Headache Management in the Neuroscience Intensive Care Unit

PURPOSE OF REVIEW

Headache is a common symptom in the Neuroscience Intensive Care Unit (NeuroICU). Our goal is to provide an overview of approaches to headache management for common neurocritical care conditions.

RECENT FINDINGS

Headache disorders afflict nearly half of patients admitted to the NICU. Commonly encountered disorders featuring headache include cerebrovascular disease, trauma, and intracranial infection. Approaches to pain are highly variable, and multimodal pain regimens are commonly employed. The overall body of evidence supporting therapeutic strategies to manage headache in the critical care setting is slim, and pain control remains suboptimal in many cases with persistent reliance on opioids. Headache is a complex, frequently occurring phenomenon in the NeuroICU care setting. At present, literature on evidence-based practice for management of headache in the critical care setting remains scarce, and despite multimodal approaches, reliance on opioids is commonplace.

Major Publications in the Critical Care Pharmacotherapy Literature: 2022

OBJECTIVES

A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022.

DATA SOURCES

PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update.

STUDY SELECTION

Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article.

DATA EXTRACTION

Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature.

DATA SYNTHESIS

The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia.

CONCLUSIONS

This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice.

Caring for two in the ICU: pharmacologic management of pregnancy-related complications

Maternal mortality continues to be an issue globally despite advances in technology and pharmacotherapy. Pregnancy can lead to complications that necessitate immediate action to prevent severe morbidity and mortality. Patients may need escalation to the ICU setting for close monitoring and administration of advanced therapies not available elsewhere. Obstetric emergencies are rare but high-stakes events that require clinicians to have prompt identification and management. The purpose of this review is to describe complications of pregnancy and provide a focused resource of pharmacotherapy considerations that clinicians may encounter. For each disease state, the epidemiology, pathophysiology, and management are summarized. Brief descriptions of non-pharmacological (e.g., cesarean or vaginal delivery of the baby) interventions are provided. Mainstays of pharmacotherapy highlighted include oxytocin for obstetric hemorrhage, methotrexate for ectopic pregnancy, magnesium and antihypertensive agents for preeclampsia and eclampsia, eculizumab for atypical hemolytic uremic syndrome, corticosteroids and immunosuppressive agents for thrombotic thrombocytopenic purpura, diuretics, metoprolol and anticoagulation for peripartum cardiomyopathy, and pulmonary vasodilators for amniotic fluid embolism.

Temperature Control After Cardiac Arrest: A Narrative Review

Cardiac arrest (CA) is a critical public health issue affecting more than half a million Americans annually. The main determinant of outcome post-CA is hypoxic-ischemic brain injury (HIBI), and temperature control is currently the only evidence-based, guideline-recommended intervention targeting secondary brain injury. Temperature control is a key component of a post-CA care bundle; however, conflicting evidence challenges its wide implementation across the vastly heterogeneous population of CA survivors. Here, we critically appraise the available literature on temperature control in HIBI, detail how the evidence has been integrated into clinical practice, and highlight the complications associated with its use and the timing of neuroprognostication after CA. Future clinical trials evaluating different temperature targets, rates of rewarming, duration of cooling, and identifying which patient phenotype benefits from different temperature control methods are needed to address these prevailing knowledge gaps.

Caring for Two in the ICU: Pharmacotherapy in the Critically Ill Pregnant Patient

Safe and thoughtful medication management of pregnant patients requiring intensive care unit (ICU) level of care is key to optimizing outcomes for both mother and fetus. Pregnancy induces physiologic alterations that closely mirror the changes expected in a critically ill patient. These changes can be predictable depending on the gestational age and trimester and will directly impact the pharmacokinetic profile of medications commonly used in the ICU; examples include decreased gastric emptying, increased blood and plasma volume, increased glomerular filtration, and increased cardiac output. When pregnant patients require ICU care, the resulting impact on drug absorption, distribution, metabolism, and elimination can be difficult to predict. In addition, there are many nuances of medication metabolism and interface with the placental barrier that should be considered when selecting pharmacotherapy for the pregnant patient. Critical care clinicians need to be aware of medication interactions with the placenta and weigh the risk versus benefit profile of medication use in this patient population. Obstetric critical care admissions have increased over the years, especially during the coronavirus waves. Therefore, understanding the interplay between pregnancy and critical illness to optimize pharmacotherapy selection is crucial to improving health outcomes of mother and fetus. This review highlights pharmacotherapy considerations in the pregnant ICU patient for the following topics: physiologic alterations, categorizing medication risk, supportive care, sepsis, cardiogenic shock, acute respiratory distress syndrome, and venous thromboembolism.

