Robert L. Muelleman

Risk factors for injury to women from domestic violence

BACKGROUND Domestic violence is the most common cause of nonfatal injury to women in the United States. To identify risk factors for such injuries, we examined the socioeconomic and behavioral characteristics of women who were victims of domestic violence and the men who injured them. METHODS We conducted a case-control study at eight large, university-affiliated emergency departments. The 256 intentionally injured women had acute injuries resulting from a physical assault by a male partner. The 659 controls were women treated for other conditions in the emergency department. Information was collected with a standardized questionnaire; no information was obtained directly from the male partners. RESULTS The 256 intentionally injured women had a total of 434 contusions and abrasions, 89 lacerations, and 41 fractures and dislocations. In a multivariate analysis, the characteristics of the partners that were most closely associated with an increased risk of inflicting injury as a result of domestic violence were alcohol abuse (adjusted relative risk, 3.6; 95 percent confidence interval, 2.2 to 5.9); drug use (adjusted relative risk, 3.5; 95 percent confidence interval, 2.0 to 6.4); intermittent employment (adjusted relative risk, 3.1; 95 percent confidence interval, 1.1 to 8.8); recent unemployment (adjusted relative risk, 2.7; 95 percent confidence interval, 1.2 to 6.5); having less than a high-school-graduates education (adjusted relative risk, 2.5; 95 percent confidence interval, 1.4 to 4.4); and being a former husband, estranged husband, or former boyfriend (adjusted relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.3). CONCLUSIONS Women at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school-graduates education, and are former husbands, estranged husbands, or former boyfriends of the women.

Battered Women: Injury Locations and Types

STUDY OBJECTIVE To characterize injuries to battered women by comparing their location, type, and severity with those of injuries to women resulting from other mechanisms. METHODS Cross-sectional study of 9,057 women between the ages of 19 and 65 years who presented for any reason to the emergency departments of 10 hospitals serving inner-city, urban, and suburban populations. RESULTS A total of 280 injured, battered women were identified during the study period. About 3.1% (95% confidence interval [Cl]. 2.7% to 3.5%) of all women seen in the ED, and 11.2% [95% Cl, 10.0% to 12.4%) of injured women with known mechanisms of injury, were determined to be positive for battering. Battered women were more likely to be injured in the head, face, neck, thorax, and abdomen (P < .001) than were women injured by other mechanisms. Twelve specific injury types were identified that occurred more frequently in battered women. CONCLUSION Although battered women experience certain injury types more frequently than women injured by other mechanisms, the low positive predictive value of these injuries supports the use of universal screening for domestic violence in all injured women.

Fatal motor vehicle crashes: variations of crash characteristics within rural regions of different population densities

OBJECTIVE While it is known that motor vehicle crash (MVC) fatality rates are inversely related to population density, there has been no description of which crash variables are related to population density. The purpose of this study was to describe crash characteristics of fatal MVCs and to determine which crash characteristics are related to population density. DESIGN This is a retrospective review of fatal accident reporting system (FARS) records. They represent four different population density regions over a 5-year period in a four-state midwest region. RESULTS There were 10,932 people in 6,318 vehicles who were involved in 4,970 fatalities. Occupant fatality rates per 100,000 persons were inversely related to population density. The variables related to lower population density were more light and heavy truck types, more frequent alcohol use and higher levels of intoxication, more frequent crashes that are noncollisions on less heavily traveled roads, more frequent crashes on gravel surface types, more frequent occupant ejection, and delayed medical care. CONCLUSION Rural areas are not homogenous in terms of fatal MVC crash characteristics. By analyzing fatal MVC crash characteristics in regions with different population densities, many crash variables were found to be related to population density. By understanding which characteristics about fatal MVCs are related to population densities, different interventions could be targeted to different rural populations.

Battered women: Where they go for help

OBJECTIVE Assistance must be available to abused women where they seek help. This study identified victims of partner abuse and asked them to indicate where they sought help when battered. The characteristics of acute battering incidents were also investigated. METHODS Consecutive women, ages 19 to 65, were recruited when they came to 10 emergency departments in two cities. Women were excluded if the following criteria existed: a language barrier, serious illness, or inability to separate subjects from accompanying persons. RESULTS Of 4448 women who completed the questionnaire, 37% acknowledged physical abuse by a partner at some time; 10% reported a present battering relationship; and 4% said their current visit to the emergency department was for abuse by an intimate partner. In 70% of surveys, the battering person was a boyfriend or ex-boyfriend. Weapons used were items near at hand. The three most common helping resources, in decreasing frequency of use, were family and friends, police, and the emergency department. DISCUSSION Resources to provide help must be available where women seek care when they are abused. Abuse among women who come to emergency departments is common, and emergency departments are the third highest resource cited by abused women. Emergency nurses should be prepared to identify and assist abused women.

Opioid toxicity recurrence after an initial response to naloxone

OBJECTIVE To determine the frequency and potential predictors of opioid toxicity recurrence after a response to naloxone in adult Emergency Department patients. METHODS A retrospective case-control study of naloxone-treated patients with opioid toxicity over an 8-year period. Both the patient response to naloxone and recurrence of opioid toxicity was determined by an expert Delphi Panel. The frequency of opioid toxicity recurrence was compared by the duration of opioid effect, the route of opioid exposure, and the presence of other CNS depressant drugs. RESULTS Ninety of 221 (41%) cases with a discharge diagnosis of opioid toxicity were treated with naloxone; six patients were excluded because of a lack of toxicity. There was a response to naloxone in 50% of the 84 cases, and recurrence of toxicity in 31% (95% CI 17-45%) of naloxone responders. The most common opioids were codeine, heroin, propoxyphene, and oxycodone/hydrocodone. Recurrence of toxicity was more common with long-acting opioids (p = 0.04), and was not associated with the route of opioid exposure (p = 0.42), or presence of ethanol and other CNS depressants (p > or = 0.87). CONCLUSION Opioid toxicity recurrence after a response to naloxone occurred in approximately 1/3 of adult Emergency Department opioid overdose cases. Recurrence was more common with long-acting opioids and was not associated with the route of opioid exposure. Other clinically useful predictors of toxicity recurrence were not identified.

