aResearch and medical services, Jesse Brown Va medical center, chicago, il, usa; bDepartment of anesthesiology, university of illinois college of medicine at chicago, chicago, il, usa; cDepartment of Emergency medicine, university of illinois college of medicine at Peoria, Peoria, il, usa; dlinus Pauling institute, oregon state university, corvallis, oR, usa; eDepartment of medicine, university of illinois college of medicine at chicago, chicago, il, usa

Introduction: Synthetic cannabinoids are a rapidly expanding subset of designer drugs widely available in the United States since 2008. In Illinois during the spring of 2018, over 160 documented cases of bleeding and prolonged coagulopathy occurred secondary to contaminated synthetic cannabinoids. Methods: We conducted a retrospective cohort study consisting of 38 patients to describe the initial emergency department (ED) presentation, diagnosis, and treatment. Results: Through serum testing we found that three long-acting anticoagulant rodenticides (LAAR) were detected in patients who had inhaled these tainted products: brodifacoum, difenacoum, and bromodialone. Discussion: This study encompasses the largest ED presentation of LAAR poisoning via the inhalational route known to date. Conclusion: The emergency physician should be aware of the potential for tainted coingestants as the cause of undifferentiated coagulopathy.

The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.

Gastrointestinal bleeding (GIB) can be a life-threatening condition if not quickly triaged and treated in the emergency department (ED). Studies have been performed about the accuracy of hemoglobin point-of-care testing but have not evaluated the impact in the ED. In this study we were interested in determining if point-of-care hemoglobin testing would decrease ED triage timing, total ED treatment time and effect overall ED disposition. A retrospective cohort study was performed involving ED patients with a complaint of GI bleeding, who presented to a large, urban, academic, Midwest ED from 2013-2018. Patients were selected for review if they had an end ICD 10 diagnosis related to GI bleeding and if they had both a HemoCue and a subsequent venous hemoglobin performed. Patients were excluded if they were less than 18, if the final diagnosis was not related to GI bleeding, or if they did not have both CBC and Hemocue testing. Using Bland-Altman plots, patients' venous hemoglobin and Hemocue were compared to assess agreement between the two methods. Patients were then divided into different arrival groups (EMS vs Ambulatory), Disposition groups (discharge or Admit). These groups were then compared to see if a difference was presents between door to room, door to MD time, overall length of stay. For univariate analysis, a Wilcoxon two sample T test was used, for multivariate analysis a robust regression model was used. A total of 7214 patients were reviewed and 324 patients were selected. Hemocue and venous hemoglobin were found to have a concordance correlation coefficient of 0.84 with 95% confidence interval of 0.82, 0.88. Patient who had a Hemocue performed were roomed faster by 4.1 minutes, but there was no overall change in door to doc time, overall length of stay for both admitted or discharged patients. Overall, we found that the point-of-care hemoglobin testing seems to positively correlate with venous hemoglobin findings. This test did slightly decrease the arrival to room time by 4.1 minutes. However, there was no significant difference seen in door to MD time, overall length of stay of either or admitted or discharged patients.

John W Hafner Brandon B Bleess Michelle Folake Famakinwa Huaping Wang Monica Coleman 1University of Illinois College of Medicine at Peoria, Department of Emergency Medicine, Peoria, IL 616137, USA; 2University of Illinois College of Medicine at Peoria, Peoria, IL, USA; 3University of Illinois College of Medicine at Peoria, Department of Internal Medicine, Peoria, IL, USA; 4American Red Cross Central and Southern Illinois Region, Peoria, IL, USA Background: Motor vehicle crashes (MVCs) are the leading cause of death in US teens, encompassing greater than one in three deaths. Mock crash reenactments have been used to promote awareness in communities about the effects of drinking and driving. The majority of these programs are for alcohol injury prevention, target high school students, and often involve a scenario of a student driving while under the influence (DUI) and sustaining a fatal car crash. Objective: The purpose of this study is to evaluate the effectiveness of a regional mock crash reenactment upon the students’ drinking and driving knowledge and behaviors. Methods: An observational pre-post study was conducted. The survey had seven five-point Likert-scale questions (1 being strongly disagree and 5 strongly agree) measuring outcomes. Students were surveyed before and after the crash reenactment concerning their knowledge and attitudes related to drinking and driving. The survey also included questions that queried participant’s age, gender, alcohol consumption history, and seatbelt usage. Results: The final study population included 947 pre-surveys and 840 post-surveys. Students demonstrated no significant increase in knowledge-based drinking and driving questions. However, after the reenactment program, students were 1.39 times less likely to report drinking and driving in the future or that they would get into a car with someone who would drive drunk. Students were 1.7 times more likely to report thinking about the risks associated with drinking and driving after participating in the program. Conclusion: After viewing a mock crash reenactment, students reported they were less likely to drink and drive in the future or get into a car with someone who would drive drunk, and were more likely often think the risks associated with drinking and driving.