Electrolyte considerations in targeted temperature management

PURPOSE

Targeted temperature management (TTM), including normothermia and therapeutic hypothermia, is used primarily for comatose patients with return of spontaneous circulation after cardiac arrest or following neurological injury. Despite the potential benefits of TTM, risks associated with physiological alterations, including electrolyte shifts, may require intervention.

SUMMARY

This review describes the normal physiological balance of electrolytes and temperature-related alterations as well as the impact of derangements on patient outcomes, providing general recommendations for repletion and monitoring of key electrolytes, including potassium, phosphate, and magnesium.

CONCLUSION

Frequent monitoring and consideration of patient variables such as renal function and other risk factors for adverse effects are important areas of awareness for clinicians caring for patients undergoing TTM.

Targeting the gut microbiome in the management of sepsis-associated encephalopathy

Brain injury resulting from sepsis, or sepsis-associated encephalopathy (SAE), occurs due to impaired end-organ perfusion, dysregulated inflammation affecting the central nervous system (CNS), blood-brain barrier (BBB) disruption, mitochondrial dysfunction, oxidative stress, accumulation of toxic neuropeptides and impaired toxin clearance secondary to sepsis-induced hepatic and renal dysfunction. The gut microbiome becomes pathologically altered in sepsis, which likely contributes to the pathogenesis of SAE. Herein, we review the literature detailing dysregulation of microbiota-gut-brain axis (MGBA) in SAE and highlight potential therapeutic strategies to modulate the gut microbiome to mitigate sepsis-induced brain injury.

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

BACKGROUND

Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH.

METHODS

We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations.

RESULTS

Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found.

CONCLUSIONS

Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

The Digital Classroom: How to Leverage Social Media for Infectious Diseases Education

Social media (SoMe) platforms have been increasingly used by infectious diseases (ID) learners and educators in recent years. This trend has only accelerated with the changes brought to our educational spaces by the coronavirus disease 2019 pandemic. Given the increasingly diverse SoMe landscape, educators may find themselves struggling with how to effectively use these tools. In this Viewpoint we describe how to use SoMe platforms (e.g., Twitter, podcasts, and open-access online content portals) in medical education, highlight medical education theories supporting their use, and discuss how educators can engage with these learning tools effectively. We focus on how these platforms harness key principles of adult learning and provide a guide for educators in the effective use of SoMe tools in educating ID learners. Finally, we suggest how to effectively interact with and leverage these increasingly important digital platforms.

Severe headache trajectory following aneurysmal subarachnoid hemorrhage: the association with lower sodium levels

BACKGROUND

A clinical hallmark of aneurysmal SAH (aSAH) is headache. Little is known about post-aSAH headache factors which may point to underlying mechanisms. In this study, we aimed to characterize the severity and trajectory of headaches in relation to clinical features of patients with aSAH.

METHODS

This is a retrospective longitudinal study of adult patients admitted to an academic tertiary care center between 2012 and 2019 with aSAH who could verbalize pain scores. Factors recorded included demographics, aneurysm characteristics, analgesia, daily morning serum sodium concentration, and occurrence of vasospasm. Group-based trajectory modeling was used to identify headache pain trajectories, and clinical factors were compared between trajectories.

RESULTS

Of 91 patients included in the analysis, mean age was 57 years and 20 (22%) were male. Headache score trajectories clustered into two groups: patients with mild-moderate and moderate-severe pain. Patients in the moderate-severe pain group were younger (P<0.05), received more opioid analgesia (P<0.001), and had lower sodium concentrations (P<0.001) than patients in the mild-moderate pain group.

CONCLUSION

We identified two distinct post-aSAH headache pain trajectory cohorts and identified an association with age, analgesia, and sodium levels. Future prospective studies considering sodium homeostasis and volume status under standardized analgesic regimens are warranted.

Evaluation of Evidence, Pharmacology, and Interplay of Fluid Resuscitation and Vasoactive Therapy in Sepsis and Septic Shock

ABSTRACT

We sought to review the pharmacology of vasoactive therapy and fluid administration in sepsis and septic shock, with specific insight into the physiologic interplay of these agents. A PubMed/MEDLINE search was conducted using the following terms (vasopressor OR vasoactive OR inotrope) AND (crystalloid OR colloid OR fluid) AND (sepsis) AND (shock OR septic shock) from 1965 to October 2020. A total of 1,022 citations were reviewed with only relevant clinical data extracted. While physiologic rationale provides a hypothetical foundation for interaction between fluid and vasopressor administration, few studies have sought to evaluate the clinical impact of this synergy. Current guidelines are not in alignment with the data available, which suggests a potential benefit from low-dose fluid administration and early vasopressor exposure. Future data must account for the impact of both of these pharmacotherapies when assessing clinical outcomes and should assess personalization of therapy based on the possible interaction.

