D. L. McArthur

Multiple organ failure: By the time you predict it, it's already there

OBJECTIVE Validate an at-risk population to study multiple organ failure and to determine the importance of organ dysfunction 24 hours after injury in determining the ultimate severity of multiple organ failure. METHODS We evaluated 105 patients admitted to five academic trauma centers during a 1-year period who survived for more than 24 hours with Injury Severity Scores > or = 25 and who received 6 or more units of blood. Organ dysfunction was scored daily with a modified multiple organ failure scoring system made up of individual adult respiratory distress syndrome score, renal dysfunction, hepatic dysfunction, and cardiac dysfunction scores. Multiple organ failure (MOF) severity was quantitated using the maximum daily multiple organ failure score and the cumulative sum of daily multiple organ failure scores for the first 7 days (MOF 7) and 10 days (MOF 10). Independent variables included markers of tissue injury, shock, host factors, physiologic response, therapeutic factors, and organ dysfunction within the first 24 hours after admission. Data were subjected to a conditional stepwise multiple regression analysis, first excluding and then including 24-hour MOF as an independent variable. RESULTS Of the 105 high-risk patients, 69 (66%) developed a maximum daily multiple organ failure score > or = 1; 50 (72%) did so on day 1 one and 60 (87%) did so by day 2. In multiple regression models, the multiple correlation coefficient increased from 0.537 to 0.720 when maximum MOF was the dependent variable, from 0.449 to 0.719 when maximum daily MOF was the dependent variable, from 0.519 to 0.812 when MOF 7 was the dependent variable, and from 0.514 to 0.759 when MOF 10 was the dependent variable. CONCLUSION We have confirmed that the population of patients with Injury Severity Scores > or = 25 who received 6 or more units of blood represent a high-risk group for the development of multiple organ failure. Our data also indicate that multiple organ failure after trauma is established within 24 hours of injury in the majority of patients who develop it. It appears that multiple organ failure is already present at the time when most published models are trying to predict whether or not it will occur.

The prevalence of non-standard helmet use and head injuries among motorcycle riders

OBJECTIVES This study examined the prevalence of non-standard helmet use among motorcycle riders following introduction of a mandatory helmet use law and the prevalence of head injuries among a sample of non-standard helmet users involved in motorcycle crashes. METHODS Motorcycle rider observations were conducted at 29 statewide locations in the 2 years following the introduction of the mandatory helmet use law in January, 1992. Medical records of motorcyclists who were injured in 1992 for whom a crash report was available and for whom medical care was administered in one of 28 hospitals were reviewed. Chi-squares and analysis of variance were used to describe differences between groups. RESULTS Prevalence of non-standard helmet use averaged 10.2%, with a range across observation sites from 0 to 48.0%. Non-standard helmet use varied by type of roadway, day of week, and time of day. Injuries to the head were more frequent and of greater severity among those wearing non-standard helmets than both those wearing no helmet and those wearing standard helmets. CONCLUSIONS Non-standard helmets appear to offer little head protection during a crash. Future study is needed to understand the dynamics leading to head injury when different types of helmets are worn.

Child pedestrian and bicyclist injuries: results of community surveillance and a case-control study.

OBJECTIVES: To describe the dimensions of childhood pedestrian and bicyclist injuries in Long Beach, California, and to identify risk factors for these injuries. POPULATION: Long Beach residents aged 0-14 years who were involved in an auto versus pedestrian or bicyclist incident that resulted in a hospital visit and/or police response, between 1 September 1988 and 31 August 1990. METHODS: Cases were identified retrospectively using hospital charts, police records, and coroners reports; demographic, clinical, and situational information were abstracted from the same. A nested case-control study was conducted to examine the street environments where children were injured, and to identify environmental risk factors at these case sites. RESULTS: 288 children comprised the sample population. Midblock dart-outs emerged as the single most common type of incident. Most incidents happened on residential streets, but the risk of injury was greatest on larger boulevards, and tended to cluster by region within the city. Adjusted odds ratios show that case sites had a larger proportion of traffic exceeding posted speed limits, and were also four times more likely to be near a convenience store, gas station, or fast food store than control sites. CONCLUSIONS: The findings of this study suggest three possible routes for the prevention of childhood pedestrian and bicyclist injuries: education, law enforcement, and environmental modification.

Driver Compliance With Stop Signs at Pedestrian Crosswalks on a University Campus

Pedestrians on college campuses interact continuously with various motorized vehicles. Rates of compliance with stop signs at pedestrian crosswalks and noncomplying vehicles were monitored in spring 1996 on a large urban campus. The number of pedestrians, pedestrian clearance, type of vehicle, hour of day, and day of week were monitored at 3 pedestrian crosswalks. The overall compliance rate for stop signs was 22.8 per 100 vehicles, ranging from 1.4 per 100 for bicycles to 46.2 per 100 for commuter vans. Compliance increased to 53 per 100 vehicles when pedestrians were present in the crosswalk. Several differences in compliance rates were found among the observation sites. Lowest compliance was observed for bicycles and motorcycles. Pedestrians on this and other college campuses risk injuries because of violations of pedestrian right-of-way laws. The problem calls for appreciable educational efforts by college health personnel.

Determining injury at work on the California death certificate.

OBJECTIVES This study examined decisions of California Country Coroners offices in determining injury at work and identified factors influencing this decision. METHODS Surveys were sent to California County Coroners offices (response rate = 93%). The survey included 23 vignettes that required the respondent to determine whether the fatality involved an injury at work. The Rasch method was used to determine internal consistency in endorsing vignettes and to determine overall endorsability of vignettes based on underlying factors. RESULTS Respondents showed internal consistency but much disagreement in their endorsement of vignettes. Decedents who were performing paid work or were on their work site during working hours were almost unanimously endorsed as having incurred an injury at work. Non-payment, travel/transportation, suicide, and nontraditional work sites and work hours led to disagreement and uncertainty among respondents. CONCLUSIONS Coroners have different methods of determining injury at work on the death certificate, and available guidelines do not define many of the ambiguous situations encountered by coroners.