Background: Motor vehicle crashes (MVCs) are the leading cause of death in US teens, encompassing greater than one in three deaths. Mock crash reenactments have been used to promote awareness in communities about the effects of drinking and driving. The majority of these programs are for alcohol injury prevention, target high school students, and often involve a scenario of a student driving while under the influence (DUI) and sustaining a fatal car crash. Objective: The purpose of this study is to evaluate the effectiveness of a regional mock crash reenactment upon the students’ drinking and driving knowledge and behaviors. Methods: An observational pre-post study was conducted. The survey had seven five-point Likert-scale questions (1 being strongly disagree and 5 strongly agree) measuring outcomes. Students were surveyed before and after the crash reenactment concerning their knowledge and attitudes related to drinking and driving. The survey also included questions that queried participant’s age, gender, alcohol consumption history, and seatbelt usage. Results: The final study population included 947 pre-surveys and 840 post-surveys. Students demonstrated no significant increase in knowledge-based drinking and driving questions. However, after the reenactment program, students were 1.39 times less likely to report drinking and driving in the future or that they would get into a car with someone who would drive drunk. Students were 1.7 times more likely to report thinking about the risks associated with drinking and driving after participating in the program. Conclusion: After viewing a mock crash reenactment, students reported they were less likely to drink and drive in the future or get into a car with someone who would drive drunk, and were more likely often think the risks associated with drinking and driving.

Abstract Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy. Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers. Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances. Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTS In patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital. LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.

Sport-related concussion refers to the subset of concussive injuries occurring duringsport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

In Illinois during the spring of 2018, a large public outbreak of vitamin-K dependent coagulopathies occurred secondary to inhalation of contaminated synthetic cannabinoids. The hematologic effects were secondary to brodifacoum (a rodenticide anticoagulant) contamination of the product, and encompass the first large brodifacoum poisoning from the inhalational route. This study seeks to characterize the victims and patterns of the outbreak. A retrospective cohort trial was conducted at 2 Illinois academic urban emergency departments (annual visits >85,000 and >120,000) of patients with suspected brodifacoum related coagulopathy from contaminated synthetic cannabinoids presenting to the emergency department. Patients were identified from internal and public health registries, from patients either self-identifying as having an exposure, or identified by hospital providers as having an exposure. ED and hospital charts were abstracted using defined variables and all data was de-identified prior to analysis. Descriptive statistics were used to describe the population, define common symptomatology, and identify successful treatment regimens. 38 patients were enrolled in the study (33 and 5 per institution). Patients were mostly adult males (68.8%), white (76.3%) and regular users of synthetic cannabinoids (72.7%). Hematuria (68.6%), hematemesis (25.8%), melena/bloody stools (20%), and hemoptysis (17.4%) were the most common bleeding presentations to the ED. Most patients (75%) presented >24 hours post exposure. Few patients had additional illicit drug or antiplatelet/anticoagulant presence. Most received between 10-50 mg of vitamin K initially, and 48.5% received FFP in either the ED or during hospitalization. Most patients were hospitalized with a mean of 4.1 days (SD 3.1) with 12 patients leaving against medical advice. Patients had a mean presenting INR of 14.5 (SD 6.3) and a discharge INR of 2.5 (SD 1.3). Most patients were discharged with a vitamin K dose of 50 mg BID (range 0 - 50 mg) and a mean duration of treatment post discharge of 26.7 days. In addition, 42.4% of patients returned to the ED for further care after their initial visit (range 0 - 5 visits). The 2018 Illinois synthetic cannabinoid vitamin K-dependent coagulopathy outbreak was the largest inhalational brodifacoum associated population poisoning to date. Most patients presented with gastrointestinal and genitourinary associated bleeding and required large doses of vitamin K in an inpatient setting.

