A meta-analysis of 21 studies shows that the effect of mandatory bicycle helmet legislation for all cyclists on head injuries results in a 20% reduction in serious injuries; however, such legislation currently seems unlikely in many US jurisdictions, except for children.Nonlegislative interventions appear to be effective in increasing observed helmet use, particularly community-based interventions and those programs providing free helmets.The clustering of unhelmeted bicyclists in automobile collisions provides the trauma center with good targets for injury prevention. The hotspots for lack of helmet use were predominantly at traffic light intersections on straight city boulevards, which may provide a joint opportunity with local officials and bicycle advocates to evaluate bicycle traffic safety and policies. The census tract home language data for the unhelmeted hotspots indicates that any injury prevention efforts should be culturally appropriate and made available in multiple languages. The class of bike lane in San Diego County also influences the number of bicyclist-automobile collisions, with the signage-only “Bike Route” being the most common involved bike lane with injuries. Separating bicycles from automobiles is an obvious prevention measure and in our study is associated with very low rates of bicycle versus automobile injury. Advocacy for better classes of bike lanes, including more Class I Bike Paths is warranted.
There appear to be opportunities for targeted injury prevention efforts for intoxicated bicyclists in our catchment,microgreen shelving given the small geographic area. Unfortunately, we do not have data on owned bikes versus rented ridesh are bikes which became ubiquitous at the end of the study period. The trauma registry kept by US trauma centers is largely used for quality and performance improvement, and to provide data to the Trauma Quality Improvement Program to allow national bench marking standards.Trauma registries can also be linked to emergency medical services registries and a call has been issued by the American College of Surgeons’ Trauma Quality Programs and the National Association of State Emergency Medical Services Officials, with support from the National Highway Traffic Safety Administration.The addition of EMS registry data provides additional information about the prehospital care of the trauma patient and this may provide additional risk factors for analysis of outcomes as well as additional data for quality and performance improvement of EMS. The California Highway Patrol’s SWITRS database is a rich source on each injury traffic collision in the state of California, providing over 122 data fields per case. Since 2002, each SWITRS record starts with a unique barcode ID number, allowing collection of scene data by law-enforcement agencies across the state. However, there has yet been no attempt to link SWITRS to EMS data in California. There have been efforts to link EMS records and traffic records in some regions of Oregon, which is accomplished by sharing of a universally unique and anonymous identifier between agencies at the accident scene.
However, in California, legal concerns over privacy have halted progress by the state EMS agency despite the low cost of such a useful improvement in the trauma and EMS registries. We believe that this should be an area for continued advocacy and research for trauma centers, providers, and their national associations. Limitations of our study approach include the inability to assign financial, educational, or language characteristics to individual patients, for those variables we can only speak of the characteristics of a census tract for a patient’s given home address,which is only useful for assessing associations in large groups of patients. In some cases, opiates or benzodiazepines may have been administered by EMS crews or trauma teams prior to urinalysis. It is possible that there are systemic errors that mean that many individual bicycle-automobile victims may be systemic outliers from their census tract characteristics, although we believe that the results are representative from our experience. Missing and incorrect data are always an issue for large databases, which may be why we were unable to match 20% of our bicyclists injured in automobile collisions in our catchment to SWITRS data, although we believe that the remainder in the study is a representative sample of our experience. The adoption of a secure linkage between traffic records databases and the EMS and trauma registries would resolve this issue. Further studies of combination of traffic records databases and trauma center registries are needed to validate our approach. Although exact determination of educational level, income and languages spoken may be impractical and excessively intrusive for individual patients, use of census tract demographic data may allow for determination of likely characteristics of groups of patients for epidemiological and injury prevention purposes.
The amount of GIS data available free online has exploded in the past 10 years. Future GIS analysis will include new social determinants for access to quality trauma care and trauma outcomes.Synthetic cannabinoids are a class of drugs that are becoming increasingly popular throughout the United States and Europe. Also known as “K2,” “spice,” spike,” or “legal marijuana,” SC are causing intoxication requiring emergency department visits in epidemic and unparalleled numbers.1 Patients present with a wide array of symptoms, ranging from nausea and vomiting to confusion, agitation, short-term memory loss, cognitive impairment, psychosis, seizures, arrhythmias, strokes and even death.2 SC have often been associated with sympathomimetic effects such as mydriasis, hypertension and tachycardia.2 We present a case series of patients with SC intoxication who presented atypically with central nervous system and cardiovascular depression over a five-month period; in addition, we present an analysis of blood, urine and SC samples using mass spectrometry. Intoxication with SC products should be considered for patients with undifferentiated psychomotor depression and bradycardia in addition to the excitatory effects previously described.In early 2015 our suburban, tertiary care EDs experienced a large influx of patients presenting with lethargy and psychomotor depression, often requiring admission to the telemetry or intensive care units and rarely requiring intubation. The patients usually experienced sudden and complete resolution of symptoms after several hours in an obtunded state. Large cohorts of these patients simultaneously presented from a nearby psychiatric center that provided inpatient, outpatient and residential services. The increased volume of intoxications exacerbated ED crowding. Patients later admitted to SC use, and some produced samples of the plant material. Questions arose regarding the potential contamination of these substances with other agents, such as clonidine or digoxin, or whether these presentations were due to newer generation SC. We selected cases for this series from the toxicology consult service database for patients suspected of SC use. Blood and urine samples were collected from the patients when possible. The unknown drug samples were analyzed and compared to a reference database to identify the compounds present.We included two tertiary care EDs in our case series. In total, 141 ED visits were selected by toxicologists from the consult service database based on abnormal triage vitals, history of SC use or an obtunded mental state upon presentation. Twelve blood and 31 urine samples were collected. The 36 samples of plant material provided by patients were collected and analyzed using liquid chromatography/mass spectrometry and gas chromatography/ mass spectrometry .
