Alcohol and injury among attendees at a busy inner city New Zealand emergency department

Self-directed violence and unclear intent presentation within a major trauma system. A multisite analysis

BACKGROUND

Determining trauma as an act of Self-directed violence (SDV) or from high risk or unclear behaviours is challenging for trauma clinicians and may be affected by patient sex and mechanism of injury. The aim of this study was to examine the differences in characteristics and outcomes between those who have intentionally directed violence towards themselves with those of unclear intent, within a regional trauma system.

METHODS

Data was collected between January 2018 and December 2021 in patients who had been identified as a result of either self-directed violence (SDV) defined as any intentional act that can cause injury to one's self, including death or participated in high-risk behaviours, where the intent was unclear (UI). Differences between female and male patients presenting with SDV and unclear intent were explored.

RESULTS

Overall, 2760 patients were identified, with a median age of 39 years (IQR 28-54) and just over a quarter of females (28 %). Falls from height were the most common mechanism of injury in all groups. SDV was recorded in 45 % of patients, and previous mental health diagnoses were almost three times as prevalent in this group compared to those of unclear intent (SDV: 42 % vs UI: 13 %). In the sex-based analysis females were more likely than males to have a history of depression (49 % vs 31 %, p < 0.0001). There were few sex differences in the SDV group but women of unclear intent were older, with a quarter being aged 65 years or over (Females: 26 % vs. Males: 11 %, p < 0.0001). Females of unclear intent were also more likely to have sustained a high level fall (Females: 29 % vs. Males:11 %, p < 0.001).

CONCLUSION

Previous mental health co-morbidity was associated with self-directed violence in our cohort. Yet the determinants of intent for over half of the patients were unclear. Trauma clinicians should actively enquire regarding intent of injury and escalate to clinical psychology or psychiatry teams as indicated. Those with mental health comorbidities, previous depression and older women may all have an increased risk where intent is unclear and warrants further investigation. Understanding the predictors and characteristics of unclear intent and high-risk behaviours are key to implementation of public health strategies around prevention of self-directed violence and suicide.

Deliberate self-harm and trauma - A descriptive analysis from a London major trauma centre

OBJECTIVES

The objective of this study is to present a retrospective analysis of patients presenting to a Major Trauma Centre (MTC) following deliberate self-harm (DSH) and identifying the precipitants of DSH and psychiatric morbidity that will serve to inform the provision of care for these patients.

PATIENTS AND METHODS

This was a retrospective observational study from a London Major Trauma Centre that identified all injured patients that presented with deliberate self-harm. Data was analysed from our established trauma database. The data was analysed using descriptive statistics.

RESULTS

This included 347 patients of whom 253 were male and 94 were female. The median age was 36 (range 14-93) years. Penetrating injuries (shooting and stabbing) occurred in 187 (54%) patients and blunt injuries in 160 (46%) patients. Self-stabbing (52%) was the most common cause for presentation followed by jumping from a height (26%). The median Injury Severity Score (ISS) was 4 (range 1-9). The median LOS was 3 days (range 0-109), with a mean stay of 8 days. Over half of the patients (n = 189) had previous contact with mental health services. Social and mental health were the main triggers for DSH.

CONCLUSIONS

Societal and economic factors as well as a mental disorder are associated with trauma related DSH. These complex group of patients presenting to MTCs have not only acute surgical needs but social and psychological as well. Raising awareness of patients' mental health needs across the whole pathway for the major trauma patient is crucial to ensure that appropriate risk assessments are undertaken at every stage. It is also essential to provide psychological support to the multi-disciplinary team for their wellbeing.

Systematic review of dog bite prevention strategies

BACKGROUND

The prevention of dog bites is an increasingly important public health topic, as the incidence of serious injury continues to rise.

OBJECTIVES

To evaluate the effectiveness of interventions to prevent dog bites and aggression.

METHODS

Online databases were searched (PubMed, Cochrane Library, Embase and Google Scholar), using the search terms: dog/s, canine, canis, kuri, bite/s, bitten, aggression, attack, death, fatal, mortality, injury/ies, prevention, intervention, for studies between 1960 and 2021. All study designs were considered. Outcomes of interest were the incidence of dog bites or dog aggression. Non-English studies, and those without full-text access were excluded.

RESULTS

Forty-three studies met the review criteria, including 15 observational and 27 interventional studies. Fifteen studies investigating dog-control legislation, including leash laws, stray dog control and infringements indicated this can reduce dog bite rates. Breed-specific legislation had less of an effect. Six studies investigating sterilisation, showed while this may reduce dog bites through a reduction in the dog population, the effect on dog aggression was unclear. An alcohol reduction programme showed a significant reduction in dog bite rates in one study. Seven studies assessing educational approaches found that intensive adult-directed education may be effective, with one study showing child-directed education was not effective. Eight studies on dog training (two police-dog related), and six evaluating dog medication or diet were generally low quality and inconclusive.

CONCLUSIONS

Multiple strategies including effective engagement with indigenous communities and organisations will be required to reduce dog-bites and other incidents involving dog aggression. This review provides some evidence that legislated dog control strategies reduce dog bite rates. Available evidence suggests greater restrictions should be made for all dogs, rather than based on breed alone. Due to a burden of child injury, protection of children should be a focus of legislation and further investigations. Prevention strategies in children require redirection away from a focus on child-directed education and future research should investigate the effectiveness of engineering barriers and reporting strategies.

Alcohol and acute traumatic brain injury in the emergency department

OBJECTIVE

There is limited research from Australasian EDs describing the demographic make-up, injury severity and impact of alcohol in patients requiring computed tomography (CT) for suspected traumatic brain injury (TBI). The present study aims to review the frequency and presenting patterns of patients who consume alcohol prior to presenting with suspected TBI.

METHODS

Retrospective observational study of patients referred for head CT to exclude TBI from a major referral centre and regional ED in New Zealand, between 1 September 2018 and 31 August 2019. Comparison groups were defined as 'alcohol involved' or 'no alcohol involved'.

RESULTS

97/425 (22.8% [95% CI 18.3-27.4]) of included TBI presentations involved alcohol. 73/97 (75.3% [95% CI 58.6-93.5]) were male and 41/97 (42.3% [95% CI 29.3-55.2]) were aged 18-30 years. The alcohol group were more likely to report assault as the injury mechanism (19.6% [95% CI 10.8-28.4] vs 5.2% [95% CI 2.7-7.7], P < 0.05) and have Glasgow Coma Scale scores reflecting more moderate (13.5% [95% CI 5.9-21.1] vs 3.5% [95% CI 1.5-5.6]) and severe (5.6% [95% CI 0.7-10.5] vs 3.2% [95% CI 1.2-5.2] TBI. Presentation times post-injury were delayed compared to the no alcohol group (3.4 h [interquartile range 1.9-14.8] vs 2.8 h [interquartile range 1.8-6.6], P < 0.05).

CONCLUSION

One quarter of patients with suspected TBI had consumed alcohol prior to their injury. Predominantly, those affected were young males who reported higher rates of assault; however, alcohol use was recorded in all age groups and sex. Alcohol-affected patients presented later, potentially delaying time to diagnosis. The present study supports the call for public health interventions that aim to reduce alcohol misuse.