Measuring response intervals in a system with a 911 primary and an emergency medical services secondary public safety answering point

STUDY OBJECTIVE Measurement of interval data is important in the accurate recording of events that occur in an emergency medical services system. Measurement of intervals should be a simple task. However, when two separate clocks are needed to record the beginning and end of an interval, accurate measurement may be difficult. We sought to accurately measure the 911 call receipt-to-vehicle departure and 911 calls receipt-to-patient access intervals in a system with primary and secondary public safety answering points (PSAPs). METHODS We conducted a descriptive study between January 1 and July 31, 1993. All 911 calls beginning at the primary PSAP, transferred to the EMS secondary PSAP, and ending with patient access times were eligible. Clock-synchronization errors and unavailability of 911 time logs were the criteria for exclusion. We measured the 911 call receipt-to-vehicle departure interval by adding the primary-PSAP and the EMS secondary-PSAP call-processing intervals. The 911 call receipt-to-patient access interval was the absolute difference between the time when the 911 primary-PSAP phone range and the time of patient access recorded by EMS personnel. RESULTS The data were best described with median and interquartile ranges (IQRs). We found 1,945 calls that met inclusion criteria. Of these, 270 were deleted because of clock errors and 616 for time log unavailability, yielding 1,059 calls for interval determinations. The median 911 call receipt-to-vehicle departure interval was 1.7 minutes (IQR, 1.2 to 2.2 minutes). The median 911 call receipt-to-patient access interval was 8.2 minutes (IQR, 6.4 to 10.5 minutes). CONCLUSION The 911 call receipt-to-vehicle departure and 911 call receipt-to-patient access intervals can be accurately measured in a system with two separate PSAP computer-aided dispatch clocks. These intervals are variable and often lengthy.

Blood pressure effects of thyrotropin-releasing hormone and epinephrine in anaphylactic shock

To compare the effects of a single dose of thyrotropin-releasing hormone (TRH), epinephrine, and control (normal saline) on mean arterial pressure (MAP) and survival over a one-hour observation period, we carried out a randomized, blinded study using a rabbit model of anaphylaxis. Epinephrine resulted in an increased MAP over normal saline and TRH at one minute after treatment (P less than .001). TRH resulted in an increased MAP over normal saline at two minutes (P less than .017) and over epinephrine at four minutes (P less than .011) after treatment. No differences in MAP were detected beyond four minutes after treatment. There was no difference in survival between treated and control animals (alpha less than .168). Although no difference in survival existed, TRH had a slower onset, but more sustained effect on MAP than did epinephrine and normal saline.

Missouri's emergency department E-code data reporting: a new level of data resource for injury prevention and control.

This article describes the results of the first statewide external cause of injury (E-code) reporting system that includes emergency department (ED) visits. The results indicate that for every injury-related death, there are 20 hospitalizations and 174 ED visits. Although firearms and motor vehicle crashes were the leading causes of injury-related deaths, falls and motor vehicle crashes were the leading causes of ED visits. An analysis of injuries in one metropolitan statistical area in the state demonstrates similarities and differences from the statewide results. The statewide reporting of cause of injury information in ED visits provides valuable information for injury control efforts.

Hemodynamic and respiratory effects of thyrotropin-releasing hormone and epinephrine in anaphylactic shock

Thyrotropin-releasing hormone (TRH) has been shown to increase mean arterial pressure during anaphylactic shock. The hemodynamic mechanism of action and the effect of TRH on the respiratory system during anaphylactic shock are not known. A rabbit model of anaphylaxis was used to determine the effect of TRH, epinephrine (EPI), and normal saline (NS) on various cardiovascular and respiratory parameters during anaphylactic shock. Anaphylactic shock was induced by antigen challenge in 31 sensitized animals. After a 25% decrease in mean arterial pressure, they were randomly treated with TRH (2 mg/kg), EPI (0.005 mg/kg), or NS (10 mL/kg). Blood was drawn at baseline and at the end of the experiment for laboratory analysis. Cardiac and respiratory parameters were monitored continuously and measured at baseline, at onset of shock (time zero), and at time intervals for 30 minutes. Animals were treated with repeated doses during the first 15 minutes as needed to maintain mean arterial pressure above shock level. Five of ten TRH-, five of 11 EPI-, and six of ten NS-treated animals survived. The TRH-treated group required fewer doses than the other groups and had increased heart rate, mean arterial pressure, peripheral vascular resistance, respiratory rate, and minute ventilation as well as decreased stroke volume index and lung compliance compared with the NS-treated group. EPI treatment resulted in increased minute ventilation and decreased pulmonary airway resistance compared with NS treatment. The EPI group also had a higher postsurvival epinephrine level than the other groups. No difference in right atrial pressure, cardiac index, acid-base status, pO2, A- a gradient, lung weight, lactate, or norepinephrine levels was found.(ABSTRACT TRUNCATED AT 250 WORDS)