- Email: [email protected]
From the Feds: research, programs, and products
FROM THE FEDS
From the Feds: Research, Programs, and Products Laurie Flaherty, RN, MS, Washington, DC Department of Health and Human Services Breeds of Dogs Involved in Fatal Human Attacks
PUBLIC HEALTH SERVICE Teens Face Serious Risk of Job-related Death in Agricultural Operations
Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC) Breeds of dogs involved in fatal human attacks: NCIPC’s
Laurie Flaherty, Mid-Maryland Chapter, is Emergency Nurse at Suburban Hospital, Bethesda, Md, and a Contract Employee of the National Highway Traffic Safety Administration in Washington, DC. For reprints, write: Laurie Flaherty, RN, MS, 3519 Rittenhouse St, NW, Washington, DC 20015; E-mail: [email protected]. J Emerg Nurs 2001;27:166-70. Copyright © 2001 by the Emergency Nurses Association. 0099-1767/2001 $35.00 + 0 18/9/113973 doi:10.1067/men.2001.113973
Division of Unintentional Injury Prevention recently released a special report that summarizes breeds of dogs involved in fatal human attacks during a 20-year period between 1979 and 1998. From 1979 through 1996, dog attacks resulted in more than 300 dog bite–related human fatalities in the United States.1-3 Most victims were children. Studies indicate that pit bull–type dogs were involved in approximately one third of deaths reported from 1981 through 1992, and rottweilers were responsible for about half of dog bite–related deaths from 1993 through 1996. These data have resulted in the inference that certain breeds of dogs are more likely to bite than are others and should, therefore, be banned or regulated more stringently.4,5 The purpose of this report was to summarize breeds associated with dog bite–related deaths during a 20year period and assess public policy implications. Data were collected from the Humane Society of the United States and from media accounts of attacks by dogs resulting in bites. The Humane Society maintains a registry of dog bite–related human fatalities, including the date of death, age, and sex of the victim, the city and state in which the attack occurred, the number and breed of dogs involved, and circumstances relating to the attack. Newspapers and periodicals were also scanned, and articles written about dog bite–related fatalities were reviewed. During the past 20 years, more than 25 breeds of dogs were involved in the 238 dog bite–related human deaths
166
JOURNAL OF EMERGENCY NURSING
Reducing Cervical Spine Radiographs in Patients With Blunt Trauma
New Standard to Require Internal Trunk Releases on Cars
Decrease in Fatalities Following Illinois .08 Blood Alcohol Content Law
Deaths and Injuries Increase in Texas and Arkansas Following Helmet Law Repeal
Child-resistant Lighters Reduce Fire Deaths
Recall to Repair Window Blinds
27:2 April 2001
FROM THE FEDS/Flaherty
for which some breed information was available. Dogs most frequently involved in fatal attacks were as follows: pit bull–type, 76; rottweiler, 44; German shepherd, 27; husky-type, 21; and wolf-dog hybrid, 15. The data have limitations related to comparison of the number of fatal attacks with the total dog breed population. However, despite these limitations, the data indicate that in 1997 and 1998, rottweilers and pit bull–type dogs accounted for 67% of dog bite–related human fatalities in the United States. It is highly unlikely that they represented anywhere near 60% of the dogs in the United States during this same period. These fatal attacks represent only the most severe manifestations of the problem. In 1986 alone, an estimated 585,000 dog bite injuries occurred that required medical attention or restricted activity.6 By 1994, an estimated 4.7 million people sustained a dog bite; 800,000 of these people sought medical care in the emergency department, and 6000 required hospital admission.7-9 These figures represent a 36% increase in bites requiring medical attention from 1986 to 1994. Although fatal dog bites receive more public attention, the increase in injuries might be a larger factor in determining public policy regarding dog bite prevention.