Objectives: Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population. Methods: A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions. Results: Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02). Conclusions: In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified.

Over 8 million patients with low risk chest pain are evaluated in the emergency department (ED) annually. Patients presenting to the ED with chest pain are increasingly managed in chest pain units with accelerated diagnostic protocols that include confirmatory stress testing. Limited protocols currently exist to describe safe and cost-effective strategies for provocative stress testing in this environment. This study aims to evaluate the efficacy and safety of an evidence-based stress testing protocol in an ED-based chest pain unit. A posttest-only nonequivalent control group trial, using a historical control group, was conducted at an academic urban emergency department (annual visits> 85,000) of patients with chest pain and a negative ED evaluation, who were admitted to an ED-based chest pain unit. Controls subjects (prior to initiation of an evidence-based stress testing protocol) from the same chest pain unit underwent physician directed cardiac stress testing and were compared to subjects who underwent stress testing using a multidisciplinary evidence-based protocol. Patient risk of acute coronary syndrome (ACS) was categorized according the American Heart Association (AHA) definitions. Outcomes were defined as positive stress testing and 30-day composite adverse outcomes (all-cause death, urgent revascularization, or myocardial infarction), and were assessed using electronic chart review and telephone survey. Cardiac stress testing protocol compliance was assessed by investigator review. Chi-square tests were used to assess categorical variables, and t tests were used to evaluate the associations with continuous variables. Multivariate analysis was conducted using logistic regression models. 466 controls and 162 intervention patients were enrolled in the study and were similar in mean age, sex, diabetes prevalence, and pacemaker presence. Intervention subjects had more intermediate ACS risk and less high ACS risk. Overall compliance with the stress test protocol was 86.4%, and lowest among the low ACS risk subjects (60%; p<0.0001). Nuclear stress testing (treadmill and chemical) decreased in the interventional subjects compared to control subjects (50% intervention versus 93.1% control; p<0.0001) and plain treadmill or treadmill echocardiogram stress testing increased (11.1% intervention versus 1.9% control for plain treadmill, 30.9% intervention versus 2.4% control for treadmill echocardiogram; p<0.0001). Both populations had similar rates of positive stress tests (8.6% intervention versus 9.5% control; p=0.76) even when adjusted for ACS risk, presence of HTN, prior history of CAD, and presence of a normal ECG. Both populations had similar low proportions of 30-day composite adverse outcomes (0.6% intervention versus 2.4% control; p=0.31). As compared to historical control patients, institution of a multidisciplinary evidence-based cardiac stress testing protocol in an ED-based cardiac observation unit demonstrated good provider compliance and decreased treadmill nuclear stress testing. Intervention and control subjects had similar proportions of positive stress tests and 30-day composite adverse outcomes.

The incidence of severe sepsis is 750,000 cases per year in the U.S. and Canada, causing significant morbidity and mortality. Current guidelines from the Surviving Sepsis Campaign (SSC) recommend administering appropriate antibiotics within the first 3 hours of recognition of severe sepsis and septic shock; delayed antibiotic treatment is associated with increased morbidity. Best practice advisories (BPAs) are reminder tools within the Epic electronic health record (EHR) system that provide clinical decision support. This study aims to evaluate if BPAs are effective at detecting potentially septic patients in an emergency department (ED) setting. A structured retrospective review of medical records was conducted at an academic urban emergency department (annual visits >85,000) of patients who initially met systemic inflammatory response syndrome (SIRS) criteria after an electronic BPA was implemented (March 1, 2014 to March 30, 2014 and the first 7-day monthly period of April 1, 2014 to September 30, 2014). The BPA Sepsis Risk Scoring System was created based on the SSC guidelines and guided by the Detecting and Treating Sepsis manual from Epic Systems. A score >2.5 meant that a patient met SIRS criteria, is potentially septic, and triggered the BPA. The definitive diagnosis of sepsis for ED SIRS visits was based upon final diagnostic related group (DRG) coding and further established by imaging modalities, urinalysis, and physical exam findings on chart review. BPAs’ sensitivity, specificity, PPV, NPV was calculated and 95% confidence intervals (CI) established. Over the course of the study period, 13,906 records were screened, 565 BPAs fired and 313 cases of sepsis were confirmed (2.3% prevalence). The BPAs’ sensitivity and specificity was 74.5% (95% CI 69.2-79.1%) and 97.6% (95% CI 97.3-97.8%) respectively, with positive and negative predictive values of 41.2% (95% CI 37.2-45.4%) and 99.4% (95% CI 99.3-99.5%) respectively. The BPA’s positive and negative likelihood ratios (LR) (weighted for prevalence) were 0.70 (95% CI 0.62-0.79) and 0.006 (95% CI 0.005-0.008). No significant changes were noted in the BPA sensitivity or specificity when confined to severe sepsis or septic shock. BPAs were an effective EHR-based tool that detected potentially septic patients with moderate sensitivity and high specificity in our ED. The test’s high negative LR and negative predictive value make it valuable in excluding sepsis as differential diagnosis in a general ED population. Future directions for follow-up studies include cost analysis, morbidity/mortality studies, and multicenter comparisons of other quality metrics that can be improved by having a system such as BPA that reduces time to appropriate medical intervention.

