A Population-based Study of Fatal and Nonfatal Firearm-related Injuries

Objective: To determine population-based firearm-related morbidity and mortality for Allegheny County, PA (population = 1.3 million), for the year 1994.
Methods: Fatalities were identified from a review of death certificates. To identify nonfatal cases, an active surveillance was conducted at all 24 acute care EDs in the county. The ED surveillance used 2 existing sources of case identification from each hospital to minimize undercount.
Results: Firearms were the leading cause of injury death to county residents, accounting for 155 deaths. The crude mortality rate from firearms was 11.7/100,000. Black males aged 15–19 years were most at risk for a firearm fatality (293/100,000). There were 514 nonfatal firearm injuries, producing a case fatality rate of 23%. The highest age-specific rate for nonfatal firearm-related injuries treated in the county EDs was observed for black males aged 15–19 years (2,245/100,000), which is 58 times higher than the firearm-related injury rate for the entire county population (38.7/100,000).
Conclusion: Firearm-related injury and death are a significant public health problem in Allegheny County. Although the crude mortality rate from firearms in the county is lower than the reported national rate, the observed rate for nonfatal injuries in the black youth of this community is the highest firearm injury incidence rate ever reported. Local surveillance of firearm-related injuries, including nonfatal events, is needed to more accurately demonstrate the magnitude of this problem.     

Serum Ethanol Clearance in Intoxicated Children and Adolescents Presenting to the ED

Objective: To determine the rate of serum ethanol clearance in 39 children and adolescents who presented intoxicated to one ED.
Methods: All pediatric patients presenting to a university hospital ED, for whom serial ethanol levels had been determined between January 1989 and May 1993, were evaluated. Age, gender, presenting complaint, initial serum glucose concentration, timed serum ethanol concentrations, and rate of serum ethanol clearance were determined retrospectively for all the patients.
Results: 39 pediatric patients had had serial serum ethanol concentrations determined. The patients ranged in age from 6 weeks to 17 years (mean 14.6 years). Initial serum ethanol levels ranged from 13.7 to 84.2 mmol/L (63–388 mg/dL) and the mean serum ethanol clearance rate was 4.0 mmol/L/hr (18.6 mg/dL/hr), consistent with clearance rates previously reported for adults.
Conclusion: These data suggest that the rate of serum ethanol clearance in children and adolescents presenting to the ED approaches that previously reported for adults. Clinical diminution of intoxication should not be more rapid for children and adolescents than it is for adults.     

Retroperitoneal organ injury caused by anterior penetrating abdominal injury in children.

OBJECTIVE: To describe the retroperitoneal organ injury pattern after anterior penetrating abdominal injury in children. SETTING: The paediatric surgical department of a university teaching hospital. PATIENTS AND METHODS: All children presenting with firearm and stab wounds to the anterior abdomen between January 1983 and April 2001. RESULTS: Forty-nine children (34%) with penetrating anterior abdominal wounds had retroperitoneal organ injury. The most injured organs were the descending colon in 17 patients (35%), ascending colon in eight patients (16%), and kidney in seven (14%). The most commonly associated injured organ was the small bowel. Postoperative septic complications were seen in 10 patients (20%). The most common postoperative complication was wound infection. When we compared patients with intraperitoneal organ injury with patients with retroperitoneal injury, there was no difference in parameters such as age, associated organ injury, morbidity and mortality between both groups. The main causative factor of retroperitoneal injuries was shotgun wounds, whereas it was stabbing in intra-abdominal injuries (P<0.05). The number of injured organs and the hospital stay is significantly greater in retroperitoneal organ injuries, and the trauma scores such as the Injury Severity Score (P<0.001) and the Penetrating Abdominal Trauma Index (P<0.001) were found to be significantly higher. CONCLUSION: Retroperitoneal organ injury is commonly associated with anterior penetrating abdominal trauma. Even if there is no preoperative sign of retroperitoneal organ injury, an exploratory laparotomy and a meticulous retroperitoneal exploration should also be performed for associated retroperitoneal organ injury.     

