SafetyLit- 26 January 2001

January 26, 2001

General Topics

Stevens RR, Lane GA; Milkovich SM; Stool D; Rider G; Stool SE. Prevention of accidental childhood strangulation. A clinical study. Ann Otol Rhinol Laryngol 2000, 109(9):797-802.

ABSTRACT: Accidental strangulation is a preventable problem, and there is limited scientific understanding of its mechanism in children. If the amount of external pressure that occludes the airway can be determined, design changes may be made to allow for production of household objects that would break apart at safe pressure levels. A force gauge was applied to the suprahyoid region in 90 children under standardized anesthesia. Three blinded observers performed the study. The anesthesiologist maintained the airway and used a stethoscope to auscultate for breath sounds and monitor the CO2 curves to evaluate obstruction. The recorder noted the numbers from the gauge. A single observer applied the force gauge. Age was the most significant variable in occluding the airway. Obstruction appears to occur at the level of the larynx. Increased knowledge regarding the external pressure required for airway occlusion would allow for the design and manufacture of products with a reduced potential for accidental strangulation.

Al West T, Rivara FP, Cummings P, Jurkovich GJ, Maier RV. Harborview assessment for risk of mortality: an improved measure of injury severity on the basis of ICD-9-CM. J Trauma 2000, 49(3):530-40; discussion 540-1.

ABSTRACT: BACKGROUND: There have been several attempts to develop a scoring system that can accurately reflect the severity of a trauma patient's injuries, particularly with respect to the effect of the injury on survival. Current methodologies require unreliable physiologic data for the assignment of a survival probability and fail to account for the potential synergism of different injury combinations. The purpose of this study was to develop a scoring system to better estimate probability of mortality on the basis of information that is readily available from the hospital discharge sheet and does not rely on physiologic data. METHODS: Records from the trauma registry from an urban Level I trauma center were analyzed using logistic regression. Included in the regression were Internation Classification of Diseases-9th Rev (ICD-9CM) codes for anatomic injury, mechanism, intent, and preexisting medical conditions, as well as age. Two-way interaction terms for several combinations of injuries were also included in the regression model. The resulting Harborview Assessment for Risk of Mortality (HARM) score was then applied to an independent test data set and compared with Trauma and Injury Severity Score (TRISS) probability of survival and ICD-9-CM Injury Severity Score (ICISS) for ability to predict mortality using the area under the receiver operator characteristic curve. RESULTS: The HARM score was based on analysis of 16,042 records (design set). When applied to an independent validation set of 15,957 records, the area under the receiver operator characteristic curve (AUC) for HARM was 0.9592. This represented significantly better discrimination than both TRISS probability of survival (AUC = 0.9473, p = 0.005) and ICISS (AUC = 0.9402, p = 0.001). HARM also had a better calibration (Hosmer-Lemeshow statistic [HL] = 19.74) than TRISS (HL = 55.71) and ICISS (HL = 709.19). Physiologic data were incomplete for 6,124 records (38%) of the validation set; TRISS could not be calculated at all for these records. CONCLUSION: The HARM score is an effective tool for predicting probability of in-hospital mortality for trauma patients. It outperforms both the TRISS and ICD9-CM Injury Severity Score (ICISS) methodologies with respect to both discrimination and calibration, using information that is readily available from hospital discharge coding, and without requiring emergency department physiologic data.

Benoit R, Watts DD, Dwyer K, Kaufmann C, Fakhry S. Windows 99: a source of suburban pediatric trauma. J Trauma 2000, 49(3):477-81; discussion 481-2

ABSTRACT: BACKGROUND: Falls from windows in urban areas cause a significant number of pediatric injuries. Window falls have not been well described in the nonurban setting. We describe the epidemiology of window falls from residential homes among pediatric patients at a suburban Level I trauma center. METHODS: A review of patients admitted from January 1991 through November 1999 to a center serving a rapidly growing suburban area was performed. RESULTS: A total of 2,322 children, ages 0-14 years, were admitted during the study period. Falls comprised 41% of these admissions, and 11% of falls were from windows, greater than twice the national average. More than 39% of children who fell from windows were admitted directly to the intensive care unit. Overall mortality rate was 4%. Ages 0 to 4 years comprised the largest percentage (83%), and all children who died were in this age group. Children < or = 4 years were more likely to have an Abbreviated Injury Score > or = 2 (head injury) than those ages 10 to 14 years (p = 0.032). More than 31% of all children injured in window falls seen at the study institution between 1991 and 1999 were admitted in the last 2 years. CONCLUSION: Pediatric falls from windows in this suburban area appear to be increasing, with an incidence greater than the national average. Children at greatest risk are less than 4 years old. Further research in injury prevention at the national level aimed at suburban areas may be warranted.