Pharmacotherapy in Coronavirus Disease 2019 and Risk of Secondary Infections: A Single-Center Case Series and Narrative Review

Since the onset of the coronavirus disease 2019 pandemic, immune modulators have been considered front-line candidates for the management of patients presenting with clinical symptoms secondary to severe acute respiratory syndrome coronavirus 2 infection. Although heavy emphasis has been placed on early clinical efficacy, we sought to evaluate the impact of pharmacologic approach to coronavirus disease 2019 within the ICU on secondary infections and clinical outcomes.

DATA SOURCES

PubMed (inception to March 2021) database search and manual selection of bibliographies from selected articles.

STUDY SELECTION AND DATA EXTRACTION

Articles relevant to coronavirus disease 2019, management of severe acute respiratory syndrome coronavirus 2-associated respiratory failure, and prevalence of secondary infections with pharmacotherapies were selected. The MeSH terms "COVID-19," "secondary infection," "SARS-CoV-2," "tocilizumab," and "corticosteroids" were used for article identification. Articles were narratively synthesized for this review.

DATA SYNTHESIS

Current data surrounding the use of tocilizumab and/or corticosteroids for coronavirus disease 2019 management are limited given the short follow-up period and conflicting results between studies. Further complicating the understanding of immune modulator role is the lack of definitive understanding of clinical impact of the immune response in coronavirus disease 2019.

CONCLUSIONS

Based on the current available literature, we suggest prolonged trials and follow-up intervals for those patients managed with immune modulating agents for the management of coronavirus disease 2019.

Interventions to reduce polypharmacy and optimize medication use in older adults with cancer

The use of polypharmacy and potentially inappropriate medications (PIMs) is an increasingly common, concerning public health issue in older adults, and a concurrent cancer diagnosis only further escalates the prevalence and complexity. Polypharmacy and PIM use has been associated with negative patient outcomes, including falls, chemotherapy toxicities and other adverse events, postoperative complications, frailty, functional impairment, and shortened survival. Despite the recognition of the harms, the prevalence of polypharmacy and PIM use continues to rise due to a lack of standardized identification and intervention methods. Efforts to reduce the prevalence have included use of explicit PIM screening tools (e.g., Beers criteria), comprehensive medication reviews, and deprescribing algorithms. However, these efforts are not widespread and the research on the effectiveness of such interventions is limited. To better understand what is known, this paper summarized available studies evaluating the effect of interventions on reducing the burden of polypharmacy/PIMs and provided recommendations to guide further practice models to reduce the negative consequences associated with polypharmacy and PIM use. Furthermore, we aim to establish a framework for clinical practice and to highlight areas for future intervention-based research to improve outcomes for older adults with cancer.

Intravenous Fluid Management in Critically Ill Adults: A Review

TOPIC

This article reviews the management of intravenous fluids and the evaluation of volume status in critically ill adults.

CLINICAL RELEVANCE

Intravenous fluid administration is one of the most common interventions in the intensive care unit. Critically ill patients have dynamic fluid requirements, making the management of fluid therapy challenging. New literature suggests that balanced salt solutions may be preferred in some patient populations.

PURPOSE OF PAPER

The bedside critical care nurse must understand the properties of various intravenous fluids and their corresponding impact on human physiology. The nurse's clinical and laboratory assessments of each patient help define the goals of fluid therapy, which will in turn be used to determine the optimal patient-specific selection and dose of fluid for administration. Nurses serve a vital role in monitoring the safety and efficacy of intravenous fluid therapy. Although this intervention can be lifesaving, inappropriate use of fluids has the potential to yield detrimental effects.

CONTENT COVERED

This article discusses fluid physiology and the goals of intravenous fluid therapy, compares the types of intravenous fluids (isotonic crystalloids, including 0.9% sodium chloride and balanced salt solutions; hypotonic and hypertonic crystalloids; and colloids) and their adverse effects and impact on hemodynamics, and describes the critical care nurse's essential role in selecting and monitoring intravenous fluid therapy.

"Capturing your audience": analysis of Twitter engagements between tweets linked with an educational infographic or a peer-reviewed journal article

Information represented through conventional text may fall short of capturing the attention and promoting engagement with today's digital audience. Transforming text into visual tools, such as infographics, has emerged as a simplified method of delivering information to attract a broader audience and enhance information dissemination. The first step to evaluate the potential value of infographics is to quantify their appeal and engagement rates over conventional text. This retrospective pilot analysis sought to evaluate the difference between engagement rates for tweets containing an of infographic compared to tweets containing a link to a peer-reviewed journal article. A total of 752 tweets were published within the study period; of these, 40 tweets met inclusion criteria. When engagement rates were compared, there was an increase in median engagement rates for tweets containing an infographic compared to a tweet linked to a peer-reviewed article at 10.97% (IQR 3.47%) and 5.33% (IQR 3.17%), respectively. This pilot study provides insight on the potential impact for infographics to enhance engagement rate, which may subsequently correlate with an increase in audience reach and readership. Prospective studies are needed to validate the utility of infographics in promoting scholarship publicity, learner engagement, and as a transferable pedagogical tool to educate medical practitioners.