During endotracheal intubation in the helicopter emergency medicine service (HEMS) setting, difficult airway visualization has led to higher complications associated with failed intubations. The Airtraq and the Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T.) are two FDA approved rescue airway devices that have been shown successful for difficult HEMS airway placement in mannequin studies. The primary goal of this pilot project was to determine the effectiveness of two alternative rescue devices (Airtraq and S.A.L.T.) for actual difficult airway intubations performed in the HEMS setting. This study utilized a structured retrospective chart review of HEMS charts from a large HEMS national agency during a difficult airway protocol implementation using either the Airtraq or S.A.L.T. devices. Prior to initation of the protocol, HEMS bases were stratified to use either the either Airtraq or S.A.L.T. device based on provider education levels, overall number of traumas, and similar pre-study successful intubation rates. Per protocol, after two missed attempts with a Macintosh/Miller laryngoscope, the airway was classified as difficult, and one of the rescue devices was used for two possible additional intubation attempts. If unsuccessful, the airway was deemed failed, and a King laryngeal tube was placed. The first attempt success of the rescue device, overall rescue device success, King laryngeal tube usage, Macintosh/Miller usage prior to intubation with rescue device, geographical information, health care personnel data, and complicating factors were recorded. Pearson Chi-square or Fisher's test was conducted for the univariate analysis, and logistic regression model was used for multivariate analysis. For all analyses, P < .05 was considered statistically significant. During the protocol timeframe (April 11, 2014 to December 31, 2014), the HEMS agency transported 26,532 patients with 1308 requiring intubation and 86 utilizing a rescue device; of which 84 met inclusion criteria and were analyzed. The overall difficult airway intubation success was higher using the Airtraq device compared to the S.A.L.T. device (71.2% vs 48.0%; P = .043). The Airtraq device had a non-significant increased trend of first attempt success compared to the S.A.L.T. device (55.9% vs 36.0%; P = .095). Potential confounding variables of airway success were investigated (cervical collar use, trauma mechanism, and CPR administration); however, the S.A.L.T. and Airtraq devices performed similarly. This pilot study showed significant differences between the Airtraq and the S.A.L.T. devices in overall intubation success. This suggests when intubating a difficult airway in the HEMS setting the Airtraq device is superior to the S.A.L.T. device in the HEMS setting. However, a larger prospective study is necessary to correlate and expand these findings.

BACKGROUND:Extracorporeal membrane oxygenation (ECMO) therapy has supported critically ill pediatric patients in the intensive care unit setting with cardiac and respiratory failure. This therapy is beginning to transition to the emergency department setting.OBJECTIVE OF REVIEW:This article describes the fundamentals of ECMO and familiarizes the emergency medicine physician with its use in critically ill pediatric patients.DISCUSSION:ECMO can be utilized as either venoarterial (VA) or venovenous (VV), to support oxygenation and perfusion in respiratory failure, sepsis, cardiac arrest, and environmental hypothermia.

Emergency physicians are required to evaluate and treat acute and complex patients with both skill and efficiency. The importance of teamwork in the busy and unpredictable emergency department (ED) setting has been described previously and various methods have been used to assess non-technical physician skills, such as communication and patient throughput. The purpose of this study is to examine how reliably ED nurses perceive EP efficiency and if there is a correlation between overall physician interpersonal skills and perceived/actual physician clinical productivity.

