Lina Brou

Epidemiology of Stress Fracture Injuries Among US High School Athletes, 2005-2006 Through 2012-2013

Background: High school athletes in the United States sustain millions of injuries annually, approximately 10% of which are fractures. However, there is no clear estimate of the number of stress fractures sustained by high school athletes annually despite reports that stress fractures account for 0.7% to 20% of injuries seen in sports medicine clinics. This suggests a high utilization of resources for a potentially preventable injury. In addition, stress fractures have been associated with low energy availability and disordered eating in young athletes, highlighting the importance of early recognition and intervention. Purpose: To investigate stress fracture rates and patterns in a large national sample of US high school athletes. Study Design: Descriptive epidemiologic study. Methods: Data from High School RIO (Reporting Information Online), a national sports injury surveillance study, were analyzed to describe rates and patterns of stress fracture injury sustained from 2005-2006 through 2012-2013, across sports and by sex. Results: From 2005-2006 through 2012-2013, a total of 51,773 injuries were sustained during 25,268,873 athlete-exposures, of which 389 (0.8%) were stress fractures, resulting in an overall stress fracture rate of 1.54 per 100,000 athlete-exposures. Rates per 100,000 athlete-exposures were highest in girls’ cross country (10.62), girls’ gymnastics (7.43), and boys’ cross country (5.42). In sex-comparable sports, girls sustained more stress fractures (63.3%) than did boys (36.7%) and had higher rates of stress fracture (2.22 vs 1.27; rate ratio, 1.75; 95% CI, 1.38-2.23). The most commonly injured sites were the lower leg (40.3% of all stress fractures), foot (34.9%), and lower back/lumbar spine/pelvis (15.2%). Management was nonsurgical in 98.7% of the cases, and 65.3% of injuries resulted in ≥3 weeks of time loss, medical disqualification, or an end to the season before athletes could return to play. Conclusion: Although a rare injury, stress fractures cause considerable morbidity for high school athletes of both sexes. Future research should evaluate risks of stress fractures to drive development of targeted prevention efforts.

Acute concussion symptom severity and delayed symptom resolution

BACKGROUND AND OBJECTIVES: Up to 30% of children who have concussion initially evaluated in the emergency department (ED) display delayed symptom resolution (DSR). Greater initial symptom severity may be an easily quantifiable predictor of DSR. We hypothesized that greater symptom severity immediately after injury increases the risk for DSR. METHODS: We conducted a prospective longitudinal cohort study of children 8 to 18 years old presenting to the ED with concussion. Acute symptom severity was assessed using a graded symptom inventory. Presence of DSR was assessed 1 month later. Graded symptom inventory scores were tested for association with DSR by sensitivity analysis. We conducted a similar analysis for post-concussion syndrome (PCS) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Potential symptoms characteristic of DSR were explored by using hierarchical cluster analysis. RESULTS: We enrolled 234 subjects; 179 (76%) completed follow-up. Thirty-eight subjects (21%) experienced DSR. Initial symptom severity was not significantly associated with DSR 1 month after concussion. A total of 22 subjects (12%) had PCS. Scores >10 (possible range, 0–28) were associated with an increased risk for PCS (RR, 3.1; 95% confidence interval 1.2–8.0). Three of 6 of the most characteristic symptoms of DSR were also most characteristic of early symptom resolution. However, cognitive symptoms were more characteristic of subjects reporting DSR. CONCLUSIONS: Greater symptom severity measured at ED presentation does not predict DSR but is associated with PCS. Risk stratification therefore depends on how the persistent symptoms are defined. Cognitive symptoms may warrant particular attention in future study. Follow-up is recommended for all patients after ED evaluation of concussion to monitor for DSR.

