Acidentes e violência na infância: evidências do inquérito sobre atendimentos de emergência por causas externas - Brasil, 2009

Compreender as características e a magnitude das causas externas (acidentes e violência) em crianças de 0 a 9 anos de idade torna-se cada vez mais importante em Saúde Pública. O objetivo do presente artigo foi analisar os atendimentos de emergência por causas externas em crianças. Utilizaram-se dados do Sistema de Vigilância de Violências e Acidentes em Serviços Sentinelas de Urgência e Emergência (Inquérito VIVA), realizado em 74 serviços de urgência do Distrito Federal e 23 capitais no ano 2009. Analisaram-se dados de 7.123 crianças: 6.897 (96,7%) vítimas de acidentes e 226 (3,3%) de violência. Em comparação às vítimas de violência, os atendimentos por acidentes foram mais frequentes entre crianças de 2 a 5 anos, de pele branca e ocorridos no domicílio (p < 0,05). Dentre os acidentes, as quedas e queimaduras predominaram no grupo de 0 a 1 ano, enquanto os acidentes de transporte foram mais frequentes no grupo de 6 a 9 anos (p < 0,001). Quanto às violências, atendimentos por negligência e agressão física predominaram, respectivamente, nos grupos extremos de faixa etária, sendo um familiar identificado como agressor (p < 0,001). Informações sobre ocorrência de causas externas em crianças podem apoiar políticas de promoção da saúde, além de orientar profissionais de saúde, educadores e famílias na prevenção destas causas.

Erros de utilização de assentos de segurança infantil por menores de 4 anos

OBJETIVO: Analisar erros de utilização de assentos de segurança infantil por crianças matriculadas em creches e fatores relacionados. MÉTODOS: Estudo observacional transversal de coleta de dados prospectiva e eixo analítico retrospectivo. RESULTADOS: Um total de 42,7% das crianças apresentava erros de utilização. O modelo de regressão logística evidenciou maiores chances de erros na presença de duas ou mais crianças no veículo (odds ratio = 5,10, p = 0,007) e menores níveis de escolaridade e renda dos pais (renda e escolaridade médias: odds ratio = 7,00, p = 0,003; renda e escolaridade baixas: odds ratio = 3,40, p = 0,03). CONCLUSÃO: Os dados são coerentes com publicações internacionais.

Fatores associados ao óbito de motociclistas nas ocorrências de trânsito

Para identificar fatores associados ao óbito em motociclistas envolvidos em ocorrências de trânsito, em Maringá-PR, foi realizado estudo retrospectivo incluindo os motociclistas envolvidos em acidentes no ano de 2004. As fontes de dados foram os registros da Polícia Militar, do SIATE e do Instituto Médico Legal. Foram realizadas análises bivariadas e regressão logística binária. Identificaram-se 2.362 motociclistas nos Boletins de Ocorrência e, destes, 1.743 tinham registros nos Relatórios de Atendimento do Socorrista. As vítimas fatais diferiram das demais quanto à faixa etária, ao local de residência, ao tempo de habilitação e as suas condições fisiológicas na cena da ocorrência. No modelo final permaneceram as seguintes variáveis: Escala de Coma de Glasgow (ECGl), Revised Trauma Score (RTS), pulso e saturação de O2 no sangue. As condições fisiológicas das vítimas na cena do acidente se destacaram no modelo final e a ECGl superou o RTS na associação com óbito.

Análise espacial de óbitos por acidentes de trânsito, antes e após a Lei Seca, nas microrregiões do estado de São Paulo