Clinical strategies for optimizing infusion center care through a pandemic

The national pandemic resulting from the novel coronavirus, COVID-19, has made the delivery of care for patients with cancer a challenge. There are competing risks of mortality from cancer versus serious complications and higher risk of death from COVID-19 in immunocompromised hosts. Furthermore, compounding these concerns is the inadequate supply of personal protective equipment, decreased hospital capacity, and paucity of effective treatments or vaccines to date for COVID-19. Guidance measures and recommendations have been published by national organizations aiming to facilitate the delivery of care in a safe and effective manner, many of which, are permanently adoptable interventions. Given the critical importance to continue chemotherapy, there remains additional interventions to further enhance patient safety while conserving healthcare resources such as adjustments in medication administration, reduction in laboratory or drug monitoring, and home delivery of specialty infusions. In this manuscript, we outline how to implement these actionable interventions of chemotherapy and supportive care delivery to further enhance the current precautionary measures while maintaining safe and effective patient care. Coupled with current published standards, these strategies can help alleviate the numerous challenges associated with this pandemic.

Review of Emerging Pharmacotherapy for the Treatment of Coronavirus Disease 2019

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved into an emergent global pandemic. Coronavirus disease 2019 (COVID-19) can manifest on a spectrum of illness from mild disease to severe respiratory failure requiring intensive care unit admission. As the incidence continues to rise at a rapid pace, critical care teams are faced with challenging treatment decisions. There is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19. Urgent identification of potential treatment strategies is a priority. Therapies include novel agents available in clinical trials or through compassionate use, and other drugs, repurposed antiviral and immunomodulating therapies. Many have demonstrated in vitro or in vivo potential against other viruses that are similar to SARS-CoV-2. Critically ill patients with COVID-19 have additional considerations related to adjustments for organ impairment and renal replacement therapies, complex lists of concurrent medications, limitations with drug administration and compatibility, and unique toxicities that should be evaluated when utilizing these therapies. The purpose of this review is to summarize practical considerations for pharmacotherapy in patients with COVID-19, with the intent of serving as a resource for health care providers at the forefront of clinical care during this pandemic.

Potential Role of Direct Oral Anticoagulants in the Management of Heparin-induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a rare, potentially life-threatening condition secondary to unfractionated heparin or low molecular weight heparin exposure. This immune-mediated drug reaction manifests as thrombocytopenia with a paradoxical hypercoagulable state that can result in life-threatening thrombosis. It is imperative to ensure cessation of heparin-based products as soon as HIT is identified. Traditional treatment options include argatroban, bivalirudin, fondaparinux, and danaparoid with a transition to warfarin upon platelet recovery. These anticoagulants are notwithstanding limitations including parenteral administration and routine laboratory monitoring leading to prolonged hospitalizations, emphasizing the need for new therapies. Direct oral anticoagulants (DOACs) have been increasingly investigated for the management of HIT and may overcome the aforementioned challenges of current therapies. The objective of this narrative review is to summarize the current HIT guidelines, discuss limitations to contemporary treatment options, provide insight into the emerging evidence for the DOACs rivaroxaban, apixaban, and dabigatran, and conclude with a clinical summary for their use in this setting. The PubMed, Google Scholar, and MEDLINE databases were searched for peer-reviewed literature from January 1, 2012, to June 31, 2018. Twenty-seven articles met inclusion criteria for review: 1 prospective trial, 5 retrospective cohort studies, and 21 case reports totaling 104 patients treated with a DOAC for HIT. The DOACs prevented new and recurrent thrombosis in 98% (n=102) of cases, and bleeding complications occurred in 3% (n=3). While current literature remains limited, it is suggestive of a potential role of DOACs for HIT, which has led to their integration into the 2018 American Society Hematology Guidelines with a conditional recommendation.

Clinical pharmacology of oncology agents in older adults: A comprehensive review of how chronologic and functional age can influence treatment-related effects

Unique challenges exist when managing older adults with cancer. Associations between cancer and age-related physiologic changes have a direct impact on pharmacokinetics and pharmacodynamics of cancer therapies and can affect drug dosing, dose intensity, efficacy, safety and quality of life. The breadth and depth of these issues, however, have not been fully evaluated because the majority of clinical trials have focused on a younger and healthier population. As a consequence, little information is available to support clinicians in making evidence-based decisions regarding treatment with cancer therapies in older adults, especially those over age 75. Prior clinical pharmacology reviews summarized the literature on how age-related physiologic changes can influence and affect conventional and targeted anti-cancer treatments. Our article provides an updated review with expanded information that includes small molecule kinase inhibitors, monoclonal antibodies, immunotherapies, hormonal, conventional, and miscellaneous agents. Additionally, our article integrates how functional age, determined by the geriatric assessment (GA), can also influence treatment-related effects and health outcomes. Broadening cancer therapy trials to capture not only chronologic age but also functional age would allow clinicians to better identify subsets of older adults who benefit from treatment versus those most vulnerable to morbidity and/or mortality.