Epidemiology of High School Sports-Related Injuries Resulting in Medical Disqualification 2005-2006 Through 2013-2014 Academic Years

Background: Although rare, season- or career-ending injuries in young athletes are concerning because they can result in time lost from sport participation and school, social costs, and economic costs of medical care. Purpose: To describe rates and patterns of medically disqualifying (MDQ) injuries among United States high school athletes overall and by sport, sex, type of athletic activity, and mechanism. Study Design: Descriptive epidemiological study. Methods: Sports-related injury data on high school athletes were collected during the 2005-2006 through 2013-2014 academic years from a large national sample of United States high schools via High School Reporting Information Online (RIO). MDQ injuries were defined as season- or career-ending injuries. Results: From 2005-2006 through 2013-2014, High School RIO captured 59,862 total injuries including 3599 MDQ injuries (6.0% of all injuries). Most MDQ injuries (60.4%) occurred in competition. Football had the highest injury rate (26.5 per 100,000 athlete-exposures), followed by gymnastics (18.6) and wrestling (17.9). MDQ injury rates were higher among girls in the sex-comparable sports of basketball (rate ratio [RR], 1.6; 95% CI, 1.3-2.0), cross-country (RR, 2.6; 95% CI, 1.0-7.5), soccer (RR, 1.6; 95% CI, 1.3-1.9), and track and field (RR, 2.6; 95% CI, 1.7-4.0). Player-player contact (48.2%) was the most common MDQ injury mechanism. The most commonly injured body site was the knee (33.7%). The most common MDQ injury diagnosis was sprains/strains (35.9%); the most common specific MDQ injury was knee sprains/strains (25.4%), with the anterior cruciate ligament being the most commonly injured knee structure. Among boys, fracture was the most common diagnosis in 3 sports, and sprain/strain was the most common in 6 sports. Among girls, sprain/strain was the most common diagnosis in 9 sports, and fracture was the most common only in softball. Conclusion: MDQ injuries vary by sport, sex, and type of athletic activity and occur most frequently as a result of player-player contact. These findings should prompt additional research into the development, implementation, and evaluation of targeted injury prevention efforts.

Comparison of Errors Using Two Length-Based Tape Systems for Prehospital Care in Children

Abstract Background: The use of a length/weight-based tape (LBT) for equipment size and drug dosing for pediatric patients is recommended in a joint statement by multiple national organizations. A new system, known as Handtevy™, allows for rapid determination of critical drug doses without performing calculations. Objective: To compare two LBT systems for dosing errors and time to medication administration in simulated prehospital scenarios. Methods: This was a prospective randomized trial comparing the Broselow Pediatric Emergency Tape™ (Broselow) and Handtevy LBT™ (Handtevy). Paramedics performed 2 pediatric simulations: cardiac arrest with epinephrine administration and hypoglycemia mandating dextrose. Each scenario was repeated utilizing both systems with a 1-year-old and 5-year-old size manikin. Facilitators recorded identified errors and time points of critical actions including time to medication. Results: We enrolled 80 paramedics, performing 320 simulations. For Dextrose, there were significantly more errors with Broselow (63.8%) compared to Handtevy (13.8%) and time to administration was longer with the Broselow system (220 seconds vs. 173 seconds). For epinephrine, the LBTs were similar in overall error rate (Broselow 21.3% vs. Handtevy 16.3%) and time to administration (89 vs. 91 seconds). Cognitive errors were more frequent when using the Broselow compared to Handtevy, particularly with dextrose administration. The frequency of procedural errors was similar between the two LBT systems. Conclusion: In simulated prehospital scenarios, use of the Handtevy LBT system resulted in fewer errors for dextrose administration compared to the Broselow LBT, with similar time to administration and accuracy of epinephrine administration.