Ivers RQ, Norton R, Cumming RG, Butler M, Campbell AJ. Visual impairment and risk of hip fracture. Am J Epidemiol 2000 Oct 1;152(7):633-9.

ABSTRACT: As part of a case-control study, the Auckland Hip Fracture Study (1991-1994), the authors examined associations between impaired vision and risk of hip fracture. Subjects (911 cases and 910 controls aged 60 years or older) completed a questionnaire and had vision measurements taken, including measurements of visual acuity and stereopsis (depth perception). Binocular visual acuity worse than 20/60 was statistically significantly associated with increased risk of hip fracture after adjustment for age, sex, proxy response, hours of activity per week, and height (odds ratio (OR) = 1.5; 95% confidence interval (CI): 1.1, 2.0), as was having poor vision (less than 20/100) in both eyes (OR = 2.4; 95% CI: 1.0, 6.1). Having no depth perception was associated with increased risk (OR = 6.0 95% CI: 3.2, 11.1), as were categories of decreasing stereopsis (trend p = 0.0001), self-reported poor vision (OR = 1.4; 95% CI: 1.0, 1.9), not wearing glasses at the time of the fall (OR = 1.2; 95% CI: 1.0, 1.6), and increasing time since the last eye examination (trend p = 0.03). The population attributable risk of hip fracture due to poor visual acuity or stereopsis was 40%. Visual factors are important fall-related factors which influence risk of hip fracture. Risk of hip fracture may be decreased by correcting refractive error, improving stereopsis, and administering regular eye examinations.

Rutherford GW Jr, Ingle R, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Unpowered Scooter-Related Injuries --- United States, 1998--2000. MMWR 2000, 49(49):1108-1110.

ABSTRACT: Injuries associated with unpowered scooters have increased dramatically since May 2000 (1). These scooters are a new version of the foot-propelled scooters first popular during the 1950s. Most scooters are made of lightweight aluminum with small, low-friction wheels similar to those on in-line skates. They weigh <10 pounds and fold for easy portability and storage. Up to 5 million scooters are expected to be sold in 2000, an increase from virtually zero last year (Consumer Product Safety Commission [CPSC], unpublished data, 2000). This report summarizes the results of a descriptive analysis of scooter-related injuries during the past 34 months and provides recommendations to reduce these injuries.

The findings in this report demonstrate the rapid increase in injuries associated with riding the new lightweight, folding, unpowered scooters, which are a fast-growing activity in the United States. Because these scooters are a recent phenomenon, scientific data about the efficacy of safety equipment to protect against scooter-related injuries are not available. However, lessons learned from similar recreational activities (e.g., in-line skating) can guide users in adopting reasonable safety precautions, such as wearing protective gear.

Helmkamp JC. Injuries and deaths and the use of all-terrain vehicles (letter). New Engl J Med 2000, 343(23).

FULL TEXT: During the late 1980s and early 1990s, deaths and injuries associated with the recreational use of all-terrain vehicles steadily decreased; however, around 1993, this trend began gradually to reverse. U.S. Consumer Product Safety Commission (CPSC) data from 1985 through 1998 indicate that an estimated 273 persons die annually from all-terrain vehicle crashes, and 35 percent of them are less than 16 years old (David J, Directorate for Epidemiology, CPSC: personal communication). Data for the same period from the National Electronic Injury Surveillance System indicate that of the estimated 68,300 annual all-terrain vehicle-related injuries requiring emergency room care, 39 percent occurred in children. Injuries have also increased among adult users of all-terrain vehicles. (figures and tables omitted)

All-terrain vehicles gained popularity in the United States in the late 1970s, and today nearly 4 million are in use. Dramatic increases in all-terrain vehicle-associated injuries and deaths in the early 1980s led the CPSC to issue a safety alert in May 1987 warning users to receive training, wear helmets, and carry no passengers. (1) The American Academy of Pediatrics recommended that pediatricians warn parents that using an all-terrain vehicle requires skill, judgment, and experience, and that they should prohibit the use of all-terrain vehicles by children less than 14 years old. (2) In 1988, a 10-year consent decree between the CPSC and manufacturers of all-terrain vehicles halted the sale of three-wheeled all-terrain vehicles, prohibited the sale of adult-sized all-terrain vehicles to children less than 16 years old, and required distributors to provide safety information and training. (3)

The explanation for the recent trends of increasing all-terrain vehicle-related injuries and deaths is not clear. Possibly the common-sense safety message is not getting to the users of all-terrain vehicles. The CPSC notes that the requirements for reporting incidents have not changed. Data have shown some increases in sales of all-terrain vehicles and exposure, but they are not enough to account for the observed increase in injuries and deaths (David J: personal communication). Renewed safety efforts initiated by the CPSC and the all-terrain vehicle industry (when the consent decree expired in 1998) should focus on youth-oriented information and safety education campaigns to help reverse the current trends. (4) These efforts must be in concert with safety education offered at home and in the community. Parents must stress that riding in all-terrain vehicles can be fun and safe if basic safety guidelines are followed by all users, including themselves.