The Frequency of Unsuspected Minor Illness or Injury in Intoxicated Patients

Objective: To determine the frequency of unsuspected minor illness or injury in a group of patients frequently seen in the ED for acute intoxication.
Methods: The medical records of the 20 patients seen most frequently in the ED for acute intoxication in 1993 were reviewed for the number of ED visits for intoxication, the number of associated documented episodes of minor trauma or illness, the extent of ED workup of discovered illness or injury, and patient disposition from the ED.
Results: The 20 study patients were evaluated in the ED 1,858 times in 1993 for acute intoxication, a mean of 92.5 visits/patient (±26.6). The most frequent injury was minor trauma above the neck, occurring a mean of 9 times (±3.6) in each of the study patients during 1993. Evaluation included repeated neurologic examinations and frequent radiography of the cervical spine ( n = 80), skull ( n = 5), facial bones ( n = 6), and mandible ( n = 5). A limited number of head CT scans also were done ( n = 8). The most frequent minor illnesses were gastritis ( n = 7), managed with hydration, and mild hypothermia ( n = 6), managed with passive rewarming.
Conclusions: The incidence of unsuspected minor illness or injury in this patient group was substantial. While most unsuspected medical problems had little clinical significance, some were potentially dangerous, and some necessitated hospitalization (e.g., hypothermia, hematemesis, and respiratory depression).     

The Potential of Using Billing Data for Emergency Department Injury Surveillance

Objective: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage.
Methods: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1-year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments.
Results: Twenty-four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data >99% of the time. More than two-thirds of the sampled records had a social security number, and total charges were recorded >90% of the time. Other variables such as name and address were contained in <50% of the records submitted. E-codes were usually not available.
Conclusions: Retrospective compilation of multihospital ED billing data to create a statewide ED data sample—with the potential for injury research and probabilistic database linkage—can be accomplished; there are, however, important limitations.     

Pediatric Trauma: Enabling Factors, Social Situations, and Outcome

Objectives: 1) To determine, for severely injured pediatric patients, which enabling factors and social situations are associated with the most severe and costly injuries; 2) to determine which subsets of patients are affected by particular enabling factors; and 3) to determine which enabling factors are associated with death.
Methods: Retrospective chart review of patients included in a pediatric trauma registry at a level I trauma center, plus review of medical examiner reports for deaths declared at the scene for one year. Abstracted data included age, gender, enabling factors (e. g., abuse/assault, neglect, endangerment, and nonuse of safety measures), mechanisms of injury, Injury Severity Scale (ISS) score, length of stay, need for intensive care unit (ICU) care, and expense.
Results: Records were reviewed for 336 identified children. There was a 2: 1 male-to-female ratio; 9. 5% died, 3. 5% at the scene. Active endangerment or neglect was associated with death (p = 0. 0004). However, the nonuse of safety devices was more common and resulted in a higher absolute number of deaths. Similarly, while inadvertent gunshot wounds, intentional injury, and environmental mishaps were more commonly lethal, motor vehicle crashes (MVCs) were more common and claimed the most lives. Cost was highest for the patients aged 14–16 years, in part reflecting the larger number of MVCs.
Conclusion: The severity of pediatric trauma is largely influenced by the mechanism of injury. Our data highlight the importance of enabling factors for such injuries overall and as a function of age group (reflecting developmental status). While injury prevention education for caregivers is necessary, the incorporation of passive safety measures also is vital for decreasing injuries and their severity.     

Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients

Background

Although the integral role of ED thoracotomy for open cardiac massage has been extensively reviewed in adult literature, this “heroic maneuver” remains very controversial and greatly debated in children.

Methods and results

A retrospective cohort review of emergency thoracotomies in children, performed at a European Level I trauma center between 1992 and 2008 was undertaken. Clinical manifestation, injury mechanism and surgical treatment were described, with special regard to prognostic factors and outcome. A total of eleven thoracotomies were performed, ten for blunt injuries (91%), and one for perforating injury (9%), with a mean age of 7.8 years, range 2.6-15.4 years, comprising eight boys and three girls. The mean Injury Severity Score of the children with blunt force trauma was 46, ranging from 25 to 66 compared with 20 of the penetrating trauma victim. Ten of eleven patients (91%) who underwent ED thoracotomy died. Nine of them were in cardiac arrest on arrival. One patient who had a penetrating knife injury and had stable vital sign on arrival survived.

Conclusions

Similar to previous studies, out data confirmed ED thoracotomy for children in cardiac arrest from blunt trauma had universally fatal outcome. The mechanism of injury and signs of life at arrival were predictive key factors that influence the outcome of ED thoracotomy.     