Background: A novel musical memory aid has been proposed for aiding laypersons in complying with the American Heart Association (AHA) cardiopulmonary resuscitation (CPR) guidelines of 100 compressions per minute (cpm). Objective: This study tested usefulness of such a memory aid to improve layperson long-term compliance with CPR compression rate guidelines. Methods: A prospective randomized controlled trial was conducted using CPR-untrained laypersons. Subjects received either a standard CPR educational experience (AHA Heartsaver (R) CPR class) or an experimental CPR educational experience (AHA Heartsaver (R) CPR class augmented with a musical metronome). Experimental group subjects were taught to perform compressions to the cadence of a pop music song (The Bee Gees "Stayin' Alive"; Saturday Night Fever, The Original Movie Soundtrack; Polygram International Music, 1977) with a tempo of 100 beats/min. Compression rates, depth of compressions, and correct compressions were measured initially and upon retesting >= 6 weeks post-training. Results: Control subjects had a higher mean compression rate both immediately (121 [standard deviation {SD} = 21] vs. 109 [SD = 15] cpm; 95% confidence interval [CI] of mean difference 4-19; p = 0.002) and at follow-up (120 [SD = 20] vs. 111 [SD = 13] cpm; 95% CI of mean difference 2-16; p = 0.014). Compression rates stratified to 100-120 cpm demonstrated no difference between groups initially (39% vs. 48%; p = 0.382), but more experimental subjects maintained these rates at follow-up (43% vs. 74%; p = 0.003). Conclusions: Subjects trained to use a musical metronome more often maintained a compression rate of 100-120 cpm at >= 6-week follow-up, suggesting the memory aid may improve long-term guideline adherence. (C) 2015 Elsevier Inc.

Purpose The population demographics found in many urban emergency departments (EDs) often mirrors those of children at risk for elevated serum lead levels. We evaluated the effectiveness of a verbal lead screening program for screening high-risk children presenting to the ED. Methods A prospective observational cohort study was conducted of children aged 9 months to 6 years, living in 2 target counties and presenting to an urban, academic, Midwestern ED. Those with a prior lead level, enrolled in a program requiring lead testing, or with an unstable medical condition were excluded. A 6-question validated verbal survey was administered to all parents of eligible children, and the results recorded in the patient’s electronic medical record. Children who screened positive were referred to their local health department for blood lead testing. Health department records were reviewed for follow-up visits and blood lead levels. Results During the study period, 3513 children were eligible (mean age, 2.6 years; 53.3% male), with 815 patients screened and 209 (25.6%) screening positive. Most positively screened patients (71.8%) documented only 1 affirmative question, most often indicating they lived in a home built before 1978. Of those children who screened positive, 14.8% (31/209) had a blood lead level performed within 6 months. Of those tested, 4 children had an elevated lead level (>10 µg/dL). Conclusions Use of an ED verbal lead exposure screening tool identified children requiring additional follow-up testing. However, health department–referred children had poor follow-up, and few children were ultimately documented with elevated lead levels.