References 1. CPSC urges caution for three-and four-wheeled all-terrain vehicles. CPSC document no. 540. Bethesda, Md.: Consumer Product Safety Commission, 1987.
2. American Academy of Pediatrics Committee on Accident and Poison Prevention. All-terrain vehicles: two-, three-, and four-wheeled unlicensed motorized vehicles. Pediatrics 1987;79:306-8.
3. U.S. District Court for the District of Columbia. 1988. United States of America v. American Honda Motor Co., Inc., et al. Washington, D.C.: U.S. District Court of the District of Columbia, 1992; Civil action no. 87-3525.
4. CPC announces all-terrain vehicle safety programs. CPSC release no. 99-034. Bethesda, Md.: Consumer Product Safety Commission, 1998.

Warner M, Smith GS, Langley JD. Drowning and alcohol in New Zealand: what do the coroner's files tell us? Aust N Z J Public Health 2000, 24(4):387-90

ABSTRACT: OBJECTIVE: To provide a systematic review of the details on alcohol involvement available in the coronial files to determine if there is enough evidence to estimate the role of alcohol in drowning. METHOD: We reviewed the coroner's files of persons 10 years or older who drowned in New Zealand between 1992-1994 inclusive. RESULTS: A total of 320 coroner's files were examined. Blood Alcohol Concentrations (BACs) were taken in 115 cases (36%) and positive for 50% of these. When accounting for the incomplete testing by using all the information on alcohol involvement collected, between 30-40% of the cases were estimated to have a positive BAC and between 17-24% to have a BAC 100 mg/dL or higher. CONCLUSION: The quality and completeness of current coronial information on alcohol involvement in drowning is insufficient to arrive at an accurate estimate of the percentage of drownings where alcohol was a factor. IMPLICATIONS: Coroners should test drowning victims 10 years and older for BAC. These data should be systematically recorded and processed with the goal of determining who should be targeted in drowning and alcohol prevention programs.

McCurdy SA, Carroll DJ. Agricultural injury. Am J Ind Med 2000, 38(4):463-80.

ABSTRACT: BACKGROUND: Agriculture is one of the most hazardous industries in the US. METHODS: We reviewed MEDLINE and NIOSHTIC to identify English-language studies addressing occupational injury among agricultural populations, focusing on North America. Additional references were identified from the reference lists of identified studies and from contacts with experts in the field. RESULTS: U.S. data indicate up to approximately 780 deaths and 140,000 cases of nonfatal disabling injuries in 1998. Risk of agricultural injuries is approximately 5-10/100 persons per year, but is higher in certain risk groups, such as males and cattle workers. Falls, machinery, and animals are among the most common causes. Unique features of the agricultural workplace and exposed population combine to increase risk and hinder accurate measurement. These features include a wide range of activities, hazards, and dispersed work places in agriculture; a seasonal hired work force that often has brief tenure, poor English skills, and a distrust of officialdom; and a history of exemption regarding occupational health and safety regulations. CONCLUSIONS: Research in agricultural injury should include epidemiologic study of risk factors and evaluation of interventions. Although only limited data are available documenting efficacy of specific preventive approaches, prevention should focus on engineering controls, regulatory approaches, and education.

McGwin G Jr; Enochs R; Roseman JM. Increased risk of agricultural injury among African-American farm workers from Alabama and Mississippi. Am J Epidemiol 2000, 152(7):640-50.

ABSTRACT: Research on the epidemiology of agriculture-related injuries has largely ignored African-Americans and farm workers. This cohort study is the first to estimate injury rates and to evaluate prospectively risk factors for agriculture-related injuries and compare them among African-American and Caucasian farmers and African-American farm workers. A total of 1,246 subjects (685 Caucasian owners, 321 African-American owners, and 240 African-American workers) from Alabama and Mississippi were selected from Agricultural Statistics Services databases and other sources and were enrolled between January 1994 and June 1996. Baseline data included detailed demographic, farm and farming, and behavioral information. From January 1994 to April 1998, subjects were contacted biannually to ascertain the occurrence of an agriculture-related injury. Injury rates were 2.9 times (95% confidence interval (CI): 2.0, 4.3) higher for African-American farm workers compared with Caucasian and African-American owners. Part-time farming (relative risk (RR) = 2.0, 95% CI: 1.3, 2.5), prior agricultural injury (RR = 1.5, 95% CI: 1.0, 2.1), and farm machinery in fair/poor condition (RR = 1.8, 95% CI: 1.2, 2.7) were also independently associated with injury rates. The results demonstrate the increased frequency of agricultural injury among farm workers and identify a number of possible ways of reducing them.