Child and adolescent injury as a result of falls from buildings and structures

OBJECTIVE

To examine incidence, demographic risk factors, and patterns of injury resulting from falls from buildings and structures in areas with and without a legislation based prevention programme.

DESIGN AND SETTING

The Health Care Cost and Utilization Project (KID-HCUP) was used to produce national estimates of hospital admissions due to falls from buildings in the US. Areas of New York with and without window guard legislation were identified through the New York Statewide Planning and Research Cooperative System (SPARCS).

SUBJECTS

Children and adolescents aged 0-18 years.

INTERVENTIONS

Legislation based window fall prevention programme with enforcement.

MAIN OUTCOME MEASURES

Hospitalization for injury as a result of falls from buildings and structures in areas with and without enforced mandatory window guard legislation.

RESULTS

New York City has a higher proportion of the population residing in multi-family dwellings with 10 or more units compared with the nation (53.8% v 12.6%, p<0.0001), but the incidence of injury resulting from falls from buildings is nearly half that observed in the US. For young children, warm weather risks begin earlier and extend later than previously reported. Incidence in very young minority children is nearly twice that of whites. Nearly 90% of children aged 0--4 years fall at home, but the proportion decreases linearly with age.

CONCLUSIONS

Window guards are associated with reduced injury resulting from falls from buildings and should be mandated in multi-family dwellings where small children reside. Prevention programmes for young children should be initiated in early spring and continued through fall.

Teenagers' perceptions of personal safety and the role of the emergency health care provider

STUDY OBJECTIVE

We designed this study to determine the experiences, attitudes, and beliefs of teenagers regarding violence in their lives and to gain an understanding of the perceived role of the emergency health care professional.

METHODS

A qualitative study involving 10-person focus groups was conducted in 4 cities representing urban/low socioeconomic and suburban/high socioeconomic areas. Participants were 14 or 15 years of age and were recruited from local community centers. Moderators were matched by sex to the teenagers, and groups were segmented by race and sex. A semistructured guide was developed to help facilitate the discussion. All groups were audiotaped and videotaped, and the tapes were reviewed by the investigators for reoccurring themes.

RESULTS

A total of 140 adolescents (14 groups of 10) participated; one half were male. Urban teenagers expressed concerns about gangs, rape, and homicide; suburban teenagers were concerned about parental pressure and suicide. The teenagers expressed distrust of teachers, police officers, and doctors and felt safest with their parents. The emergency department was viewed as a confusing and frightening place, and participants believed that the role of the ED staff was to treat the patient's medical problem and not inquire or counsel about violence.

CONCLUSION

All of the teenagers, regardless of socioeconomic status, were concerned about violence in their lives. All of the teenagers believed that the emergency department is not the place for patients to be counseled about safety and violence prevention. A better understanding of the problem of violence from the point of view of the teenager is important in refining an effective role for the emergency health care provider in adolescent violent injury prevention.

Injury prevention and emergency medical services for children in a managed care environment

Each year, 1 in 5 US children receives medical care as a result of injury. Injuries are the leading cause of medical spending for children ages 5 to 21 years, accounting for more than 20% of hospital admissions and days spent in the hospital. Pediatric injuries become an important issue for managed care organizations because of concern for member safety and increasing medical costs related to treatment. Because effective prevention decreases health care consumption, injury prevention often costs less than treating injuries. Simple devices, such as bicycle helmets, smoke detectors, and child safety seats, help keep children safe and save money. Appropriate emergency care at the scene of an injury, poison control centers that dispense expert advice over the telephone, and triaged regional trauma systems improve the outcome and save money at the same time. This article continues the white paper series by the Emergency Medical Services for Children Managed Care Task Force.

