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Evaluation of the injury profile of personnel in a busy urban EMS system
ABSTRACTS
patients had C trachomatis reisolated after therapy. Twelve posttreatment isolates of C trachomatis were available for serotyping, and all showed the same serotype as the initial infecting strain. It was concluded that ciprofloxacin in both regimens of as much as 2 g daily is as effective as d0xycycline for the treatment of t h e c l i n i c a l s y n d r o m e of n o n gonococca] urethritis, but that the ciprofloxacin regimens were ineffective in curing chlamydial urethritis.
James Bodenhamer, MD
seat belt syndrome; abdominal trauma, blunt
Delayed onset of intestinal obstruction in children a f t e r unrecognized seat belt injury Hardacre JM, West KW, Rescorla FR, et al J Pediatr Surg 25:967-969 Sep 1990
Safety seats and seat belts have considerably decreased the mortality of children involved in motor Vehicle accidents. However, the use of these devices has contributed to the increasing number of cases of a spectrum of injuries, including intestinal perforation, mesenteric disruptions, lumbar fractures, and dislocations, termed the "seat belt syndrome." The authors present two cases of delayed-onset intestinal obstruction attributed to Unrecognized abdominal trauma. In both cases, the children were restrained with adult lap belts only. Both had significant concomitant injuries (L-4 vertebral compres sion fracture and splenic rupture, respectively) and presented three to six weeks after the accident with symptoms of small bowel obstruction: bilious emesis, nausea, and abdominal pain. The children were evaluated by abdominal radiograph in one case and abdominal computed tom0graphy and a small bowel contrast study in the other. At exploratory laparotomy, both were found to have volvulus secondary to an omental adhesion, Most visceral injuries are detected and treated promptly, often with the aid of the seat belt sign: 20:1 January 1991
contusions, petechiae, and abrasions across the chest or lower abdomen. Recommendations are to maintain a high index of suspicion for these injuries, encourage the use of shoulder harnesses, and promptly investigate the signs and symptoms of smallbowel obstructions in the post-traumatic pediatric patient.
Anne Winiarski, MD
motor vehicle accidents, smoking
Risk of automobile a c c i d e n t s in c i g a r e t t e smokers Brison RJ Can ,J Pubfic Health 81:102-106 Mar 1990
Cigarette smoking has been shown to be a risk factor for accidental injury. Controversy remains whether smokers have an increased risk of motor vehicle crash that is independent of alcohol use. The author undertook a case-control study to identify any increased risk of motor vehicle crash m cigarette smokers over nonsmokers. To minimize variability expected by age and sex with respect to known risk factors of motor vehicle crashes Lalcohol use, number of miles driven per year, car ownership), the sample was restricted to men from 30 to 39 years old. Cases were defined as presence of a motor vehicle crash over a two-year period, and crashes studied were those resulting in property damage alone. Twentyone hundred self-administered questionnaires Ii,100 control and 1,000 case) were mailed to Washington state residents asking about motor vehicle crash history, smoking status, proportion of time one smokes while driving, usual use of alcohol, usual driving speed, average annual mileage, age, income, and marital status; the response rate was 55%. Questionnaires lacking information on s m o k i n g or other i n f o r m a t i o n were excluded, resulting in a sample of 595 cases and 548 controls. The case group included those individuals w i t h d o c u m e n t e d m o t o r vehicle crash on state motor vehicle records and/or those declaring themselves inAnnals
of EmergencyMedicine
volved in a motor vehicle crash on the questionnaire. The Case group was then subdivided into those admitting to at least partial responsibility for the accident (356) and those not at fault (239). Unadjusted relative risk estimates and logistic regression analysis found that for drivers at fault, cigarette smokers have a 50% higher risk for motor vehicle crash. Increased number of miles driven per year and younger age increased risk regardless of fault. Alcohol was not a statistically significant risk factor for motor vehicle crash in this group, although a trend toward increasing risk of crash with increasing alcohol use was noted. Increased risk for motor vehicle crash also was seen with increasing frequency of smoking while driving. Seat belt use, speed while driving, income. and marital status were not found to be statistically significant risk factors for motor vehicle crashes. It was concluded that there is an association between smoking and automobile accidents that is likely to be independent of the risk of alcohol use, and the t e n d e n c y to s m e k e while driving shows a strong association with the risk of motor vehicle crashes. Several postulates as to why a relationship between motor vehicle crash and smoking may exist include distraction from driving, behavioral differences in smokers, and possible carbon monoxide toxicity.