• Fewer than 1% of fatal cases were caused by leashed animals off the owner’s property. • Fatal bite reports reviewed indicated that problem behaviors (of dogs and owners) preceded attacks in a great many cases and might be considered sufficient evidence for preemptive action. Public policy cannot address the fact that a dog of any breed can become dangerous when bred or trained to become aggressive. Furthermore, a ban on any specific breed might cause people to simply turn to another breed for the same qualities they sought in the original dog. However, enforcement of existing animal control laws and educational and policy strategies to reduce inappropriate dog and owner behaviors, based on scientific reports such as this, may result in benefits to communities and may well decrease the number of dog bite injuries and fatalities. National Institute for Occupational Safety and Health (NIOSH) Teens face serious risk of job-related death in agricultural operations: Emergency nurses working in rural areas will
Some other interesting points were raised by the report. Several factors affect a dog’s propensity to bite, including heredity, gender, early experience, socialization and training, health, reproductive status, quality of ownership and supervision, and victim behavior. One study showed that male dogs were 6.2 times more likely to bite than were females, sexually intact dogs were 2.6 times more likely to bite than were neutered dogs, and chained dogs were 2.8 times more likely to bite than were unchained dogs.10 Other interesting facts of note: • Twenty-four percent of fatalities were caused by owned dogs that roamed off the owner’s property.
not be surprised by a recent report released by NIOSH, which states that teens face serious risk of job-related death in agricultural operations. NIOSH analyzed 5 years of data and found that 12.2 occupational fatalities occurred for every 100,000 youths working in agriculture, more than twice the rate for fatal occupational injuries overall in the United States for a comparable period (5.1 fatalities per 100,000 workers). The NIOSH findings are consistent with results from earlier research showing that youths who work and live on farms are at risk for injury and death. Each year, approximately 33,000 people younger than 20 years are seriously injured on farms, and more than 100 are killed. Other findings include the following: • Half the fatalities involved transportation incidents, including collisions, incidents involving loss of control of vehicle or equipment, and falls from moving vehicles. Tractors were the major cause of vehicle-related fatalities, accounting for 23% of all deaths. • Incidence of fatalities increased by age for people younger than 20 years, with the highest proportion occurring among 18- to 19-year-olds (30% of the total) and the next highest among 16- to 17-year-olds (25%). • Fatalities more often occurred among young people working for wages than in family agriculture operations.
April 2001 27:2
JOURNAL OF EMERGENCY NURSING
Dogs most frequently involved in fatal attacks were as follows: pit bull–type, 76; rottweiler, 44; German shepherd, 27; husky-type, 21; and wolf-dog hybrid, 15.
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FROM THE FEDS/Flaherty
• Forty-six percent of fatalities occurred in the Midwest, followed by 22 percent in the South; these were the regions with the highest prevalence. NIOSH works extensively with a broad coalition of partners in the safety, health, and agricultural communities to prevent injury and death among young people in agriculture. Additional information about these activities and recommendations about agricultural safety and health are available on the NIOSH Web site at www.cdc.gog/ niosh/agtopics.html. Information is also available from the National Children’s Center for Rural and Agricultural Health and Safety at http://research.marshfieldclinic.org/children, the National Safety Council at www.nsc.org/farmsafe.htm, and Farm Safety 4 Just Kids, at www.fs4jk.org. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)
Reducing cervical spine radiographs in patients with blunt trauma: ED patients who have sustained blunt trauma rou-
tinely have cervical spine radiographs performed to rule out hidden cervical spine injuries. A new study, supported by AHRQ, suggests that a simple set of clinical criteria can identify patients who have a very low probability of spinal injury and consequently do not need spinal radiographs. The study, performed at the University of California, Los Angeles, examined the performance of 5 clinical criteria to predict the likelihood of cervical spine injury in 34,069 patients who underwent radiographs of the cervical spine after blunt trauma at 21 centers across the United States. The following 5 clinical criteria were used as predictors of cervical spine injury: (1) no midline cervical tenderness, (2) no focal neurologic deficit, (3) normal alertness, (4) no intoxication, and (5) no painful or distracting injuries. Using this approach, all but 8 of the 818 patients who had cervical spine injury were identified, representing a sensitivity of 99%. Only 2 of these 8 patients were considered to have a clinically significant injury, and only 1 of these 2 patients underwent surgery to repair the injury. According to study results, cervical spine radiographs could have been avoided in the cases of 4309 (12.6%) of the 34,069 patients. Replication of this study, even on a small scale, would be an interesting next step toward the possibility of chang-