Desapriya EBR., Nobutada I. Commentary: Lower legal BAC limit and traffic safety - some international evidence. J Traffic Med 2001, 28(1-2):7-20.

ABSTRACT: This review examines control of driving after drinking through legislation and enforcement of per se laws. The reviewers present evidence that lower BAC limits are likely to translate into a reduction in traffic crashes when the public believes that they are likely to be arrested and punished for driving after drinking alcohol. The report summarizes research on public opinion about drinking and driving, laws to control that behavior, and the enforcement of those laws. The article also includes a summary of roadside survey data with international comparisons.

Insurance Institute for Highway Safety. State traffic laws rated good to poor, revealing the nation's best and worst. IIHS Status Report 2000, 35(10):2-7.

ABSTRACT: This report compares the existence and quality of state laws related to driving under the influence of alcohol, graduated licensing, safety belt use, child restraint use, motorcycle helmet use, and red light cameras.

Litmanovitz I, Dolfin T, Arnon S, Fleser C, Rathouse V, Feigin M, Regev RH. Fetal intrathoracic injuries following mild maternal motor vehicle accident. J Perinat Med 2000;28(2):158-60

ABSTRACT: Reported herein are the cases of three infants who were born with serious intrathoracic injuries, apparently sustained at the time of the mother's involvement in a motor vehicle accident. The accidents occurred at 26th, 29th and 36th weeks of pregnancy and resulted in minimal injuries to the mothers themselves. The infants were born four weeks, three hours and two days later, respectively. Their injuries were manifested (singly) by hemothorax, pneumothorax and contusion of lung, the latter in a setting of multi-organ trauma. We suggest that chest x-ray, in addition to brain ultrasound, be routinely included in the evaluation of neonates whose mothers were involved in a motor vehicle accident during pregnancy, not excluding cases wherein the mother's injuries were negligible or inapparent and regardless of the time elapsed between accident and delivery.

Holland AJ, Liang RW, Singh SJ, Schell DN, Ross FI, Cass DT. Driveway motor vehicle injuries in children. Med J Aust 2000, 173(4):192-5.

ABSTRACT: OBJECTIVES: To describe the frequency, nature and outcome of driveway injuries in children. DESIGN: Retrospective case series of driveway-related injuries in children under 16 years of age admitted to the New Children's Hospital (NCH), New South Wales, from November 1995 to February 2000, and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry from January 1988 to December 1999. MAIN OUTCOME MEASURES: Circumstances of injury; type and number of injuries identified. RESULTS: 42 children were admitted to our institution with driveway-related injuries over four years and four months. These represent 12% of all children admitted with pedestrian motor vehicle injuries. Fourteen deaths (including one of the children admitted to NCH) were reported to the NPTD Registry over 12 years, accounting for 8% of all paediatric pedestrian motor vehicle deaths reported to the registry. Typically, the injury involved a parent or relative reversing a motor vehicle in the home driveway over a toddler or preschool-age child in the late afternoon or early evening. Four-wheel-drive or light commercial vehicles were involved in 42% of all injuries, although they accounted for just 30.4% of registered vehicles in NSW. These vehicles were associated with a 2.5-times increased risk of fatality. In 13 of the 14 deaths, the cause was a severe head injury not amenable to medical intervention. CONCLUSIONS: Driveway injuries in children account for a significant proportion of paediatric pedestrian motor vehicle injuries and deaths in NSW. Prevention represents the only effective approach to reducing deaths from this cause.

Becher EC, Cassel CK, Nelson EA. Physician firearm ownership as a predictor of firearm injury prevention practice. Am J Public Health 2000, 90(10):1626-8.

ABSTRACT: OBJECTIVES: This study explored the relation between physicians' gun ownership and their attitudes and practices regarding firearm injury prevention. METHODS: Internists and surgeons were surveyed, and logistic regression models were developed with physicians' personal involvement with firearms (in the form of a gun score) as the primary independent variable. RESULTS: Higher gun scores were associated with less agreement that firearm injury is a public health issue and that physicians should be involved in firearm injury prevention but with a greater likelihood of reporting the inclusion of firearm ownership and storage as part of patient safety counseling. CONCLUSIONS: Despite being less likely to say that doctors should participate in firearm injury prevention, physician gun owners are more likely than nonowners to report counseling patients about firearm safety.

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