OBJETIVO: Identificar aglomerados espaciais de microrregiões segundo taxas de óbito por acidentes de trânsito, no Estado de São Paulo, 1 ano antes e 1 ano após a Lei Seca. MÉTODOS: Estudo ecológico e exploratório, no período de 2007 e 2009, em 63 microrregiões do Estado de SP, Brasil. Utilizaram-se ferramentas de geoprocessamento com dados do DATASUS; analisando óbitos decorrentes de acidentes de trânsito em taxas por 100 mil habitantes, construindo coropletes. Nova estatística foi obtida subtraindo-se a taxa de 2009 de 2007, observando regiões de melhora ou piora. RESULTADOS: Em 2007, ocorreram 5.204 óbitos, com média de 83 óbitos/microrregião, variando entre 1 e 1.440. Já 2009 obteve 5.065 óbitos com a média de 80 óbitos/microrregião, variando entre 1 e 1.453. O coeficiente de Moran em 2007 foi I = 0,09 (p = 0,04) com correlação espacial positiva e 2009 obteve I = 0,04 (p = 0,16), sem correlação. A diferença entre as taxas obteve I = 0,23 (p = 0, 007), indicando associação espacial. Em 2007, Presidente Prudente, Rio Claro, Campinas, Bragança Paulista, Osasco e São Paulo tiveram altas taxas de óbito. Dessas regiões citadas, somente Osasco não se destacou em 2009. Ribeirão Preto, Ourinhos e Avaré obtiveram piora em 2009. A diferença entre as taxas de 2009 e 2007 mostrou que Amparo, Bragança Paulista e Campinas tiveram melhora, e Presidente Prudente e Ourinhos apresentaram piora. CONCLUSÃO: Foi possível identificar os locais com as maiores taxas de mortalidade, apontando locais onde as ações de fiscalização devem ser revisadas.

What types of unintentional injuries kill our children? Do infants die of the same types of injuries? A systematic review

The objective of this study was to review mortality from external causes (accidental injury) in children and adolescents in systematically selected journals. This was a systematic review of the literature on mortality from accidental injury in children and adolescents. We searched the Pubrvled, Latin-American and Caribbean Health Sciences and Excerpta Medica databases for articles published between July of 2001 and June of 2011. National data from official agencies, retrieved by manual searches, were also reviewed. We reviewed 15 journal articles, the 2011 edition of a National Safety Council publication and 2010 statistical data from the Brazilian National Ministry of Health Mortality Database. Most published data were related to high-income countries. Mortality from accidental injury was highest among children less than 1 year of age. Accidental threats to breathing (non-drowning threats) constituted the leading cause of death among this age group in the published articles. Across the pediatric age group in the surveyed studies, traffic accidents were the leading cause of death, followed by accidental drowning and submersion. Traffic accidents constitute the leading external cause of accidental death among children in the countries understudy. However, infants were vulnerable to external causes, particularly to accidental non-drowning threats to breathing, and this age group had the highest mortality rates for external causes. Actions to reduce such events are suggested. Further studies investigating the occurrence of accidental deaths in low-income countries are needed to improve the understanding of these preventable events.

Haptics in forensics: the possibilities and advantages in using the haptic device for reconstruction approaches in forensic science

Non-invasive documentation methods such as surface scanning and radiological imaging are gaining in importance in the forensic field. These three-dimensional technologies provide digital 3D data, which are processed and handled in the computer. However, the sense of touch gets lost using the virtual approach. The haptic device enables the use of the sense of touch to handle and feel digital 3D data. The multifunctional application of a haptic device for forensic approaches is evaluated and illustrated in three different cases: the representation of bone fractures of the lower extremities, by traffic accidents, in a non-invasive manner; the comparison of bone injuries with the presumed injury-inflicting instrument; and in a gunshot case, the identification of the gun by the muzzle imprint, and the reconstruction of the holding position of the gun. The 3D models of the bones are generated from the Computed Tomography (CT) images. The 3D models of the exterior injuries, the injury-inflicting tools and the bone injuries, where a higher resolution is necessary, are created by the optical surface scan. The haptic device is used in combination with the software FreeForm Modelling Plus for touching the surface of the 3D models to feel the minute injuries and the surface of tools, to reposition displaced bone parts and to compare an injury-causing instrument with an injury. The repositioning of 3D models in a reconstruction is easier, faster and more precisely executed by means of using the sense of touch and with the user-friendly movement in the 3D space. For representation purposes, the fracture lines of bones are coloured. This work demonstrates that the haptic device is a suitable and efficient application in forensic science. The haptic device offers a new way in the handling of digital data in the virtual 3D space.