168
ing standard practice, especially for emergency nurses who see patients with potential cervical spine injuries on a daily basis. More details of this study can be found in the article “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma” by Hoffman et al in the July 13, 2000, issue of the New England Journal of Medicine (2000;343:94-9). Department of Transportation
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)
New standard to require internal trunk releases on cars:
NHTSA recently announced a new requirement that all passenger cars with trunks have a release or other automatic system inside to allow children or adults to escape. The requirement is effective as of September 1, 2001. Trunk entrapment involves both children trapped in trunks, often during play or other innocent circumstances, and adults trapped in trunks, generally as a result of criminal actions. In the summer of 1998, 11 children died from exposure to heat after inadvertently being trapped in car trunks. A study released that year by the CDC documented a total of 19 cases of children ages 6 years and younger who died in car trunks between 1987 and 1998. The new NHTSA standard adopts the approach recommended by an expert panel on trunk entrapment, established in November 1998. The panel included experts on child psychology and behavior, safety advocacy, automotive engineering, vehicle manufacturing, law enforcement, the health care community, and other groups. The final rule establishes a new Federal Motor Vehicle Safety Standard (FMVSS) Number 401, Internal Trunk Release. Decrease in fatalities following Illinois .08 blood alcohol content law: New compelling evidence has been added to
the argument that .08 blood alcohol concentration (BAC) laws significantly reduce fatalities. A study done by NHTSA found that the .08 law in Illinois, effective in July of 1997, was associated with a 13.7% decline in the number of drinking drivers involved in fatal crashes. The reduction included drivers at both high and low BAC levels. The study, entitled “Effectiveness of the Illinois .08 Law,” also found no significant change in the number of
JOURNAL OF EMERGENCY NURSING
27:2 April 2001
FROM THE FEDS/Flaherty
alcohol-positive drivers involved in fatal crashes in the 5 neighboring states with .10 BAC laws during this time, and there was no negative impact on law enforcement, prosecution, or the courts following enactment of the .08 law. The Pacific Institute for Research and Evaluation conducted the time-series analysis, using data from the Fatality Analysis Reporting System for the years from 1988-1998. It compared the experience in Illinois with that of 5 surrounding states—Indiana, Iowa, Kentucky, Missouri, and Wisconsin—all of which have .10 laws. The study reinforces the findings of several other NHTSA studies examining the effectiveness of .08 BAC laws. Deaths and injuries increase in Texas and Arkansas following helmet law repeal: As of the mid 1970s, 47 states
head injuries among injured motorcyclists rose from 18.5% in 1996 to 31.6% in 1998. • Treatment costs for traumatic brain injury increased following the law change, whereas treatment costs for other injury cases did not change markedly. The average cost for traumatic brain injury per case increased by 75%, from $18,418 to $32,209. The median cost rose by more than 300%, from $4585 to $22,531. The average cost of treating injured motorcyclists who did not sustain traumatic brain injuries declined slightly, and the median cost for the care of these motorcyclists was essentially unchanged. • Texas Trauma Registry data showed an increase in traumatic brain injury from 18% to 25%. Treatment costs for traumatic brain injury increased substantially, whereas treatment costs for other cases did not change markedly.
and the District of Columbia had adopted universal helmet use laws. In 1975, however, Congress dropped its requirement that federal aid highway construction funds be withheld from states without universal helmet laws. By 1978, half the states had repealed their helmet laws or amended them to cover only riders younger than a specified age. Since then, many states have enacted, amended, repealed, and re-enacted their helmet laws, usually amid intense public debate. In 1997, Arkansas and Texas modified their mandatory helmet usage laws. Effective August 1, 1997, Arkansas required helmet use only for riders younger than 21 years, and effective September 1, 1997, Texas required helmet use only for riders younger than 21 years and for older riders who have not completed a rider education course, or who do not have at least $10,000 medical insurance coverage. This new report examines data from Arkansas and Texas to assess the effects of their helmet law changes on helmet use, injuries and fatalities, and motorcycle injury costs. Emergency nurses who care for injured motorcyclists will not be surprised at the results. Both states had helmet use rates of 97% before the laws were repealed. Subsequent data showed the following: • By May 1998, helmet use dropped to 52% in Arkansas and 66% in Texas. • In Arkansas, motorcycle fatalities rose 21% in the first full year following repeal of helmet laws, and deaths rose by 31% in Texas during the same time period. • In Arkansas, medical data show that the percentage of