Prevention of youth injuries

There are four categories of causes responsible for the majority of injuries in youth 10-19 years of age: 1) motor vehicle traffic; 2) violence (intra-familial, extra-familial, self, pregnancy-related); 3) recreational; and 4) occupational. This article presents data from the National Center for Health Statistics mortality data and the National Pediatric Trauma Registry morbidity data. Nationwide, the pediatric injury death rate is highest among adolescents 15-19 years of age. Motor vehicle-related deaths account for 41% and firearm-related deaths account for 36% of injury deaths in this age group. For youths aged 10-14 years, motor vehicle-related deaths account for 38% and; firearm-related deaths account for 26% of injury deaths. For both age groups, occupant motor vehicle-related deaths account for the majority of deaths and underscore the need for seat belt use. Using theoretical principles based on the Haddon matrix and a knowledge of adolescent development, proposed interventions to decrease injuries and deaths related to motor vehicles and firearms include graduated licensing, occupant restraint, speed limits, conflict resolution, and gun control. Occupational injuries, particularly injury associated with agricultural production, account for an estimated 100,000 injuries per year. Preventive strategies include OSHA regulations imposing standards for protective devices and further study for guidelines for adolescent work in agriculture. Injuries related to recreation include drowning and sports injuries. Preventive strategies may include proper supervision and risk reduction with respect to use of alcohol/drugs. The data presented support the use of primary prevention to achieve the most effective, safe community interventions targeting adolescents.

Epidemiology and prevention of traffic injuries to urban children and adolescents

OBJECTIVES

To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community.

MATERIALS AND METHODS

Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983-1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community.

PRIMARY RESULTS

Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983-1988), severe traffic injuries occurred at a rate of 147.2/100 000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100 000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for >/=1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness >/=1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; chi2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio:.64; 95% CI:.58,.72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio:.55; 95% CI:.38,.79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio:.89; 95% CI:.72, 1.09) or in traffic injuries among younger children who

The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs

OBJECTIVE

To describe the incidence and causes of pediatric head, spinal cord, and peripheral nerve injuries in an urban setting and to assess the implications of these data for injury prevention programs.

METHODS

Pediatric deaths and hospital admissions secondary to neurological trauma included in the Northern Manhattan Injury Surveillance System from 1983 to 1992 were linked to census counts to compute incidence rates. Rates before the implementation of a nonspecific injury prevention program were compared with rates after the implementation, and rates for the target population were compared to rates for the control population. Rates were analyzed on the basis of the cause of injury as well as the age, gender, and neighborhood income level of the injured.

RESULTS

The incidence of neurological injuries resulting in hospitalization or death was 155 incidents per 100,000 population per year; the mortality rate was 6 people per 100,000 population per year. Neurological injuries represented 18% of all pediatric injuries and accounted for 23% of all traumatic deaths. Spinal cord and peripheral nerve injuries were relatively rare (5%) compared to head injuries (95%). Minor head injuries, including isolated cranial fractures, minor concussions (<1 h loss of consciousness), and unspecified minor head injuries, accounted for the majority of neurological injuries (76%), whereas severe head injuries, including severe concussion (>1 h loss of consciousness), cerebral laceration/contusion, intracerebral hemorrhage, and unspecified major injuries, were less common (18% of all neurological injuries). Boys were more often affected than girls at every age, and this preference increased with age. Children younger than 1 year showed the highest incidence of both major and minor injuries. One- to 4-year olds showed the lowest rates, with steady increases thereafter. Traffic accidents and falls were the leading causes (38 and 34%, respectively), and assaults were the next leading causes (12%). Among children admitted to surveillance system hospitals, falls were most common in children younger than 4 years, pedestrian motor vehicle accidents were most common in late childhood, and assaults were most common in early adolescence.

CASE

fatality rates were 5 to 7% for all age groups except 5- to 12-year-olds, for whom the case:fatality rate was 1.9%. Residence in a low-income neighborhood was associated with an increased risk of injury (rate ratio, 1.71; confidence interval, 95%, 1.54, 1.89). The average hospitalization cost per injury was $8502. Medicaid (54%) and other government sources (5%) covered the majority of expenses, including indirect reimbursement of usually uncollected self-pay billing (19%). Although injury incidence rates fell in both the control and intervention cohorts during implementation of a nonspecific injury prevention program, targeted age and population groups demonstrated greater relative reductions in injuries than nontargeted ones, suggesting a positive effect.

CONCLUSIONS

Deaths and hospital admissions secondary to pediatric neurological trauma represent a significant public health problem, with the majority of the direct cost being born by government agencies. Future efforts to prevent neurological trauma in children who live in inner cities should focus on families with low incomes and provide novel education programs regarding infant abuse, infant neglect, and infant injury avoidance. Age-appropriate school-based programs should also be developed to address traffic safety and conflict resolution.

Internists' and surgeons' attitudes toward guns and firearm injury prevention

BACKGROUND

The high rates of death, injury, and long-term disability related to firearms in the United States have led to growing concern in the health care community. Medical organizations and journals are devoting increasing attention to firearm violence as a public health problem; however, few reports discuss physician attitudes toward guns and prevention of firearm-related injury.

OBJECTIVE

To determine internists' and surgeons' attitudes toward guns and firearm injury prevention.

DESIGN

Analysis of results of a structured telephone interview.

SETTING

Internal medicine and surgical offices.

PARTICIPANTS

457 internists and 458 surgeons.