Pelvic radiography in ATLS algorithms: A diminishing role?

ABSTRACT: BACKGROUND: Pelvic x-ray is a routine part of the primary survey of polytraumatized patients according to Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard imaging technique in the diagnosis of pelvic fractures. This study was conducted to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis in favour of later pelvic examination by CT scan. METHODS: We conducted a retrospective analysis of all polytraumatized patients in our emergency room between 01.07.2004 and 31.01.2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and a stable pelvis on clinical examination. We excluded patients requiring immediate intervention because of hemodynamic instability. RESULTS: We reviewed the records of n = 452 polytraumatized patients, of which n = 91 fulfilled inclusion criteria (56% male, mean age = 45 years). The mechanism of trauma included 43% road traffic accidents, 47% falls. In 68/91 (75%) patients, both a pelvic x-ray and a CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None of these 6 patients was found having a false positive pelvic x-ray, i.e. there was no fracture on pelvic CT scan. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT (false negative on x-ray). None of the diagnosed fractures needed an immediate therapeutic intervention. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23). CONCLUSION: While pelvic x-ray is an integral part of ATLS assessment, this retrospective study suggests that in hemodynamically stable patients with clinically stable pevis, its sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination if such is planned in adjunct assessment and available. The results support the safety and utility of our modified ATLS algorithm. A randomized controlled trial using the algorithm can safely be conducted to confirm the results.

Interventions for the management of mandibular fractures

BACKGROUND Fractures of the mandible (lower jaw) are a common occurrence and usually related to interpersonal violence or road traffic accidents. Mandibular fractures may be treated using open (surgical) and closed (non-surgical) techniques. Fracture sites are immobilized with intermaxillary fixation (IMF) or other external or internal devices (i.e. plates and screws) to allow bone healing. Various techniques have been used, however uncertainty exists with respect to the specific indications for each approach. OBJECTIVES The objective of this review is to provide reliable evidence of the effects of any interventions either open (surgical) or closed (non-surgical) that can be used in the management of mandibular fractures, excluding the condyles, in adult patients. SEARCH METHODS We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 28 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE via OVID (1950 to 28 February 2013), EMBASE via OVID (1980 to 28 February 2013), metaRegister of Controlled Trials (to 7 April 2013), ClinicalTrials.gov (to 7 April 2013) and the WHO International Clinical Trials Registry Platform (to 7 April 2013). The reference lists of all trials identified were checked for further studies. There were no restrictions regarding language or date of publication. SELECTION CRITERIA Randomised controlled trials evaluating the management of mandibular fractures without condylar involvement. Any studies that compared different treatment approaches were included. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated to include both clinical and methodological factors. MAIN RESULTS Twelve studies, assessed as high (six) and unclear (six) risk of bias, comprising 689 participants (830 fractures), were included. Interventions examined different plate materials and morphology; use of one or two lag screws; microplate versus miniplate; early and delayed mobilization; eyelet wires versus Rapid IMF™ and the management of angle fractures with intraoral access alone or combined with a transbuccal approach. Patient-oriented outcomes were largely ignored and post-operative pain scores were inadequately reported. Unfortunately, only one or two trials with small sample sizes were conducted for each comparison and outcome. Our results and conclusions should therefore be interpreted with caution. We were able to pool the results for two comparisons assessing one outcome. Pooled data from two studies comparing two miniplates versus one miniplate revealed no significant difference in the risk of post-operative infection of surgical site (risk ratio (RR) 1.32, 95% CI 0.41 to 4.22, P = 0.64, I(2) = 0%). Similarly, no difference in post-operative infection between the use of two 3-dimensional (3D) and standard (2D) miniplates was determined (RR 1.26, 95% CI 0.19 to 8.13, P = 0.81, I(2) = 27%). The included studies involved a small number of participants with a low number of events. AUTHORS' CONCLUSIONS This review illustrates that there is currently inadequate evidence to support the effectiveness of a single approach in the management of mandibular fractures without condylar involvement. The lack of high quality evidence may be explained by clinical diversity, variability in assessment tools used and difficulty in grading outcomes with existing measurement tools. Until high level evidence is available, treatment decisions should continue to be based on the clinician's prior experience and the individual circumstances.