Child-resistant lighters reduce fire deaths: A new report issued by the CPSC shows that fire deaths associated with children playing with lighters dropped 43% since the CPSC required cigarette lighters to be child-resistant in 1994. Deaths related to children playing with lighters fell from 230 in 1994 to 130 in 1998. Children younger than 5 years accounted for 170 of the deaths in 1994 and 40 of the deaths in 1998. Overall, fires related to lighters dropped 45% between 1994 and 1998. In 1994, 11,000 residential fires were
April 2001 27:2
JOURNAL OF EMERGENCY NURSING
The experience in Arkansas and Texas is consistent with studies conducted in other states. The accumulated evidence is overwhelming that helmet use reduces motorcyclist fatalities, injuries, and treatment costs and that universal helmet use laws increase helmet use substantially. The societal issues regarding the use of helmets are also clear. The price for societal benefits is that individual actions are restricted. The public debate regarding helmet use is not likely to be resolved very soon, but armed with this new knowledge, emergency nurses and other injury prevention advocates can actively engage in the discussion. Independent Federal Agency
CONSUMER PRODUCT SAFETY COMMISSION (CPSC)
169
FROM THE FEDS/Flaherty
associated with children playing with lighters. By 1998, that number declined to 6100. By comparison, residential structure fires resulting from other causes dropped by 15% in that period. Injuries related to lighter fires also declined. Injuries dropped 49%, from 1600 in 1994 to 810 in 1998. The cigarette lighter safety standard requires disposable and novelty lighters to have a child-resistant mechanism that makes lighters difficult for children younger than 5 years to operate. At the time the standard was developed, it was estimated that children younger than 5 years ignited 73% of all residential structure fires started by children playing with cigarette lighters. Despite the good news, fires caused by children playing with lighters remain a concern. It is expected that the new standard requiring child-resistant mechanisms on household multipurpose lighters, which became effective December 2000, will help reduce fires and deaths from fires even further. Recall to repair window blinds: The CPSC and the
Window Covering Safety Council are announcing a recall to repair horizontal window blinds to prevent the risk of strangulation to young children. The recall involves millions of window blinds with pull cords and inner cords that can form a loop and cause strangulation. About 85 million window blinds are sold each year. Since 1991, CPSC has received reports of 130 strangulations involving cords on window blinds. Most of these, 114, involve the outer pull cords, and 16 involve the inner cords that hold the blind slats. In 1995, CPSC worked with the window covering industry to redesign new window blinds to eliminate the outer loop on the end of pull cords and provide free repair kits so consumers could fix their existing blinds. Window blinds sold since 1995 no longer have pull cords ending in loops. Last year, CPSC began a new investigation of window blind deaths. In an extensive review of incidents, CPSC found that children could become entangled in the inner cords that are used to raise the slats of blinds. These entrapments occur when a young child pulls on an inner cord and it forms a loop that a child can hang in. All of these deaths involved children in cribs placed next to windows. In most cases, the outer pull cords were placed out of reach, but the children strangled when they pulled on the
170
inner cords of the blinds. The strangulation victims ranged in age from 9 to 17 months. As a result of the new CPSC investigation, window blinds have been further redesigned. Newly manufactured blinds have attachments on the pull cords so that the inner cords cannot form a loop if pulled by a young child. Consumers with existing blinds should have them repaired, which can be done without removing the blinds. Parents should keep window covering cords and chains permanently out of the reach of children. A child’s crib should never be placed within reach of a window blind. CPSC also recommends that parents never knot or tie the cords together because this creates a new loop in which a child could become entangled. REFERENCES 1. Sacks JJ, Sattin RW, Bonzo SE. Dog bite–related fatalities in the United States, 1979-1988. JAMA 1989;262:1489-92. 2. Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks, 1989-1994. Pediatrics 1996;97:891-5. 3. Centers for Disease Control and Prevention. Dog bite related fatalities—United States, 1995-1996. MMWR 1997;46:463-7. 4. Lockwood R. Humane concerns about dangerous dog laws. Univ Dayton Law Rev 1988;13:267-77. 5. Lockwood R, Rindy K. Are “pit bulls” different? An analysis of the pit bull terrier controversy. Anthrozoos 1987;1:2-8. 6. Sosin DM, Sacks JJ, Sattin RW. Causes of nonfatal injuries in the United States, 1986. Accid Anal Prev 1992;24:685-7. 7. Sacks JJ, Kresnow M, Houston B. Dog bites: How big a problem? Inj Prev 1996;2:52-4. 8. Weiss HB, Friedman D, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1988;279: 51-3. 9. Quinlan KP, Sacks JJ, Wright JC. Hospitalizations for dog bite injuries. JAMA 1999;281:232-3. 10. Gershman KA, Sacks JJ, Wright JC. Which dogs bite? A casecontrol study of risk factors. Pediatrics 1994;93:913-7.