MEASURES

55 questions that covered six domains: experience with firearms, knowledge about clinical sequelae of firearm injury, knowledge about public policies on firearm violence, attitudes toward public policies on firearm violence, clinical practice behavior, and education and training.

RESULTS

The interview response rate was 45.3%, with a compliance rate of 82.5% and a 95% probability (error rate, +/- 5%). Ninety-four percent of internists and 87% of surgeons believe firearm violence is a major public health issue. A majority of internists and surgeons also support community efforts to enact legislation to restrict the possession or sale of handguns (84% and 64%, respectively). Furthermore, although 84% of internists and 72% of surgeons believe that physicians should be involved with firearm injury prevention, less than 20% of respondents usually engage in some form of firearm injury prevention practice in patient care.

CONCLUSION

Many internists and surgeons think that firearm injuries are a public health issue of growing importance, that physicians should incorporate firearm safety screening and counseling into their practice, that physicians should join community efforts to regulate handguns, and that specific gun regulation measures should be adopted as public policy.

Epidemiology and prevention of severe assault and gun injuries to children in an urban community

OBJECTIVES

To describe the epidemiology of severe assault and gun injuries to children in an urban population and consider the impact of a comprehensive injury prevention program.

MATERIALS AND METHODS

Pediatric injury deaths and hospital admissions for Northern Manhattan (1983-1992) were linked to census counts to compute incidence. Poisson regression was used to compare trends in incidence of assault and gun injuries before and during a community-wide pediatric injury prevention program in Central Harlem.

MAIN RESULTS

The incidence of severe nonfatal assault injury was 60.94/100,000/year, 10 times the fatality rate. The incidence of all gun injuries was 31.13. In adolescence, guns were the leading cause of both fatal and severe nonfatal assault injury, and were the most lethal method of assault (case-fatality = 18.5% for gun vs. 1.2% for all non-gun assault injury). Rates of assault and gun injuries declined by nearly 50% in the intervention community, while they increased in a neighboring community.

CONCLUSIONS

Comprehensive interventions may be effective in curbing the incidence of severe assault injuries to urban youth. Further controlled evaluations are needed to confirm the effectiveness of programs such as this and to better understand the prevention of violent injuries.

Children who are shot: a 30-year experience

Three data sets describe the pattern of gunshot injuries to children from 1960 to 1993: The Harlem Hospital pediatric trauma registry (HHPTR), the northern Manhattan injury surveillance system (NMISS) a population-based study, and the National Pediatric Trauma Registry (NPTR). A small case-control study compares the characteristics of injured children with a control group. Before 1970 gunshot injuries to Harlem children were rare. In 1971 an initial rise in pediatric gunshot admissions occurred, and by 1988 pediatric gunshot injuries at Harlem Hospital had peaked at 33. Population-based data through NMISS showed that the gunshot rate for Central Harlem children 10 to 16 years of age rose from 64.6 per 100,000 in 1986 to 267.6 per 100,000 in 1987, a 400% increase. The case fatality for children admitted to Harlem Hospital (1960 to 1993) was 3%, usually because of brain injury, but the majority of deaths occurred before hospitalization. During the same period, felony drug arrests in Harlem increased by 163%. The neighboring South Bronx experienced the same increase in gunshot wound admissions and felony arrests from 1986 to 1993. The NPTR showed a similar injury pattern for other communities in the United States. In a case-control analysis. Harlem adolescents who had sustained gunshot wounds were more likely to have dropped out of school, to have lived in a household without a biological parent, to have experienced parental death, and to have known of a relative or friend who had been shot than community adolescents treated for other medical or surgical problems.(ABSTRACT TRUNCATED AT 250 WORDS)

The surgeon and emergency medical services for children

A central focus of emergency medical services for children is the critically injured child, whose potential for recovery is great. Yet trauma remains the leading cause of mortality and morbidity among American children 1-14 years of age. Much unnecessary death and disability can be avoided through aggressive professional and public education in pediatric advanced life support and injury prevention. As the primary-care physician of the critically injured child, the surgeon plays a leading role in ensuring that trauma and emergency medical services systems are optimally prepared to meet the dual challenges of providing optimal pediatric trauma care and obviating the need for such treatment through all means possible.