Jeffrey Hill. MD
emergency medical services, occuoatlona injury
Evaluation of the injury profile of personnel in a busy urban EMS s y s t e m Hogya PT, Ellis L Am J Emerg Med 4:308 Jul 1990
This retrospective study of 254 injuries, occurring over a three-to-fiveyear period in a busy emergency medical services system suggests an occupational injury profile among emergency medical technicians (EMTs} and paramedics. The most common injury was low back strain, 112/155
ABSTRACTS
.with a higher rate among EMTs than paramedics. In 31% of the personnel, the back injuries were recurrent. There was no correlation between job experience and injury rates. Overall, injury rates were higher in EMTs than in paramedics, in women than in men, and i n personnel less than 30 years old. Approximately 96 injuries a c c o u n t e d for 48 lost w o r k days, while low back strain accounted for 375 lost work days. Guidelines for prevention are discussed, including proper lifting techniques and not attempting to lift weights beyond one's capability. .Robin Johnson, MD
prehospital care, protocols
Does p a r a m e d i c - b a s e hospital c o n t a c t result in beneficiai deviations from standard prehospital protocols? Hoffman JR, Luo J, Schriger D, et al West J Med 153:283-287 Sep 1990
In some Prehospital systems, paramedics are authorized to provide care essentially 0nly under the direct supervision of certified base hospital physicians or certified mobile intensive care nurses. For many prehospital chief complaints, treatments almost never vary and generally follow simple protocols. The authors hypothesized that the preh0spital management of patients with these complaints would be easily amenable to an algorithm-directed system and bypass the need for direct hospital communication. Four common prehospital chief complaints (abdominal pain, syncope, seizure, and altered mental status) were selected and algorithms were abstracted from standard local protocols. A retrospective review of the written and audio records of paramedic:base hospital radio contact for all patients (659) with one of these chief complaints was performed to d e t e r m i n e w h e t h e r t r e a t m e n t differed from that suggested in the abstracted algorithms. Cases that involved unanticipated treatments were reviewed to determine the basis 156/113
for the variation in treatment. Unanticipated therapies were administered to only 13 patients, all of whom had abnormal vital signs, diaphoresis, r e s p i r a t o r y distress, or a second p r o m i n e n t s y m p t o m . It was concluded that protocols could replace radio contact for most patients and that the few who might benefit from radio contact could be identified easily. S u c h selective base-station contact would not only decrease the time spent in the prehospital environment, but would dramatically diminish the number of radio contacts, thus allowing consolidation of base stations and u l t i m a t e l y translating into cost savings. [Edftor's note: It is interesting to note the variability between those prehospita] care systems requiring m a n d a t o r y base station contact and those using field management with standing protocols and select base station contact. Those of us involved with the latter type of system realize that it is a safe and efficient means of delivering prehospital care, provided there is an ongoing audit of paramedic runs.] Mark Copeland, MD
trauma, blunt chest; myocardial contusion
S u s p e c t e d myocardial contusion: Triage and indications for monitoring Wisner DH, Reed WH, Riddick RS Ann Surg 212:82-86 Jul 1990
In this r e t r o s p e c t i v e study, all 3,010 blunt trauma admissions for a 16-month c o n s e c u t i v e period tO a t r a u m a center were reviewed. Of these patients, 10l were declared dead in the emergency department; 14 had autopsy evidence of myocardial contusion, and another 12 had other types of cardiac injury. Thirteen patients died in the operating room, and one had evidence of myocardial contusion. Of the 644 patients admitted to monitored beds, there were 47 deaths. None of these p a t i e n t s had a u t o p s y evidence of myocardial contusion. There were 2,252 a d m i s s i o n s to u n m o n i t o r e d beds; nine of these patients required