JOURNAL OF EMERGENCY NURSING
27:2 April 2001
From the Feds: Research, Programs, and Products Laurie Flaherty, RN, MS, Washington, DC Department of Health and Human Services Breeds of Dogs Involved in Fatal Human Attacks
PUBLIC HEALTH SERVICE Teens Face Serious Risk of Job-related Death in Agricultural Operations
Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC) Breeds of dogs involved in fatal human attacks: NCIPC’s
Laurie Flaherty, Mid-Maryland Chapter, is Emergency Nurse at Suburban Hospital, Bethesda, Md, and a Contract Employee of the National Highway Traffic Safety Administration in Washington, DC. For reprints, write: Laurie Flaherty, RN, MS, 3519 Rittenhouse St, NW, Washington, DC 20015; E-mail: [email protected]. J Emerg Nurs 2001;27:166-70. Copyright © 2001 by the Emergency Nurses Association. 0099-1767/2001 $35.00 + 0 18/9/113973 doi:10.1067/men.2001.113973
Division of Unintentional Injury Prevention recently released a special report that summarizes breeds of dogs involved in fatal human attacks during a 20-year period between 1979 and 1998. From 1979 through 1996, dog attacks resulted in more than 300 dog bite–related human fatalities in the United States.1-3 Most victims were children. Studies indicate that pit bull–type dogs were involved in approximately one third of deaths reported from 1981 through 1992, and rottweilers were responsible for about half of dog bite–related deaths from 1993 through 1996. These data have resulted in the inference that certain breeds of dogs are more likely to bite than are others and should, therefore, be banned or regulated more stringently.4,5 The purpose of this report was to summarize breeds associated with dog bite–related deaths during a 20year period and assess public policy implications. Data were collected from the Humane Society of the United States and from media accounts of attacks by dogs resulting in bites. The Humane Society maintains a registry of dog bite–related human fatalities, including the date of death, age, and sex of the victim, the city and state in which the attack occurred, the number and breed of dogs involved, and circumstances relating to the attack. Newspapers and periodicals were also scanned, and articles written about dog bite–related fatalities were reviewed. During the past 20 years, more than 25 breeds of dogs were involved in the 238 dog bite–related human deaths
166
JOURNAL OF EMERGENCY NURSING
Reducing Cervical Spine Radiographs in Patients With Blunt Trauma
New Standard to Require Internal Trunk Releases on Cars
Decrease in Fatalities Following Illinois .08 Blood Alcohol Content Law
Deaths and Injuries Increase in Texas and Arkansas Following Helmet Law Repeal
Child-resistant Lighters Reduce Fire Deaths
Recall to Repair Window Blinds
27:2 April 2001
FROM THE FEDS/Flaherty
for which some breed information was available. Dogs most frequently involved in fatal attacks were as follows: pit bull–type, 76; rottweiler, 44; German shepherd, 27; husky-type, 21; and wolf-dog hybrid, 15. The data have limitations related to comparison of the number of fatal attacks with the total dog breed population. However, despite these limitations, the data indicate that in 1997 and 1998, rottweilers and pit bull–type dogs accounted for 67% of dog bite–related human fatalities in the United States. It is highly unlikely that they represented anywhere near 60% of the dogs in the United States during this same period. These fatal attacks represent only the most severe manifestations of the problem. In 1986 alone, an estimated 585,000 dog bite injuries occurred that required medical attention or restricted activity.6 By 1994, an estimated 4.7 million people sustained a dog bite; 800,000 of these people sought medical care in the emergency department, and 6000 required hospital admission.7-9 These figures represent a 36% increase in bites requiring medical attention from 1986 to 1994. Although fatal dog bites receive more public attention, the increase in injuries might be a larger factor in determining public policy regarding dog bite prevention.
• Fewer than 1% of fatal cases were caused by leashed animals off the owner’s property. • Fatal bite reports reviewed indicated that problem behaviors (of dogs and owners) preceded attacks in a great many cases and might be considered sufficient evidence for preemptive action. Public policy cannot address the fact that a dog of any breed can become dangerous when bred or trained to become aggressive. Furthermore, a ban on any specific breed might cause people to simply turn to another breed for the same qualities they sought in the original dog. However, enforcement of existing animal control laws and educational and policy strategies to reduce inappropriate dog and owner behaviors, based on scientific reports such as this, may result in benefits to communities and may well decrease the number of dog bite injuries and fatalities. National Institute for Occupational Safety and Health (NIOSH) Teens face serious risk of job-related death in agricultural operations: Emergency nurses working in rural areas will
Some other interesting points were raised by the report. Several factors affect a dog’s propensity to bite, including heredity, gender, early experience, socialization and training, health, reproductive status, quality of ownership and supervision, and victim behavior. One study showed that male dogs were 6.2 times more likely to bite than were females, sexually intact dogs were 2.6 times more likely to bite than were neutered dogs, and chained dogs were 2.8 times more likely to bite than were unchained dogs.10 Other interesting facts of note: • Twenty-four percent of fatalities were caused by owned dogs that roamed off the owner’s property.