Does normalized signal intensity of cervical discs on T2 weighted MRI images change in whiplash patients?

PURPOSE We tested the hypothesis that whiplash trauma leads to changes of the signal intensity of cervical discs in T2-weighted images. METHODS AND MATERIALS 50 whiplash patients (18-65 years) were examined within 48h after motor vehicle accident, and again after 3 and 6 months and compared to 50 age- and sex-matched controls. Signal intensity in ROI's of the discs at the levels C2/3 to C7/T1 and the adjacent vertebral bodies were measured on sagittal T2 weighted MR images and normalized using the average of ROI's in fat tissue. The contrast between discs and both adjacent vertebrae was calculated and disc degeneration was graded by the Pfirrmann-grading system. RESULTS Whiplash trauma did not have a significant effect on the normalized signals from discs and vertebrae, on the contrast between discs and adjacent vertebrae, or on the Pfirrmann grading. However, the contrast between discs and adjacent vertebrae and the Pfirrmann grading showed a strong correlation. In healthy volunteers, the contrast between discs and adjacent vertebrae and Pfirrmann grading increased with age and was dependent on the disc level. CONCLUSION We could not find any trauma related changes of cervical disc signal intensities. Normalized signals of discs and Pfirrmann grading changed with age and varied between disc levels with the used MR sequence.

Accident or homicide - virtual crime scene reconstruction using 3D methods

The analysis and reconstruction of forensically relevant events, such as traffic accidents, criminal assaults and homicides are based on external and internal morphological findings of the injured or deceased person. For this approach high-tech methods are gaining increasing importance in forensic investigations. The non-contact optical 3D digitising system GOM ATOS is applied as a suitable tool for whole body surface and wound documentation and analysis in order to identify injury-causing instruments and to reconstruct the course of event. In addition to the surface documentation, cross-sectional imaging methods deliver medical internal findings of the body. These 3D data are fused into a whole body model of the deceased. Additional to the findings of the bodies, the injury inflicting instruments and incident scene is documented in 3D. The 3D data of the incident scene, generated by 3D laser scanning and photogrammetry, is also included into the reconstruction. Two cases illustrate the methods. In the fist case a man was shot in his bedroom and the main question was, if the offender shot the man intentionally or accidentally, as he declared. In the second case a woman was hit by a car, driving backwards into a garage. It was unclear if the driver drove backwards once or twice, which would indicate that he willingly injured and killed the woman. With this work, we demonstrate how 3D documentation, data merging and animation enable to answer reconstructive questions regarding the dynamic development of patterned injuries, and how this leads to a real data based reconstruction of the course of event.

First results from a Swiss level I trauma centre participating in the UK Trauma Audit and Research Network (TARN): Prospective cohort study

QUESTIONS UNDER STUDY: Patient characteristics and risk factors for death of Swiss trauma patients in the Trauma Audit and Research Network (TARN). METHODS: Descriptive analysis of trauma patients (≥16 years) admitted to a level I trauma centre in Switzerland (September 1, 2009 to August 31, 2010) and entered into TARN. Multivariable logistic regression analysis was used to identify predictors of 30-day mortality. RESULTS: Of 458 patients 71% were male. The median age was 50.5 years (inter-quartile range [IQR] 32.2-67.7), median Injury Severity Score (ISS) was 14 (IQR 9-20) and median Glasgow Coma Score (GCS) was 15 (IQR 14-15). The ISS was >15 for 47%, and 14% had an ISS >25. A total of 17 patients (3.7%) died within 30 days of trauma. All deaths were in patients with ISS >15. Most injuries were due to falls <2 m (35%) or road traffic accidents (29%). Injuries to the head (39%) were followed by injuries to the lower limbs (33%), spine (28%) and chest (27%). The time of admission peaked between 12:00 and 22:00, with a second peak between 00:00 and 02:00. A total of 64% of patients were admitted directly to our trauma centre. The median time to CT was 30 min (IQR 18-54 min). Using multivariable regression analysis, the predictors of mortality were older age, higher ISS and lower GCS. CONCLUSIONS: Characteristics of Swiss trauma patients derived from TARN were described for the first time, providing a detailed overview of the institutional trauma population. Based on these results, patient management and hospital resources (e.g. triage of patients, time to CT, staffing during night shifts) could be evaluated as a further step.

