RESULTS: The mean trauma-to-death interval was 71 minutes (< 60 minutes in 57% of the cases). Injuries likely to interfere with in situ perfusion were present in 41% of the cases. The tissue donation consent rate was 45%. Assuming a similar organ donation consent rate, the potential donor yield was 9% after excluding victims who were younger than 60 years of age, warm ischemia times that were less than 60 minutes, and patients who had injuries precluding perfusion. CONCLUSIONS: The potential organ yield from non-heart-beating, blunt trauma victims is low, which highlights the ethical and legal problems of this approach.     

After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices

BACKGROUND: After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. OBJECTIVES: This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. METHODS: After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. RESULTS: In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. CONCLUSIONS: Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.