Annals of EmergencyMedicine
transfer to the iCU, and two subsequently died. Neither had clinical/ autopsy evidence of myocardial contusion. Of the 95 patients admitted with diagnosis of rule-out myocardial contusion, none developed subsequent cardiac failure. A r r h y t h m i a s occurred in 19 patients, four of whom were considered serious enough to require treatment; three of these patients had conduction abnormalities on admission ECG, and the other was s u b s e q u e n t l y d e t e r m i n e d to have a benign baseline arrhythmia. CPK-MB fractions and echocardiograms were poor predictors of serious arrhythmias. It was concluded that patients with clinically significant blunt cardiac injury will manifest signs of injury shortly after trauma and that stable patients with no conduction abnormalities on admission ECG can Safely be admitted to unmonitored beds. Ilya Chern, MD
cerebrovascular accidents, cocaine
Cerebrovascular complications of the u s e of the " c r a c k " form of alkaloid cocaine Levine SR, Brust JCM, Futrell N, et al N Engl J Med 323:699-704 Sep 1990
A mixed prospective and retrospective review of 28 patients who had strokes temporally related to the use of alkaloid cocaine (crack) was performed. Patients were included in the study if there was a confirmatory history of smoking crack cocaine within 72 hours of their neurologic event. P a t i e n t s were e x c l u d e d f r o m the study if they had used cocaine hydrochloride in the recent past or if the nature of their cocaine use was in doubt. Toxicology screening was performed on 16 of the 28 patients and was positive for cocaine in all 16. The mean age of the patients was 34 years (range, 23 to 49 years). Eighteen (64%) had acute neurologic sympt o m s i m m e d i a t e l y or w i t h i n one hour of using crack, and five (18%) developed s y m p t o m s within one to 20:1 January 1991
patients had C trachomatis reisolated after therapy. Twelve posttreatment isolates of C trachomatis were available for serotyping, and all showed the same serotype as the initial infecting strain. It was concluded that ciprofloxacin in both regimens of as much as 2 g daily is as effective as d0xycycline for the treatment of t h e c l i n i c a l s y n d r o m e of n o n gonococca] urethritis, but that the ciprofloxacin regimens were ineffective in curing chlamydial urethritis.
James Bodenhamer, MD
seat belt syndrome; abdominal trauma, blunt
Delayed onset of intestinal obstruction in children a f t e r unrecognized seat belt injury Hardacre JM, West KW, Rescorla FR, et al J Pediatr Surg 25:967-969 Sep 1990
Safety seats and seat belts have considerably decreased the mortality of children involved in motor Vehicle accidents. However, the use of these devices has contributed to the increasing number of cases of a spectrum of injuries, including intestinal perforation, mesenteric disruptions, lumbar fractures, and dislocations, termed the "seat belt syndrome." The authors present two cases of delayed-onset intestinal obstruction attributed to Unrecognized abdominal trauma. In both cases, the children were restrained with adult lap belts only. Both had significant concomitant injuries (L-4 vertebral compres sion fracture and splenic rupture, respectively) and presented three to six weeks after the accident with symptoms of small bowel obstruction: bilious emesis, nausea, and abdominal pain. The children were evaluated by abdominal radiograph in one case and abdominal computed tom0graphy and a small bowel contrast study in the other. At exploratory laparotomy, both were found to have volvulus secondary to an omental adhesion, Most visceral injuries are detected and treated promptly, often with the aid of the seat belt sign: 20:1 January 1991
contusions, petechiae, and abrasions across the chest or lower abdomen. Recommendations are to maintain a high index of suspicion for these injuries, encourage the use of shoulder harnesses, and promptly investigate the signs and symptoms of smallbowel obstructions in the post-traumatic pediatric patient.