Injury prevention in an urban setting: challenges and successes

The Harlem Hospital Injury Prevention Program (HHIPP) was established in 1988 with the goal of reducing injuries to children in central Harlem by providing safe play areas, supervised activities, and injury prevention education. To achieve this goal, a broad-based coalition was formed with state and local governmental agencies interested in injury prevention and with community groups, schools, parents, and hospital staff. An evaluation of the program in terms of both process and outcome formed a critical element of this effort. Since 1988 the HHIPP, as the lead agency for the Healthy Neighborhoods/Safe Kids Coalition, developed or participated in two types of programs: injury-prevention education programs and programs that provide safe activities and/or environments for children. The educational programs included Window Guards campaign; Safety City Program; Kids, Injuries and Street Smarts Program (KISS); Burn Prevention Curriculum and Smoke Detector Distribution; Harlem Alternative to Violence Program; Adolescent Outreach Program; and Critical Incident Stress Management Teams. The safe activities and environmental programs included the Bicycle Safety Program/Urban Youth Bike Corps; Playground Injury Prevention Program; the Greening of Harlem Program; the Harlem Horizon Art Studio; Harlem Hospital Dance Clinic; Unity through Murals project; baseball at the Harlem Little League; winter baseball clinic; and the soccer league. Each program was conceived using injury data, coupled with parental concern and activism, which acted as catalysts to create a community coalition to respond to a specific problem. Data systems developed over time, which monitored the prevalence and incidence of childhood injuries in northern Manhattan, including central Harlem, became essential not only to identify specific types of childhood injuries in this community but also to evaluate these programs for the prevention of injuries in children.

Low-income neighborhoods and the risk of severe pediatric injury: a small-area analysis in northern Manhattan

OBJECTIVES

The purpose of this study was to investigate the relationship between socioeconomic disadvantage and the incidence of severe childhood injury.

METHODS

Small-area analysis was used to examine socioeconomic risk factors for pediatric injury resulting in hospitalization or death in Northern Manhattan, New York, NY, during a 9-year period (1983 through 1991).

RESULTS

The average annual incidence of all causes of severe pediatric injury was 72.5 per 10,000 children; the case-fatality rate was 2.6%. Census tract proportions of low-income households, single-parent families, non-high school graduates, and unemployment were significant predictors of risk for both unintentional and intentional injury. Among the socioeconomic factors considered, low income was the single most important predictor of all injuries; other socioeconomic variables were not independent contributors once income was included in the model. Compared with children living in areas with few low-income households, children in areas with predominantly low-income households were more than twice as likely to receive injuries from all causes and four and one half times as likely to receive assault injuries. The effect of neighborhood income disparities on injury risk persisted after race was controlled.

CONCLUSIONS

These results illuminate the impact of socioeconomic disparities on child health and point to the need for injury prevention efforts targeting low-income neighborhoods.

The impact of the Safe Kids/Healthy Neighborhoods Injury Prevention Program in Harlem, 1988 through 1991

OBJECTIVES

This study evaluated the effectiveness of a community coalition to prevent severe injuries to children in Central Harlem, New York, NY. It was hypothesized that injury incidence rates would decline during the intervention (1989 through 1991) relative to preintervention years (1983 through 1988); that the decline would be greatest for the targeted age group (5 through 16 years) and targeted injury causes (traffic accidents, assaults, firearms, outdoor falls); and that the decline would occur in the intervention community rather than a control community.

METHODS

Surveillance of injuries that result in hospitalization and/or death among children in the two communities has been under way since 1983. Data from this surveillance were used to test whether the incidence of severe injury declined during the intervention; other temporal variations were controlled by Poisson regression.

RESULTS

The incidence of injury among school-aged children in central Harlem declined during the intervention. The decline was specific to the targeted age group and targeted causes. A nonspecific decline also occurred in the control community.

CONCLUSIONS

The declining incidence rate in Central Harlem is consistent with a favorable program effect, but additional investigation of possible secular trend or spillover effects is needed.

Mortality and truncal injury: the pediatric perspective

To determine the extent and consequences of major truncal injury in children, we analyzed data collected prospectively by the National Pediatric Trauma Registry (NPTR) from 1985 to 1991. Of the 25,301 patients entered into the study, 1,553 (6%) had thoracic injuries (T); 2,047 (8%) had abdominal injuries (A). Blunt mechanisms predominated for both groups (86% T, 83% A), with the automobile being the most frequent blunt agent (74% T, 59% A); gunshot wounds were responsible for the majority of penetrating injuries (60% T, 56% A). Fifteen percent (195) of those with blunt thoracic injuries died; however, in only 14% of these cases (27) was thoracic injury the cause of death. Fourteen percent (33) of those with penetrating thoracic injuries died, with thoracic injury the cause of death in 97% of these cases (32). Only 9% (161) of those with blunt abdominal injuries died; in 22% (35) abdominal injury was the cause of death. Likewise, only 6% (15) of those with penetrating abdominal injuries died, but abdominal injury was the cause of death in 67% (10). The pleural space, lung, and ribs were the most frequently damaged thoracic organs; with the exception of lung contusion, injuries to these structures were associated with fatality rates in excess of 50%. The liver, spleen, kidneys, and gastrointestinal tract were the most frequently damaged abdominal organs; injuries to these structures were associated with fatality rates of 15% or less, except for injuries involving major blood vessels.(ABSTRACT TRUNCATED AT 250 WORDS)