Temporal variability of damage potential on roads as a conceptual contribution towards a short-term avalanche risk simulation

The fatality risk caused by avalanches on road networks can be analysed using a long-term approach, resulting in a mean value of risk, and with emphasis on short-term fluctuations due to the temporal variability of both, the hazard potential and the damage potential. In this study, the approach for analysing the long-term fatality risk has been adapted by modelling the highly variable short-term risk. The emphasis was on the temporal variability of the damage potential and the related risk peaks. For defined hazard scenarios resulting from classified amounts of snow accumulation, the fatality risk was calculated by modelling the hazard potential and observing the traffic volume. The avalanche occurrence probability was calculated using a statistical relationship between new snow height and observed avalanche releases. The number of persons at risk was determined from the recorded traffic density. The method resulted in a value for the fatality risk within the observed time frame for the studied road segment. The long-term fatality risk due to snow avalanches as well as the short-term fatality risk was compared to the average fatality risk due to traffic accidents. The application of the method had shown that the long-term avalanche risk is lower than the fatality risk due to traffic accidents. The analyses of short-term avalanche-induced fatality risk provided risk peaks that were 50 times higher than the statistical accident risk. Apart from situations with high hazard level and high traffic density, risk peaks result from both, a high hazard level combined with a low traffic density and a high traffic density combined with a low hazard level. This provided evidence for the importance of the temporal variability of the damage potential for risk simulations on road networks. The assumed dependence of the risk calculation on the sum of precipitation within three days is a simplified model. Thus, further research is needed for an improved determination of the diurnal avalanche probability. Nevertheless, the presented approach may contribute as a conceptual step towards a risk-based decision-making in risk management.

Changing epidemiology of trauma deaths leads to a bimodal distribution

Introduction. Injury mortality was classically described with a tri-modal distribution, with immediate deaths at the scene, early deaths due to hemorrhage, and late deaths from organ failure. We hypothesized that trauma systems development have improved pre-hospital care, early resuscitation, and critical care, and altered this pattern. ^ Methods. This is a population-based study of all trauma deaths in an urban county with a mature trauma system (n=678, median age 33 years, 81% male, 43% gunshot, 20% motor vehicle crashes). Deaths were classified as immediate (scene), early (in hospital, ≤ 4 hours from injury), or late (>4 hours post injury). Multinomial regression was used to identify independent predictors of immediate and early vs. late deaths, adjusted for age, gender, race, intention, mechanism, toxicology and cause of death. ^ Results. There were 416 (61%) immediate, 199 (29%) early, and 63 (10%) late deaths. Immediate deaths remained unchanged and early deaths occurred much earlier (median 52 minutes vs. 120). However, unlike the classic trimodal distribution, there was no late peak. Intentional injuries, alcohol intoxication, asphyxia, and injuries to the head and chest were independent predictors of immediate deaths. Alcohol intoxication and injuries to the chest were predictors of early deaths, while pelvic fractures and blunt assaults were associated with late deaths. ^ Conclusion. Trauma deaths now have a bimodal distribution. Elimination of the late peak likely represents advancements in resuscitation and critical care that have reduced organ failure. Further reductions in mortality will likely come from prevention of intentional injuries, and injuries associated with alcohol intoxication. ^

A Su Salud Injury Prevention expansion: Analysis of injury prevention perceptions in a Hispanic community