Anne Winiarski, MD
motor vehicle accidents, smoking
Risk of automobile a c c i d e n t s in c i g a r e t t e smokers Brison RJ Can ,J Pubfic Health 81:102-106 Mar 1990
Cigarette smoking has been shown to be a risk factor for accidental injury. Controversy remains whether smokers have an increased risk of motor vehicle crash that is independent of alcohol use. The author undertook a case-control study to identify any increased risk of motor vehicle crash m cigarette smokers over nonsmokers. To minimize variability expected by age and sex with respect to known risk factors of motor vehicle crashes Lalcohol use, number of miles driven per year, car ownership), the sample was restricted to men from 30 to 39 years old. Cases were defined as presence of a motor vehicle crash over a two-year period, and crashes studied were those resulting in property damage alone. Twentyone hundred self-administered questionnaires Ii,100 control and 1,000 case) were mailed to Washington state residents asking about motor vehicle crash history, smoking status, proportion of time one smokes while driving, usual use of alcohol, usual driving speed, average annual mileage, age, income, and marital status; the response rate was 55%. Questionnaires lacking information on s m o k i n g or other i n f o r m a t i o n were excluded, resulting in a sample of 595 cases and 548 controls. The case group included those individuals w i t h d o c u m e n t e d m o t o r vehicle crash on state motor vehicle records and/or those declaring themselves inAnnals
of EmergencyMedicine
volved in a motor vehicle crash on the questionnaire. The Case group was then subdivided into those admitting to at least partial responsibility for the accident (356) and those not at fault (239). Unadjusted relative risk estimates and logistic regression analysis found that for drivers at fault, cigarette smokers have a 50% higher risk for motor vehicle crash. Increased number of miles driven per year and younger age increased risk regardless of fault. Alcohol was not a statistically significant risk factor for motor vehicle crash in this group, although a trend toward increasing risk of crash with increasing alcohol use was noted. Increased risk for motor vehicle crash also was seen with increasing frequency of smoking while driving. Seat belt use, speed while driving, income. and marital status were not found to be statistically significant risk factors for motor vehicle crashes. It was concluded that there is an association between smoking and automobile accidents that is likely to be independent of the risk of alcohol use, and the t e n d e n c y to s m e k e while driving shows a strong association with the risk of motor vehicle crashes. Several postulates as to why a relationship between motor vehicle crash and smoking may exist include distraction from driving, behavioral differences in smokers, and possible carbon monoxide toxicity.
Jeffrey Hill. MD
emergency medical services, occuoatlona injury
Evaluation of the injury profile of personnel in a busy urban EMS s y s t e m Hogya PT, Ellis L Am J Emerg Med 4:308 Jul 1990
This retrospective study of 254 injuries, occurring over a three-to-fiveyear period in a busy emergency medical services system suggests an occupational injury profile among emergency medical technicians (EMTs} and paramedics. The most common injury was low back strain, 112/155
ABSTRACTS
.with a higher rate among EMTs than paramedics. In 31% of the personnel, the back injuries were recurrent. There was no correlation between job experience and injury rates. Overall, injury rates were higher in EMTs than in paramedics, in women than in men, and i n personnel less than 30 years old. Approximately 96 injuries a c c o u n t e d for 48 lost w o r k days, while low back strain accounted for 375 lost work days. Guidelines for prevention are discussed, including proper lifting techniques and not attempting to lift weights beyond one's capability. .Robin Johnson, MD
prehospital care, protocols
Does p a r a m e d i c - b a s e hospital c o n t a c t result in beneficiai deviations from standard prehospital protocols? Hoffman JR, Luo J, Schriger D, et al West J Med 153:283-287 Sep 1990
