Chair’s Corner - Trauma & Injury Prevention Section Newsletter, September 2013
Welcome to our Summer 2013 Trauma & Injury Prevention Section newsletter. We have had a busy summer at TIPS, both developing new initiatives and expanding on old ones.
Most significantly, we are formalizing our subcommittees (Education; Guidelines; and Gun Violence Prevention). Please see the piece below, detailing each subcommittee’s goals and activities. If you are interested in getting involved with these, send an email to me or the subcommittee chair.
Some important dates and times to remember for ACEP13 in Seattle, WA:
1. SECTION MEETING: Tuesday 10/15, 1p-2:30p.
Our afternoon meeting will be dedicated to our section activities: choosing next year’s Chair-Elect and Newsletter Editor; discussing our new subcommittees; council resolutions; and other new business. We welcome your ideas and involvement.
2. ACEP13: LECTURE ON INTERVENTION STRATEGIES FOR INJURY RISK BEHAVIORS: Monday 10/14, 12:30p-2:20p
Organizers of ACEP13 are taking a chance by including this public health lecture this year, which was written and is being given by TIPS members. The lecture will discuss real-world strategies for the implementation of ED-based SBIRT for alcohol/drugs, partner violence, and peer violence.
We would love to see this talk become a fixture of ACEP’s annual meetings. Please tell your colleagues about, sign up for, and attend, ACEP’s first public health lecture in years. Help us to show the ACEP13 planners that public health and injury prevention matters to ACEP members. You may also find that it gives you some great ideas to bring home to your own shop!
3. JOINT EDUCATIONAL SESSION: Tuesday 10/15 9:30a-12:30p.
The educational portion of our section meeting will occur in collaboration with the International EM section. We will have a series of lectures and workshops regarding global injury prevention. See the piece below in the newsletter, by Shawn D’Andrea, who is helping to organize this effort.
4. SATELLITE CONFERENCE ON ED-BASED SUBSTANCE ABUSE INTERVENTION: Sunday 10/13, all day
This novel satellite conference represents a collaborative effort between National Institute on Drug Abuse (NIDA), Centers for Disease Control and Prevention (CDC), and ACEP. The morning session will highlight best-practices for opioid abuse screening and prevention. The afternoon session will feature Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substances in general. Linda Degutis, the director of the CDC National Center for Injury Prevention and Control, will be giving the keynote lecture. Many TIPS members, including myself, will be lecturing as well. This daylong satellite conference will provide a more in-depth look at the topics that will be discussed during the ACEP13 lecture. As our section members are the experts in this topic, your attendance is valued and important.
5. COUNCIL RESOLUTIONS:
We submitted 1 resolution and co-sponsored 2 others, all related to violence prevention. If you are planning on attending the reference committees or council meeting, please let me know, so I can brief you on these resolutions.
Please read on through the newsletter for more details!
Thanks as always for your support, and I will see you on October 15th.
Megan L. Ranney MD MPH FACEP
Injury Prevention Ctr, Department of Emergency Medicine, Brown University/Rhode Island Hospital
Chair, ACEP Trauma & Injury Prevention Section
TIPS Subcommittees: Call to Action - Trauma & Injury Prevention Section Newsletter, September 2013
In order to capitalize upon the momentum that TIPS has built over the past few years, we would like to expand our efforts by forming three standing subcommittees within the Section. Each subcommittee will have specific goals and activities, which will be discussed and ratified at ACEP13 and each annual meeting thereafter. Each subcommittee will also have dedicated time to present their progress over the prior year during the TIPS annual meeting.
Chair: Mark Sochor, MD
University of Virginia
Email Dr. Sochor
The Guidelines Subcommittee will represent TIPS expertise and interests, both within ACEP and externally. Subcommittee members will offer their expertise to the ACEP Clinical Policies Committee as the CPC develops policies regarding injury prevention and the evaluation and treatment of patients with traumatic injuries. Similarly, subcommittee members will offer both emergency medicine and TIPS expertise to guidelines committees from other professional organizations (EAST, ACS-COT, AST, SAVIR, etc) in order to ensure that any guidelines regarding the care of our mutual patients have true multispecialty input. Perhaps most importantly, the subcommittee will be charged with synthesizing and summarizing external guidelines related to trauma and injury prevention for the Section in order for our members to stay abreast of the most recent recommendations and treatment algorithms.
TIPS has had significant success over the past year developing and co-developing educational content for ACEP13 (see Chair’s Corner above) and the Education Subcommittee will be responsible for continuing to organize sessions that can both showcase TIPS members’ expertise and offer specific trauma and injury prevention content to wider audiences, both within ACEP and in other venues. We hope to build upon the satellite conferences, joint educational sessions, and lectures developed this year and also reach out to other conferences to increase their awareness of our specialty’s contributions in injury prevention and trauma care (the World Injury Conference, for example, has already solicited TIPS assistance and expertise).