Emergency Department Visits for Pediatric Trampoline-related Injuries: An Update

Objectives: To describe the epidemiology of emergency department (ED) visits for trampoline-related injuries among U.S. children from January 1, 2000, to December 31, 2005, using the National Electronic Injury Surveillance System (NEISS) and to compare recent trampoline injury demographics and injury characteristics with those previously published for 1990–1995 using the same data source.
Methods: A stratified probability sample of U.S. hospitals providing emergency services in NEISS was utilized for 2000–2005. Nonfatal trampoline-related injury visits to the ED were analyzed for patients from 0 to 18 years of age.
Results: In 2000–2005, there was a mean of 88,563 ED visits per year for trampoline-related injuries among 0–18-year-olds, 95% of which occurred at home. This represents a significantly increased number of visits compared with 1990–1995, when there was an average of 41,600 visits per year. Primary diagnosis and principal body part affected remained similar between the two study periods.
Conclusions: ED visits for trampoline-related injuries in 2000–2005 increased in frequency by 113% over the number of visits for 1990–1995. Trampoline use at home continues to be a significant source of childhood injury morbidity.     

Causes and Patterns of Injury from Ladder Falls

Objectives: To review all ladder fall injuries seen in a community ED and to identify patterns of injury, factors that contribute to falls, and what pre-event and event factors could have reduced the likelihood of a fall or a resulting injury.
Methods: This was a retrospective, observational study involving patients who presented to a community hospital ED from January 1993 through December 1995 with injuries from a ladder fall. The medical records of all patients were reviewed. Patients then underwent a structured telephone interview to provide additional information about the circumstances of the fall.
Results: There were 59 patients who sustained injuries relating to ladder falls. All were adults, aged >18 years (mean 42.9 ± 16.2 years), were predominantly male (93%), and had fallen a distance of 1–15 feet (mean 7.2 ± 3.6 feet). Thirteen percent were admitted to the hospital, and there was 1 death. Fractures were observed in 21 patients (36%) and usually involved an extremity (77%). There was no relationship between the distance fallen and the occurrence of fracture. Other primary injuries included sprain (27%), contusion (24%), laceration (10%), abrasion (3%), and subdural hematoma (2%). Of the 59 patients, 42 (71%) were contacted directly. Most falls (79%) resulted from excessive reaching or incorrect ladder placement. Fifty percent of the described falls were occupationally related.
Conclusions: Falls from ladders, both in the occupational and nonoccupational settings, often result in significant injury. Simple safety measures may have prevented the majority of falls in this study. Public health efforts should emphasize education on safe ladder practices and techniques to reduce the possibility of injury in the event of a fall.     

Firearm-related personal and clinical characteristics of US medical students

BACKGROUND: Firearm injuries are the second leading cause of fatal injury in the US, and several medical specialty societies encourage patient counseling about firearm injury prevention. Because personal choices. influence physicians' willingness to counsel, it would be valuable to know how frequently guns are kept in the homes of physicians-in-training, as well as their perceptions and current rates of counseling about firearm injury prevention. METHODS: At a nationally representative sample of 16 medical schools, we surveyed the class of 2003 at freshman orientation, entrance to wards, and during senior year. RESULTS: A total of 2,316 students provided data (response rate = 80.3%). Among freshmen, 16% reported living in a home with a firearm, 13% did so at entry to wards, as did 14% of seniors (14% overall, women = 9%, men = 19%). Only 34% of seniors reported counseling their patients more often than "never/rarely" about firearm possession and storage. CONCLUSIONS: US medical students reported substantially lower rates of household gun ownership than the general population, but their participation in firearm-related counseling is also low.     

Transcranial Doppler Ultrasound Use in Pediatric Patients With Penetrating Traumatic Brain Injuries

The purpose of this article is to increase awareness of the usefulness of transcranial Doppler (TCD) ultrasound as a noninvasive neuromonitor and bedside ultrasound in pediatric patients who have experienced a penetrative traumatic brain injury (TBI) as a result of a firearm. To date, the use of TCD is not standard of care in pediatric TBI patients. TCD is a portable ultrasound that can be performed in any care environment. The use of TCD in pediatric TBI studies have demonstrated abnormalities in cerebral blood flow velocity, autoregulation, and embolic events; all of which have been associated with poor neurocognitive and functional outcomes. A penetrating brain injury as a result of a firearm is associated with ongoing vascular injury and thereby an increased risk for poor neurologic sequelae. We discuss two exemplars of TCD use in children who experienced a firearm-related penetrating TBI and their TCD findings. Both exemplars identified the unique insights provided by TCD that were unappreciated by clinical observation. This article provides early evidence for the use of TCD as a neuromonitor in pediatric penetrating TBI.     