not be surprised by a recent report released by NIOSH, which states that teens face serious risk of job-related death in agricultural operations. NIOSH analyzed 5 years of data and found that 12.2 occupational fatalities occurred for every 100,000 youths working in agriculture, more than twice the rate for fatal occupational injuries overall in the United States for a comparable period (5.1 fatalities per 100,000 workers). The NIOSH findings are consistent with results from earlier research showing that youths who work and live on farms are at risk for injury and death. Each year, approximately 33,000 people younger than 20 years are seriously injured on farms, and more than 100 are killed. Other findings include the following: • Half the fatalities involved transportation incidents, including collisions, incidents involving loss of control of vehicle or equipment, and falls from moving vehicles. Tractors were the major cause of vehicle-related fatalities, accounting for 23% of all deaths. • Incidence of fatalities increased by age for people younger than 20 years, with the highest proportion occurring among 18- to 19-year-olds (30% of the total) and the next highest among 16- to 17-year-olds (25%). • Fatalities more often occurred among young people working for wages than in family agriculture operations.
April 2001 27:2
JOURNAL OF EMERGENCY NURSING
Dogs most frequently involved in fatal attacks were as follows: pit bull–type, 76; rottweiler, 44; German shepherd, 27; husky-type, 21; and wolf-dog hybrid, 15.
167
FROM THE FEDS/Flaherty
• Forty-six percent of fatalities occurred in the Midwest, followed by 22 percent in the South; these were the regions with the highest prevalence. NIOSH works extensively with a broad coalition of partners in the safety, health, and agricultural communities to prevent injury and death among young people in agriculture. Additional information about these activities and recommendations about agricultural safety and health are available on the NIOSH Web site at www.cdc.gog/ niosh/agtopics.html. Information is also available from the National Children’s Center for Rural and Agricultural Health and Safety at http://research.marshfieldclinic.org/children, the National Safety Council at www.nsc.org/farmsafe.htm, and Farm Safety 4 Just Kids, at www.fs4jk.org. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)
Reducing cervical spine radiographs in patients with blunt trauma: ED patients who have sustained blunt trauma rou-
tinely have cervical spine radiographs performed to rule out hidden cervical spine injuries. A new study, supported by AHRQ, suggests that a simple set of clinical criteria can identify patients who have a very low probability of spinal injury and consequently do not need spinal radiographs. The study, performed at the University of California, Los Angeles, examined the performance of 5 clinical criteria to predict the likelihood of cervical spine injury in 34,069 patients who underwent radiographs of the cervical spine after blunt trauma at 21 centers across the United States. The following 5 clinical criteria were used as predictors of cervical spine injury: (1) no midline cervical tenderness, (2) no focal neurologic deficit, (3) normal alertness, (4) no intoxication, and (5) no painful or distracting injuries. Using this approach, all but 8 of the 818 patients who had cervical spine injury were identified, representing a sensitivity of 99%. Only 2 of these 8 patients were considered to have a clinically significant injury, and only 1 of these 2 patients underwent surgery to repair the injury. According to study results, cervical spine radiographs could have been avoided in the cases of 4309 (12.6%) of the 34,069 patients. Replication of this study, even on a small scale, would be an interesting next step toward the possibility of chang-
168
ing standard practice, especially for emergency nurses who see patients with potential cervical spine injuries on a daily basis. More details of this study can be found in the article “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma” by Hoffman et al in the July 13, 2000, issue of the New England Journal of Medicine (2000;343:94-9). Department of Transportation
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)
New standard to require internal trunk releases on cars:
NHTSA recently announced a new requirement that all passenger cars with trunks have a release or other automatic system inside to allow children or adults to escape. The requirement is effective as of September 1, 2001. Trunk entrapment involves both children trapped in trunks, often during play or other innocent circumstances, and adults trapped in trunks, generally as a result of criminal actions. In the summer of 1998, 11 children died from exposure to heat after inadvertently being trapped in car trunks. A study released that year by the CDC documented a total of 19 cases of children ages 6 years and younger who died in car trunks between 1987 and 1998. The new NHTSA standard adopts the approach recommended by an expert panel on trunk entrapment, established in November 1998. The panel included experts on child psychology and behavior, safety advocacy, automotive engineering, vehicle manufacturing, law enforcement, the health care community, and other groups. The final rule establishes a new Federal Motor Vehicle Safety Standard (FMVSS) Number 401, Internal Trunk Release. Decrease in fatalities following Illinois .08 blood alcohol content law: New compelling evidence has been added to
the argument that .08 blood alcohol concentration (BAC) laws significantly reduce fatalities. A study done by NHTSA found that the .08 law in Illinois, effective in July of 1997, was associated with a 13.7% decline in the number of drinking drivers involved in fatal crashes. The reduction included drivers at both high and low BAC levels. The study, entitled “Effectiveness of the Illinois .08 Law,” also found no significant change in the number of
JOURNAL OF EMERGENCY NURSING
27:2 April 2001
FROM THE FEDS/Flaherty
alcohol-positive drivers involved in fatal crashes in the 5 neighboring states with .10 BAC laws during this time, and there was no negative impact on law enforcement, prosecution, or the courts following enactment of the .08 law. The Pacific Institute for Research and Evaluation conducted the time-series analysis, using data from the Fatality Analysis Reporting System for the years from 1988-1998. It compared the experience in Illinois with that of 5 surrounding states—Indiana, Iowa, Kentucky, Missouri, and Wisconsin—all of which have .10 laws. The study reinforces the findings of several other NHTSA studies examining the effectiveness of .08 BAC laws. Deaths and injuries increase in Texas and Arkansas following helmet law repeal: As of the mid 1970s, 47 states
head injuries among injured motorcyclists rose from 18.5% in 1996 to 31.6% in 1998. • Treatment costs for traumatic brain injury increased following the law change, whereas treatment costs for other injury cases did not change markedly. The average cost for traumatic brain injury per case increased by 75%, from $18,418 to $32,209. The median cost rose by more than 300%, from $4585 to $22,531. The average cost of treating injured motorcyclists who did not sustain traumatic brain injuries declined slightly, and the median cost for the care of these motorcyclists was essentially unchanged. • Texas Trauma Registry data showed an increase in traumatic brain injury from 18% to 25%. Treatment costs for traumatic brain injury increased substantially, whereas treatment costs for other cases did not change markedly.
and the District of Columbia had adopted universal helmet use laws. In 1975, however, Congress dropped its requirement that federal aid highway construction funds be withheld from states without universal helmet laws. By 1978, half the states had repealed their helmet laws or amended them to cover only riders younger than a specified age. Since then, many states have enacted, amended, repealed, and re-enacted their helmet laws, usually amid intense public debate. In 1997, Arkansas and Texas modified their mandatory helmet usage laws. Effective August 1, 1997, Arkansas required helmet use only for riders younger than 21 years, and effective September 1, 1997, Texas required helmet use only for riders younger than 21 years and for older riders who have not completed a rider education course, or who do not have at least $10,000 medical insurance coverage. This new report examines data from Arkansas and Texas to assess the effects of their helmet law changes on helmet use, injuries and fatalities, and motorcycle injury costs. Emergency nurses who care for injured motorcyclists will not be surprised at the results. Both states had helmet use rates of 97% before the laws were repealed. Subsequent data showed the following: • By May 1998, helmet use dropped to 52% in Arkansas and 66% in Texas. • In Arkansas, motorcycle fatalities rose 21% in the first full year following repeal of helmet laws, and deaths rose by 31% in Texas during the same time period. • In Arkansas, medical data show that the percentage of
Child-resistant lighters reduce fire deaths: A new report issued by the CPSC shows that fire deaths associated with children playing with lighters dropped 43% since the CPSC required cigarette lighters to be child-resistant in 1994. Deaths related to children playing with lighters fell from 230 in 1994 to 130 in 1998. Children younger than 5 years accounted for 170 of the deaths in 1994 and 40 of the deaths in 1998. Overall, fires related to lighters dropped 45% between 1994 and 1998. In 1994, 11,000 residential fires were
April 2001 27:2
JOURNAL OF EMERGENCY NURSING