Timing of Lower Extremity Injuries in Competition and Practice in High School Sports

Background: Laboratory-based experiments demonstrate that fatigue may contribute to lower extremity injury (LEI). Few studies have examined the timing of LEIs during competition and practice, specifically in high school athletes across multiple sports, to consider the possible relationship between fatigue and LEIs during sport events. Hypothesis: The purpose of this study was to describe the timing of LEIs in high school athletes within games and practices across multiple sports, with a hypothesis that more and severe injuries occur later in games and practices. Study Design: Descriptive epidemiologic study. Level of Evidence: Level 4. Methods: Using the National High School RIO (Reporting Information Online) sport injury surveillance system, LEI severity and time of occurrence data during practice and competition were extracted for 9 high school sports. Results: During the school years 2005-2006 through 2013-2014, 16,967,702 athlete exposures and 19,676 total LEIs were examined. In all sports surveyed, there was a higher LEI rate, relative risk for LEI, and LEI requiring surgery during competition than practice. During practice, the majority of LEIs occurred over an hour into practice in all sports. In quarter-based competition, more LEIs occurred in the second (31% to 32%) and third quarters (30% to 35%) than in the first (11% to 15%) and fourth quarters (22% to 26%). In games with halves, the majority (53% to 66%) of LEIs occurred in the second half. The greater severity LEIs tended to occur earlier in games. Conclusion: Fatigue may play a role in the predominance of injuries in the second half of games, though various factors may be involved. Greater severity of injuries earlier in games may be because of higher energy injuries when athletes are not fatigued. Clinical Relevance: These findings can help prepare sports medicine personnel and guide further related research to prevent LEIs.

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Abstract Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.

Hand and Wrist Injuries Among US High School Athletes: 2005/06–2015/16

Through retrospective data review, the authors of this study explore the epidemiology of hand/wrist injuries in high school athletes, identifying injury trends and areas for injury prevention efforts. BACKGROUND: The risk of hand/wrist injuries is present across various sports. Little is known about the epidemiology of such injuries. The objective of this study was to calculate the rates of hand/wrist injuries and investigate injury patterns among high school athletes. METHODS: Athlete exposure (AE) and hand/wrist injury data were collected during 11 academic years, 2005/06 through 2015/16, from a large sample of US high schools as part of the National High School Sports-Related Injury Surveillance Study. RESULTS: There were 6723 hand/wrist injuries sustained during 40 195 806 AEs, a rate of 1.7 per 10 000 AEs. The rate of injury in competition (3.3) was higher than in practice (1.1) (95% confidence interval: 2.8–3.1). Rates of hand/wrist injuries varied by sport, with the highest rates in football (4.3), boys’ lacrosse (1.9), girls’ softball (1.9), wrestling (1.8), girls’ field hockey (1.7), boys’ ice hockey (1.7), and girls’ basketball (1.7). The most common injuries were fracture (45.0%), contusion (11.6%), and ligament sprain (9.0%). Athletes most frequently returned to play in <7 days (45.7%), but 12.4% of injuries kept athletes out ≥3 weeks. CONCLUSIONS: High school athletes are at risk for hand/wrist injuries. Such injuries can keep athletes out of play and many require substantial medical treatment. Stick and ball or puck sports and full contact sports have high rates of hand/wrist injuries relative to other sports, which is indicative of a need for sport-specific prevention efforts.

1371: USING LACTATE AND BLOOD PRESSURE TO CLASSIFY SHOCK IN PEDIATRIC SEPSIS: AN EHR-BASED APPROACH.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) COPD (P = 0.039), and had lower APACHE scores at presentation (P = 0.002). Per kg, obese patients received the lowest volume of fluid at 3 and 6 hours (30.4, 36.0), followed by overweight patients (35.5, 43.2), and normal/underweight patients (44.9, 54.3; P < 0.001, P < 0.001). There was no difference in mortality among the groups (P=0.11). Conclusions: The obesity paradox was not observed in patients with severe sepsis in the era of protocolized sepsis care. Despite implementation of a standardized weight-based volume administration protocol, obese patients received significantly less fluid per kg than did overweight or normal/ underweight patients, similar to findings from earlier studies that did show an obesity paradox. These results argue against the theory that “under-resuscitation” is a contributor to lower mortality in obese patients.