Air vs ground transport and outcome in trauma patients requiring urgent operative interventions

Objective. To study trauma patients requiring urgent operative interventions to determine whether transport mode was associated with outcome difference. Methods. Eligible patients were injured adults and children who presented over a 57-month period to the emergency department (ED) at the study hospital (annual ED census 36,000) after air or ground transport from trauma scenes or referring hospitals. Patients included were those whose ED lengths of stay were <60 minutes prior to transfer to an operating room. Data collected included injury severity score (ISS), ED and hospital lengths of stay, and mortality. Continuous data, which were not distributed normally, were analyzed using Wilcoxon nonparametric analysis. Categorical variables were analyzed using chi-square testing. Multivariate logistic regression was used to account for confounding variables and isolate the effects of transport mode on mortality. Alpha for all tests was set at 0.05. Results. 272 patients were eligible for study; 168 air medical and 104 ground transports. No between-group differences were found for ED length of stay, ISS, or mortality. A significantly longer hospital stay was found for air-transported patients. Subgroup analysis of patients with penetrating trauma and ISS of ≥25 revealed mortalities of 28% and 45% for air- and ground-transported patients, respectively; this difference was not statistically significant (p = 0.24), but the study had a power of only 22% to detect a difference at this magnitude. Conclusion. This study failed to identify, but had insufficient power to rule out, outcome benefit to air medical transport in a subset of trauma patients requiring urgent operative interventions.     

Subsequent Suicide Mortality among Emergency Department Patients Seen for Suicidal Behavior

Objectives: To determine whether suicide mortality rates for a cohort of patients seen and subsequently discharged from the ED for a suicide-related complaint were higher than for ED comparison groups.
Methods: This was a nonconcurrent cohort study set at a university-affiliated urban ED and Level 1 trauma center. All ED patients 10 years and older, with at least one ED visit between February 1994 and November 2004, were eligible. ED visit characteristics defined the cohort exposure. Patients with visits for suicide attempt or ideation, self-harm, or overdose (exposed) were compared with patients without these visits (unexposed). Exposure classification was determined from billing diagnoses, E-codes (E950–E959), and free-text searching of the ED tracking system data for suicide, overdose , and spelling variants. Emergency department patient data were probabilistically linked to state mortality records. The principal outcome was suicide death. Suicide mortality rates were calculated by using person-year (py) analyses. Relative rates (RR) and 95% confidence intervals (95% CIs) were calculated from Cox proportional hazards models.
Results: Among the 218,304 patients, the average follow-up was 6.0 years; there were 408 suicide deaths (incidence rate [IR]: 31.2 per 100,000 py). Males (IR: 48.3) had a higher rate than females (IR: 13.5; RR: 3.6; 95% CI = 2.8 to 4.6). A single ED visit for overdose (RR: 5.7; 95% CI = 4.5 to 7.4), suicidal ideation (RR: 6.7; 95% CI = 5.0 to 9.1), or self-harm (RR: 5.8; 95% CI = 5.1 to 10.6) was strongly associated with increased suicide risk, relative to other patients.
Conclusions: The suicide rate among these ED patients is higher than population-based estimates. Rates among patients with suicidal ideation, overdose, or self-harm are especially high, supporting policies that mandate psychiatric interventions in all cases.     

A Truncated E-code System for Injury Surveillance in the Emergency Department: Description and Clinometric Testing

Objectives: ED injury surveillance requires accurate information about mechanism. This study explored the clinometric properties of an E-code system specifically designed to track ED injuries.
Methods: All patients assessed in the ED had cause-of-injury information documented using a truncated E-code system. Patient records were hand-searched to determine coding compliance. A selection of 98 charts (50 injury/48 noninjury) were coded by 7 physicians, 2 nurses, and 2 nosologists. Agreements (interrater and intrarater) on the diagnosis of trauma and exact E-codes were determined (using kappa; κ).
Results: E-coding compliance was high (overall 90%: 95% CI: 85–93%), and accuracy of injury classification was 99%. Compared with an expert's coding, agreement on injury classification was excellent for physicians (κ = 0.91; 95% CI: 0.80–1.0), nurses (κ = 0.88; 95% CI: 0.75–1.0), and nosologists (κ = 0.92; 95% CI: 0.81–1.0). Agreement was substantial for the exact E-codes between physicians (κ = 0.77; 95% CI: 0.60- 0.94) and nurses (κ = 0.72; 95% CI: 0.54–0.90). Recode reliability was also excellent for physicians (κ = 0.88; 95% CI: 0.75–1.0) and nurses (κ = 0.96; 95% CI: 0.88–1.0).
Conclusions: Injury coding using a truncated E-code system can provide valid and reliable data from the ED. Differences between nurses, physicians, and nosologists in the ability to accurately code using this system were minimal, thus eliminating the need for additional staff and resources.     

The Epidemiology of Emergency Department Trauma Discharges in the United States

Objective

Injury‐related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.