The experience in Arkansas and Texas is consistent with studies conducted in other states. The accumulated evidence is overwhelming that helmet use reduces motorcyclist fatalities, injuries, and treatment costs and that universal helmet use laws increase helmet use substantially. The societal issues regarding the use of helmets are also clear. The price for societal benefits is that individual actions are restricted. The public debate regarding helmet use is not likely to be resolved very soon, but armed with this new knowledge, emergency nurses and other injury prevention advocates can actively engage in the discussion. Independent Federal Agency
CONSUMER PRODUCT SAFETY COMMISSION (CPSC)
169
FROM THE FEDS/Flaherty
associated with children playing with lighters. By 1998, that number declined to 6100. By comparison, residential structure fires resulting from other causes dropped by 15% in that period. Injuries related to lighter fires also declined. Injuries dropped 49%, from 1600 in 1994 to 810 in 1998. The cigarette lighter safety standard requires disposable and novelty lighters to have a child-resistant mechanism that makes lighters difficult for children younger than 5 years to operate. At the time the standard was developed, it was estimated that children younger than 5 years ignited 73% of all residential structure fires started by children playing with cigarette lighters. Despite the good news, fires caused by children playing with lighters remain a concern. It is expected that the new standard requiring child-resistant mechanisms on household multipurpose lighters, which became effective December 2000, will help reduce fires and deaths from fires even further. Recall to repair window blinds: The CPSC and the
Window Covering Safety Council are announcing a recall to repair horizontal window blinds to prevent the risk of strangulation to young children. The recall involves millions of window blinds with pull cords and inner cords that can form a loop and cause strangulation. About 85 million window blinds are sold each year. Since 1991, CPSC has received reports of 130 strangulations involving cords on window blinds. Most of these, 114, involve the outer pull cords, and 16 involve the inner cords that hold the blind slats. In 1995, CPSC worked with the window covering industry to redesign new window blinds to eliminate the outer loop on the end of pull cords and provide free repair kits so consumers could fix their existing blinds. Window blinds sold since 1995 no longer have pull cords ending in loops. Last year, CPSC began a new investigation of window blind deaths. In an extensive review of incidents, CPSC found that children could become entangled in the inner cords that are used to raise the slats of blinds. These entrapments occur when a young child pulls on an inner cord and it forms a loop that a child can hang in. All of these deaths involved children in cribs placed next to windows. In most cases, the outer pull cords were placed out of reach, but the children strangled when they pulled on the
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inner cords of the blinds. The strangulation victims ranged in age from 9 to 17 months. As a result of the new CPSC investigation, window blinds have been further redesigned. Newly manufactured blinds have attachments on the pull cords so that the inner cords cannot form a loop if pulled by a young child. Consumers with existing blinds should have them repaired, which can be done without removing the blinds. Parents should keep window covering cords and chains permanently out of the reach of children. A child’s crib should never be placed within reach of a window blind. CPSC also recommends that parents never knot or tie the cords together because this creates a new loop in which a child could become entangled. REFERENCES 1. Sacks JJ, Sattin RW, Bonzo SE. Dog bite–related fatalities in the United States, 1979-1988. JAMA 1989;262:1489-92. 2. Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks, 1989-1994. Pediatrics 1996;97:891-5. 3. Centers for Disease Control and Prevention. Dog bite related fatalities—United States, 1995-1996. MMWR 1997;46:463-7. 4. Lockwood R. Humane concerns about dangerous dog laws. Univ Dayton Law Rev 1988;13:267-77. 5. Lockwood R, Rindy K. Are “pit bulls” different? An analysis of the pit bull terrier controversy. Anthrozoos 1987;1:2-8. 6. Sosin DM, Sacks JJ, Sattin RW. Causes of nonfatal injuries in the United States, 1986. Accid Anal Prev 1992;24:685-7. 7. Sacks JJ, Kresnow M, Houston B. Dog bites: How big a problem? Inj Prev 1996;2:52-4. 8. Weiss HB, Friedman D, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1988;279: 51-3. 9. Quinlan KP, Sacks JJ, Wright JC. Hospitalizations for dog bite injuries. JAMA 1999;281:232-3. 10. Gershman KA, Sacks JJ, Wright JC. Which dogs bite? A casecontrol study of risk factors. Pediatrics 1994;93:913-7.
JOURNAL OF EMERGENCY NURSING
27:2 April 2001