In some Prehospital systems, paramedics are authorized to provide care essentially 0nly under the direct supervision of certified base hospital physicians or certified mobile intensive care nurses. For many prehospital chief complaints, treatments almost never vary and generally follow simple protocols. The authors hypothesized that the preh0spital management of patients with these complaints would be easily amenable to an algorithm-directed system and bypass the need for direct hospital communication. Four common prehospital chief complaints (abdominal pain, syncope, seizure, and altered mental status) were selected and algorithms were abstracted from standard local protocols. A retrospective review of the written and audio records of paramedic:base hospital radio contact for all patients (659) with one of these chief complaints was performed to d e t e r m i n e w h e t h e r t r e a t m e n t differed from that suggested in the abstracted algorithms. Cases that involved unanticipated treatments were reviewed to determine the basis 156/113
for the variation in treatment. Unanticipated therapies were administered to only 13 patients, all of whom had abnormal vital signs, diaphoresis, r e s p i r a t o r y distress, or a second p r o m i n e n t s y m p t o m . It was concluded that protocols could replace radio contact for most patients and that the few who might benefit from radio contact could be identified easily. S u c h selective base-station contact would not only decrease the time spent in the prehospital environment, but would dramatically diminish the number of radio contacts, thus allowing consolidation of base stations and u l t i m a t e l y translating into cost savings. [Edftor's note: It is interesting to note the variability between those prehospita] care systems requiring m a n d a t o r y base station contact and those using field management with standing protocols and select base station contact. Those of us involved with the latter type of system realize that it is a safe and efficient means of delivering prehospital care, provided there is an ongoing audit of paramedic runs.] Mark Copeland, MD
trauma, blunt chest; myocardial contusion
S u s p e c t e d myocardial contusion: Triage and indications for monitoring Wisner DH, Reed WH, Riddick RS Ann Surg 212:82-86 Jul 1990
In this r e t r o s p e c t i v e study, all 3,010 blunt trauma admissions for a 16-month c o n s e c u t i v e period tO a t r a u m a center were reviewed. Of these patients, 10l were declared dead in the emergency department; 14 had autopsy evidence of myocardial contusion, and another 12 had other types of cardiac injury. Thirteen patients died in the operating room, and one had evidence of myocardial contusion. Of the 644 patients admitted to monitored beds, there were 47 deaths. None of these p a t i e n t s had a u t o p s y evidence of myocardial contusion. There were 2,252 a d m i s s i o n s to u n m o n i t o r e d beds; nine of these patients required
Annals of EmergencyMedicine
transfer to the iCU, and two subsequently died. Neither had clinical/ autopsy evidence of myocardial contusion. Of the 95 patients admitted with diagnosis of rule-out myocardial contusion, none developed subsequent cardiac failure. A r r h y t h m i a s occurred in 19 patients, four of whom were considered serious enough to require treatment; three of these patients had conduction abnormalities on admission ECG, and the other was s u b s e q u e n t l y d e t e r m i n e d to have a benign baseline arrhythmia. CPK-MB fractions and echocardiograms were poor predictors of serious arrhythmias. It was concluded that patients with clinically significant blunt cardiac injury will manifest signs of injury shortly after trauma and that stable patients with no conduction abnormalities on admission ECG can Safely be admitted to unmonitored beds. Ilya Chern, MD
cerebrovascular accidents, cocaine
Cerebrovascular complications of the u s e of the " c r a c k " form of alkaloid cocaine Levine SR, Brust JCM, Futrell N, et al N Engl J Med 323:699-704 Sep 1990
A mixed prospective and retrospective review of 28 patients who had strokes temporally related to the use of alkaloid cocaine (crack) was performed. Patients were included in the study if there was a confirmatory history of smoking crack cocaine within 72 hours of their neurologic event. P a t i e n t s were e x c l u d e d f r o m the study if they had used cocaine hydrochloride in the recent past or if the nature of their cocaine use was in doubt. Toxicology screening was performed on 16 of the 28 patients and was positive for cocaine in all 16. The mean age of the patients was 34 years (range, 23 to 49 years). Eighteen (64%) had acute neurologic sympt o m s i m m e d i a t e l y or w i t h i n one hour of using crack, and five (18%) developed s y m p t o m s within one to 20:1 January 1991