Methods

We conducted a secondary retrospective, repeated cross‐sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all‐payer ED survey database in the United States. Main outcomes and measures were survey‐adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age‐stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey‐adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status.

Results

There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year‐to‐year decrease of 143 (95% CI = –184.3 to –68.5) visits per 100,000 U.S. population during the study period. The all‐age, all‐cause case‐fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case‐fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age‐stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm‐related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation‐adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion).

Conclusions

Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm‐related trauma presenting increased challenges.     

The Significance of Out-of-hospital Hypotension in Blunt Trauma Patients

Objective: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.
Methods: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.
Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).
Conclusion: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.     

Victimization from Physical Violence in Pennsylvania: Prevalence and Health Care Use

Objectives : To determine the prevalence of interpersonal physical violence (IPV) among Pennsylvania adults, to identify the personal characteristics of the victims, and to determine their health care use for resulting injuries.
Methods : Population-based data describing physical violence were obtained through a statewide telephone survey of 3,620 Pennsylvania adults selected from households by random-digit dialing in 1994. The prevalence and 95% confidence interval (95% CI) of victimization from IPV along with ED or other medical care facility use for IPV-related injuries were computed by several personal characteristics. Logistic regression was used to compare victims of IPV and their levels of health care use.
Results : The prevalence of reported victimization from IPV was 5.6% (95% CI = 4.9, 6.3). Significantly more victimization was reported by males, persons aged 18–29 years, those employed, and unmarried persons. The proportion of victims who reported to have gone to an ED or other medical care facility for IPV-related injury treatment was 12.9%. Significantly more persons with annual household incomes <$20,000 reported health care use for injuries resulting from IPV than did those with incomes of ≥$20,000 (OR = 3.98; 95% CI = 1. 27, 12.48). Health care use for injuries was not found to be related to gender, age. race, employment, or marital status.
Conclusions : This population-based study of health care use for IPV-related injuries found that victims of physical violence in Pennsylvania were not only young and unmarried men, but also employed. Health care use for resulting injuries was greater among persons with lower incomes.     

Rates of At-risk Drinking among Patients Presenting to the Emergency Department with Occupational and Nonoccupational Injury

OBJECTIVES: To compare the characteristics and rates of at-risk drinking among patients presenting to the emergency department (ED) with occupational and nonoccupational injury. METHODS: Cross-sectional survey of injured patients presenting to a university hospital ED. Injured patients were prospectively identified, and consenting patients completed a survey including questions regarding quantity/frequency of alcohol use, TWEAK, CAGE, and work-relatedness of injury. Major trauma and motor-vehicle collisions were excluded. Demographic and injury information was obtained from the medical record. Patients with a TWEAK score > or =3, CAGE score > or =2, or who exceeded NIAAA quantity/frequency guidelines were defined as at-risk drinkers. Analysis utilized the Student t-test for continuous variables, and frequency and chi-square analysis for categorical variables. RESULTS: Among 3,476 enrolled patients, 766 (22%) had work injuries and 2,710 (78%) had nonwork injuries. Patients with work injuries were as likely as patients with nonwork injuries to be at-risk drinkers; 35% of patients with an occupational injury and 36% of those with a nonoccupational injury were at-risk drinkers (odds ratio = 0.96). CONCLUSIONS: Patients presenting to the ED with an occupational injury have rates of at-risk drinking similar to other injury patients, and may be an important group in which to target brief alcohol interventions.     

Weapon Carriage among Major Trauma Victims in the Emergency Department

Objective: To determine the occurrence of weapon carriage by major trauma patients at a university/county hospital ED.
Methods: Retrospective observational study of major trauma patients seen in the ED of a major urban trauma center in Los Angeles from 1979 to 1993. All major trauma patients were searched routinely for weapons by the security police. Cases of violence in the ED caused by these weapons were reviewed.
Results: Over the 14-year period, 26.7% of the victims of major trauma presenting to ED were armed with lethal weapons. The occurrence of automatic weapon seizure increased significantly from an annual rate of only 0.2 in the first five years to an average of 17 over the last five years (p < 0.001). A total of 115 "incidents" of violence involving weapons in the ED were recorded during this period; 1.7% of the weapons brought to the ED led to violence and injury. There were four fatalities of armed and dangerous patients, but only six minor injuries to the staff. No other (unarmed) patient in the ED at the time of these incidents was injured.
Conclusions: ED major trauma patients at one urban trauma center in Los Angeles frequently carry weapons, including automatic military weapons. In addition to violence prevention measures such as weapon confiscation, plans must be made and practiced for the management of violence within the "sacrosanct" hospital doors to protect both patients and ED personnel.