Gun Violence Prevention Subcommittee
Chair: Jeffrey Sankoff, MD
Denver Health Medical Center
Email Dr. Sankoff
In the summer of 2012, not long after the tragic mass shooting in a theater in Aurora, CO, the boards of the Colorado and California state chapters of ACEP as well as the leadership of the Trauma and Injury Prevention section of ACEP independently began working on separate resolutions on firearm violence to be presented at the ACEP Council meeting. When each of these groups learned of the others’ efforts, they banded together to present a joint resolution that passed in part last Otober.
Some of the EPs who had worked so hard on this and felt passionately about this issue decided that more work remained to be done and decided to start a working group to press forward with further advocacy and legislative initiatives on firearm violence. Anna Webster and Andrew Fenton from Cal-ACEP, Jeff Sankoff and Dave Ross from CO-ACEP and Megan Ranney from TIPS formed the initial membership of the group but it rapidly grew with the addition of Garen Wintemute and others.
The need for our work became even more pressing with the events at Sandy Hook in December and our group expanded yet again with the addition of Rob Bazuro and others from Newtown.
To date, members have worked to help assure passage of firearms legislation in both California and Colorado and have teamed with national organizations such as the AMA and the National Physicians Alliance to educate and advocate for stronger regulations on magazine capacity, background checks and restrictions on assault weapons bans. In addition, we have worked with legislators in both Connecticut and Rhode Island towards the same ends.
We have also written numerous op-ed pieces published in newspapers across the country and had an editorial published in the Annals of Emergency Medicine.
Unfortunately, this is a complex issue and although there have been some successes; the forces aligned against us are strong and well-organized. In the future, the working group is looking towards further legislative efforts and ACEP resolutions to press for firearms research. In addition, we believe that education on the facts of firearms ownership may help diminish the desire for weapons in the first place.
Firearm violence remains a scourge in this country and there is much work to be done. The firearms violence working group is eager to welcome interested and enthusiastic individuals who share our desire to see this scourge wane.
ACEP Trauma and Injury Prevention / International Sections Collaborative Education Program - Trauma & Injury Prevention Section Newsletter, September 2013
Shawn D’Andrea, MD
Brigham and Women’s Hospital / Harvard Medical School
ACEP13 -Seattle, WA
Tuesday, October 15th
9:30AM – 12:30PM
Trauma is a major cause of morbidity and mortality worldwide. However, the vast majority of morbidity due to injuries occurs in the developing world. Road traffic accidents alone cause 1.24 million deaths annually around the world, with 91% of these fatal injuries taking place in low and middle income countries. An additional 20 to 50 million non-fatal injuries due to road traffic accidents across the globe also occur each year.1
Violence causes an additional 1.6 million deaths worldwide and, again, a disproportionate percentage of these deaths (greater than 90%) occur in low and middle income countries.2 While trauma care has been evolving in the US for decades, most of the world has systems of trauma care that are under resourced or non-existent. Similarly, in the US, programs and strategies for trauma and injury prevention have been growing for years, while many countries lack the medical or public health infrastructures to initiate such programs.3
As the specialty of emergency medicine takes a more prominent role in both trauma and injury prevention and international health, the broad prevalence of trauma worldwide is a call for our membership to merge this expertise and take a leadership role in global trauma and injury prevention.
To address this challenge, the Trauma and Injury Prevention and International Sections are proud to offer a collaborative education program. The program will include both didactic and small group simulation components, and participants will be working with colleagues to create and share initiatives to address trauma and injury care and prevention in the developing world. At the end of this three hour program, members will have acquired the skills and knowledge to understand the scope of the problem, and to design and operationalize programs to address this fundamental emergency medicine challenge in different regions of the world.
Identifying Physical Abuse in Children - Trauma & Injury Prevention Section Newsletter, September 2013
Daniel Lindberg MD FACEP
University of Colorado Denver
Most people whose children have a life-threatening disease search high and low to find the best available expert in that disease – unless the disease is child abuse. With the 2006 establishment of Child Abuse Pediatrics as an official subspecialty within Pediatrics, board-certified specialists are more available to care for abused children and to follow them through their interactions with child protective services (CPS) and law enforcement. However, most caregivers will not seek out these experts, and the duty to raise the red flag continues to fall predominantly on emergency physicians. Here are a few pearls from the recent literature:
Surprise! Abuse does not decrease during a recession.
One commonly cited count of substantiated reports to CPS suggested that all forms of abuse were actually decreasing during the recent economic recession – in contrast to both experience and expectations. Several threads of evidence now suggest that this is probably more likely to be artifactual, perhaps as a result of changes when CPS agencies decreased resources but increased caseloads. Child abuse teams1 and hospitals2,3 are seeing more of the most serious types of child abuse, and novel techniques have also shown an up-tick in Google searches, suggesting physical abuse.4
The skeletal survey is still the king of abuse screening – we should get more of them.