Unintentional injury is the leading cause of death for American ages one to 44 and is ranked in the top ten causes of death for all age groups (CDC, 2006a). A Su Salud Injury Prevention was developed to address injury prevention awareness and education. The program is a mass media education campaign that uses role models, mass media, and community outreach to prevent injury. In 2009, University Health System (UHS) expanded the program. Baseline data were collected from 426 residents in targeted neighborhoods northwest of downtown San Antonio to support the expansion. The purpose of this study was to explore injury perceptions, knowledge, and behaviors of adults living in the expansion area, and define the predominant factors associated with these perceptions. A secondary aim was to assess community awareness and willingness to participate in the program.^ Survey results showed motor vehicle crashes (MVC), falls, drinking and driving, and guns and assaults were considered the most serious injures for adults. The most serious child injuries were MVC, abuse and neglect, falls, and head injuries. Residents were knowledgeable of state seatbelt policy, and over 90% responded as compliant for seatbelt and child car seat use. Most were knowledgeable about drinking and driving state policy and negative outcomes. However, 70% of those reporting driving under the influence of alcohol within the last year engaged in repeat high risk behavior. Men and residents under the age of 55 were more likely to engage in repeat drinking and driving (OR= 3.6, 7.0 respectively). Residents consider injury prevention an important issue, and have interest in a local injury prevention program. Younger women are the most likely to participate in a local program as potential role models and volunteers.^ Results from the study are summarized into an injury prevention and demographic profile of the community that will be used to develop tailored injury prevention messages to create a more effective program, and support program coordinators in effective community engagement. Results will also be used as a comparative basis for future evaluation of a behavioral injury prevention program focused on a predominantly Mexican-American community.^

Prevalence and risk factors of asthma and work -related asthma among U.S. adults: Data from the Third National Health and Nutrition Examination Survey, 1988--1994

This cross-sectional analysis of the data from the Third National Health and Nutrition Examination Survey was conducted to determine the prevalence and determinants of asthma and wheezing among US adults, and to identify the occupations and industries at high risk of developing work-related asthma and work-related wheezing. Separate logistic models were developed for physician-diagnosed asthma (MD asthma), wheezing in the previous 12 months (wheezing), work-related asthma and work-related wheezing. Major risk factors including demographic, socioeconomic, indoor air quality, allergy, and other characteristics were analyzed. The prevalence of lifetime MD asthma was 7.7% and the prevalence of wheezing was 17.2%. Mexican-Americans exhibited the lowest prevalence of MD asthma (4.8%; 95% confidence interval (CI): 4.2, 5.4) when compared to other race-ethnic groups. The prevalence of MD asthma or wheezing did not vary by gender. Multiple logistic regression analysis showed that Mexican-Americans were less likely to develop MD asthma (adjusted odds ratio (ORa) = 0.64, 95%CI: 0.45, 0.90) and wheezing (ORa = 0.55, 95%CI: 0.44, 0.69) when compared to non-Hispanic whites. Low education level, current and past smoking status, pet ownership, lifetime diagnosis of physician-diagnosed hay fever and obesity were all significantly associated with MD asthma and wheezing. No significant effect of indoor air pollutants on asthma and wheezing was observed in this study. The prevalence of work-related asthma was 3.70% (95%CI: 2.88, 4.52) and the prevalence of work-related wheezing was 11.46% (95%CI: 9.87, 13.05). The major occupations identified at risk of developing work-related asthma and wheezing were cleaners; farm and agriculture related occupations; entertainment related occupations; protective service occupations; construction; mechanics and repairers; textile; fabricators and assemblers; other transportation and material moving occupations; freight, stock and material movers; motor vehicle operators; and equipment cleaners. The population attributable risk for work-related asthma and wheeze were 26% and 27% respectively. The major industries identified at risk of work-related asthma and wheeze include entertainment related industry; agriculture, forestry and fishing; construction; electrical machinery; repair services; and lodging places. The population attributable risk for work-related asthma was 36.5% and work-related wheezing was 28.5% for industries. Asthma remains an important public health issue in the US and in the other regions of the world. ^