The samples were not correlated with specific patients. This retrospective chart review was approved by an institutional review board.Samples were extracted with organic solvent and concentrated to isolate any drugs present on the plant material. Briefly, 5 mg aliquots of an unknown plant material, or 100 μL of submitted blood/urine,greenhouse tables were transferred to screwtop centrifuge tubes. Two mL of ethyl acetate were added and the samples were thoroughly mixed. Samples were extracted for 10 minutes on a nutating mixer at 24 revolutions per minute. The solvent was transferred to clean test tubes and the extracts were evaporated to dryness under nitrogen at 45°C. Samples were reconstituted in 50 μL methanol and 50 μL 0.1% formic acid in water and transferred to conical autosampler vials for analysis by liquid chromatography time-of-flight mass spectrometry. Similarly, samples were reconstituted in 50 μL ethyl acetate for GC/MS confirmation analysis. Biological samples underwent a 20-minute room temperature hydrolysis period prior to liquid-liquid extraction. We used an Agilent Technologies 1290 liquid chromatograph equipped with a Zorbax Eclipse Plus C-18 column for chromatographic separation of the unknown plant material extract. The LC columns were maintained at 50°C in the thermostated column compartment. Mobile phases consisted of 0.1% formic acid in deionized water and 100% methanol . The mobile phase flow rate was set at 0.7 mL/min. Initial mobile phase conditions were held at 0%B for 0.5 minutes then increased to 95%B over five minutes. Mobile phase conditions returned to initial starting conditions for a final run time of six minutes.Hundreds of distinct SC compounds have been identified.SCs are responsible for a rapidly growing number of presentations to EDs throughout the U.S. in the past several years.1 SC use causes intense highs and has become popularized due to accessibility, affordability and limited detectability in common drug screens.Intoxications often present in clusters due to local distribution of a single product and great variability in the herbal mixtures. One study found a range of 2.3-22.9 mg/g of cannabimimetics in the herbal mixtures.In addition, SC have been found to be more potent than Δ9 -THC;2 the SC 5F-ADBPINACA, a CID compound similar to a SC detected in our study, is over 1,000 times more potent than Δ9 -THC.In March 2011 the U.S. Department of Justice categorized the five most commonly abused SCs as Schedule I drugs under 21 U.S.C.811 of the Controlled Substances Act.As local outbreaks continued, the novel compounds were identified and added to the Controlled Substances Act. ED visits increased from 11,406 in 2010 to 28,531 in 2011.Visits from patients 12-17 years old more than doubled from 3,780 to 7,584, while visits from patients18-20 years old increased from 1,881 to 8,212.In 2011, SCs were the second most commonly used drug in the 10th grade and the third most common in eighth grade following marijuana and inhalants.Despite the federal ban on SCs that year, there was no decline in frequency of use in high school students the following year. However, use declined in each of the next three years.Users of SCs vary greatly in both demographics and motivation, but are typically males aged 13-59, most with polydrug use and are found in larger, urban populations.SCs are known to interact with the cannabinoid receptors, CB1 and CB2 , leading to changes in levels of multiple neurotransmitters including acetylcholine, dopamine, noradrenaline, glutamine and GABA.Genetic polymorphisms in enzymes responsible for metabolism of SCs can lead to increased blood levels of the parent compound and prolonged duration of action, and therefore a potential increased risk of adverse events.In addition, many SC metabolites retain biological activity.Combination of these metabolites with accumulation of the parent drug creates complex pharmacodynamics, especially when the multitude of other compounds typically found within herbal mixtures is considered. SCs have been reported to exhibit a wide array of effects. CNS effects include psychosis, anxiety, agitation, irritability, memory changes, sedation, confusion and hallucinations,in addition to lowering the seizure threshold in susceptible individuals.Reported cardiovascular effects include tachycardia, chest pain, dysrhythmias, myocardial ischemia13 and cerebrovascular accident caused by embolisms due to cardiac arrhythmias or reversible cerebral vasoconstriction syndrome.In an analysis of a Centers for Disease Control and Prevention report of 3,573 calls to poison control for SC-related adverse events, the most common effects were agitation , tachycardia , drowsiness or lethargy , vomiting , and confusion .In early 2010, JWH-018 was detected in 100% of SC products. However, as legislation regarding SCs changed in 2010 and 2011, the incidence of JWH-018 decreased, while similar yet compositionally distinct compounds appeared. By the end of 2012, JWH-018 was not detected in samples, and XLR-11 became the most common SC detected, as exhibited in our sample analysis. In our case series, CID and alkyl SC derivatives, such as INACA compounds and XLR-11,were the most commonly detected with no opiates, imidazoline receptor agonists, benzodiazepines or other sedative-hypnotics detected that might explain the atypical presentations. Sixty-one percent of the confiscated products contained a SC and 31% contained both XLR-11 and CID. Seventy-five percent of blood samples and 77% of urine samples tested positive for SC. Unlike their predecessors, novel SC appear to be associated with significant CNS depression and bradycardia. The compounds detected in our case series tended to be full agonists at the cannabinoid receptor and are more potent than Δ9-THC.20 The lack of other CNS and cardiovascular depressants suggests that the clinical findings are due to the combination of these compounds and not coingestants or adulterants.