A good skeletal survey can turn a tough case into a slam dunk. Recent studies show higher than expected rates of positive skeletal surveys in both infants with skull fractures (6%)5,6 and siblings of abused children (12%),7 and also show disturbing variability in survey completion by center8 and according to race or income level.9,10 A recent suggestion to curtail the number of films obtained11 has been roundly repudiated.12-14
There is, however, some complexity in conducting, and skill in reading, skeletal surveys, so consider transfer to a pediatric center if this isn’t something your hospital does commonly. To increase fracture detection, specialists are also ordering an increasing number of follow-up skeletal surveys 10-14 days after the initial survey15,16, something you may want to suggest, or counsel patients to expect.
Sentinel injuries are common.
A retrospective analysis of several hundred children evaluated at one center found that nearly a quarter of the children coded as “definitely abused” had been diagnosed with at least one sentinel injury (bruising, oral injury) in the months prior to diagnosis.17 Emergency physicians should be alert to bruising in infants who aren’t yet crawling or “cruising” as well as injuries to the lips, ears, frenula, or pharynx without the old “running with a toothbrush” history
Screen more aggressively for abdominal injuries.
While recent data from PECARN18 will hopefully result in fewer CT scans in children with accidental trauma, the PECARN algorithm did not include abuse outcomes.19 Evidence suggests that we should obtain AST and ALT levels in all children with a concern for physical abuse and that those patients in whom either marker is elevated (>80 IU/L) should have an abdominal CT with IV contrast.20-22 Amylase and lipase are much less likely to show additional injuries, and can be omitted. Replacing CT with ultrasound, or waiting to see if the labs normalize is not the answer.23,24 Risks from radiation are far lower than risks from missed abuse.
- Berger RP, Fromkin JB, Stutz H, et al. Abusive head trauma during a time of increased unemployment: a multicenter analysis. Pediatrics 2011;128:637-43.
- Leventhal JM, Gaither JR. Incidence of serious injuries due to physical abuse in the United States: 1997 to 2009. Pediatrics 2012;130:e847-52.
- Wood JN, Medina SP, Feudtner C, et al. Local macroeconomic trends and hospital admissions for child abuse, 2000-2009. Pediatrics 2012;130:e358-64.
- Stephens-Davidovitz S. Op-Ed: How Googling Unmasks Child Abuse. New York Times 2013 July 14, 2013;Sect. SR5.
- Deye K, Lindberg D, for the ExSTRA Investigators. Screening for Occult Injuries in Children with Apparently Isolated Skull Fractures. Helfer Society Annual Meeting. Austin, TX2012.
- Laskey AL, Stump TE, Hicks RA, Smith JL. Yield of skeletal surveys in children </= 18 months of age presenting with isolated skull fractures. The Journal of pediatrics 2013;162:86-9.
- Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193-201.
- Wood JN, Feudtner C, Medina SP, Luan X, Localio R, Rubin DM. Variation in Occult Injury Screening for Children With Suspected Abuse in Selected US Children's Hospitals. Pediatrics 2012.
- Wood JN, Hall M, Schilling S, Keren R, Mitra N, Rubin DM. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics 2010;126:408-1
- Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA : the journal of the American Medical Association 2002;288:1603-9.
- Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR American journal of roentgenology 2011;197:W159-63.
- Barber I, Perez-Rossello JM, Wilson CR, Silvera MV, Kleinman PK. Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatric radiology 2013.
- Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. AJR American journal of roentgenology 2013;200:641-4.
- Lindberg DM, Harper NS, Laskey AL, Berger RP, the ExSTRA Investigators. Prevalence of Abusive Fractures of the Hands, Feet, Spine, or Pelvis on Skeletal Survey: Perhaps "Uncommon" Is More Common Than Suggested. Pediatric emergency care 2013;29:26-9.
- Harper NS, Eddleman S, Lindberg DM, for the ExSTRA Investigators. The utility of follow-up skeletal surveys in child abuse. Pediatrics 2013;131:e672-8.
- Singh R, Squires J, Fromkin JB, Berger RP. Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. The journal of trauma and acute care surgery 2012.
- Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel Injuries in Infants Evaluated for Child Physical Abuse. Pediatrics 2013.
- Holmes JF, Lillis K, Monroe D, et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Annals of emergency medicine 2013.
- Lindberg DM, Berger RP, Lane WG. PECARN Abdominal Injury Rule Should Exclude Potentially Abused Children. Ann Emerg Med 2013;62:276-7.
- Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP, Ex Si. Utility of hepatic transaminases in children with concern for abuse. Pediatrics 2013;131:268-75.
- Lindberg D, Makoroff K, Harper N, et al. Utility of Hepatic Transaminases to Recognize Abuse in Children. Pediatrics 2009;124:509-16.
- Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics 2009;124:1595-602.
- Kleinman PK, Di Pietro MA, Brody AS, et al. Diagnostic imaging of child abuse. Pediatrics 2009;123:1430-5.
- Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood-Their range and recognition. Child abuse & neglect 2013;37:430-45.