Study ObjectivesMixed martial arts (MMA) is rapidly gaining acceptance as a combat sport, and is currently more popular than boxing amongst males 18-34 years. The sport allows athletes to use a hybrid of combat disciplines including boxing, martial arts, kickboxing, and wrestling, to either knock out, force an opponent to submit (give up), or win by judge's scorecard. Despite the sport's popularity, the overall injury patterns of MMA participants have not been well described. This study seeks to identify the general injury patterns associated with both amateur and professional MMA athletes in training and competition.MethodsA structured anonymous survey was posted as a link on several MMA sites and forums on the World Wide Web. Data was collected over a two-month period. Multiple choice, Likert scales (1 most negative and 5 most positive), and free-text answers were employed. Demographic data including sex, age, athlete class (amateur vs. professional), and experience were obtained; subjects were asked to identify up to ten of their most significant injuries in each body region. Injury data included body part, type of injury, medical care sought, and recovery time. Chi square test and Wilcoxon Two-Sample Test were conducted for categorical, continuous outcome variables, respectively. GEE model was used for adjusting for correlate data. SAS 9.2 was used for statistical analysis and p <0.05 was considered significant results.ResultsA total of 298 participants (97.6% male, median age of 30 years) were included in the final analysis. Most participants were amateurs (82.8%) participated in MMA for 6 or more years (26.6%) and trained 7-9 hours per week (32.7%). A total of 891 injuries were reported. The mean number of injuries reported were 3.0 (SD 4.6) and 58.4% of participants reported no injuries. The most common body parts injured were: head/face/neck (29.5%, n=263), leg/ankle/foot (20.2%, n=180), and upper extremity/arm (18.74%, n=167). The most common injury types were sprain/strain (23.3%, n=208), bruise/contusion (20.7%, n=184) and fracture (14.0%, n=125). Head injuries (concussion or knockout) represented 4.5% (40/891 injuries) of the total injuries, a rate of 1 head injury per 7.5 participants. A total of 195 injuries (22.2%) required immediate treatment or transport to the emergency department, 240 (34.1%) resulted in the inability to train for >1 week, and 5 (0.6%) of the injuries resulted in a permanent inability to train. Compared to all other injuries, head injuries trended towards more immediate treatment or transport to the emergency department (22.8% vs.42.5%; p=0.07; OR 1.8, 95% CI [0.95, 3.38]), but had no difference in the ability to train within 1 week or the permanent inability to train (14.6% vs. 12.5%; p=0.708; OR 1.2, 95% CI [0.45, 3.26]). There was no statistically significant difference for injury proportions by age, sex, height, weight, or time spent training. Professional athletes were 2.8 times more likely than amateur athletes to report an injury (p=0.0012, 95% CI [1.48, 5.28]).ConclusionsIn a national convenience sample of MMA athletes, injuries were common and most often represented sprains/strains and bruises/contusions to the head/face/neck and extremities. A small number of head injuries were reported; these did not result in more frequent immediate treatment or differ in recovery or disability rates. Professional athletes were more likely to report an injury than amateurs. Study ObjectivesMixed martial arts (MMA) is rapidly gaining acceptance as a combat sport, and is currently more popular than boxing amongst males 18-34 years. The sport allows athletes to use a hybrid of combat disciplines including boxing, martial arts, kickboxing, and wrestling, to either knock out, force an opponent to submit (give up), or win by judge's scorecard. Despite the sport's popularity, the overall injury patterns of MMA participants have not been well described. This study seeks to identify the general injury patterns associated with both amateur and professional MMA athletes in training and competition. Mixed martial arts (MMA) is rapidly gaining acceptance as a combat sport, and is currently more popular than boxing amongst males 18-34 years. The sport allows athletes to use a hybrid of combat disciplines including boxing, martial arts, kickboxing, and wrestling, to either knock out, force an opponent to submit (give up), or win by judge's scorecard. Despite the sport's popularity, the overall injury patterns of MMA participants have not been well described. This study seeks to identify the general injury patterns associated with both amateur and professional MMA athletes in training and competition. MethodsA structured anonymous survey was posted as a link on several MMA sites and forums on the World Wide Web. Data was collected over a two-month period. Multiple choice, Likert scales (1 most negative and 5 most positive), and free-text answers were employed. Demographic data including sex, age, athlete class (amateur vs. professional), and experience were obtained; subjects were asked to identify up to ten of their most significant injuries in each body region. Injury data included body part, type of injury, medical care sought, and recovery time. Chi square test and Wilcoxon Two-Sample Test were conducted for categorical, continuous outcome variables, respectively. GEE model was used for adjusting for correlate data. SAS 9.2 was used for statistical analysis and p <0.05 was considered significant results. A structured anonymous survey was posted as a link on several MMA sites and forums on the World Wide Web. Data was collected over a two-month period. Multiple choice, Likert scales (1 most negative and 5 most positive), and free-text answers were employed. Demographic data including sex, age, athlete class (amateur vs. professional), and experience were obtained; subjects were asked to identify up to ten of their most significant injuries in each body region. Injury data included body part, type of injury, medical care sought, and recovery time. Chi square test and Wilcoxon Two-Sample Test were conducted for categorical, continuous outcome variables, respectively. GEE model was used for adjusting for correlate data. SAS 9.2 was used for statistical analysis and p <0.05 was considered significant results. ResultsA total of 298 participants (97.6% male, median age of 30 years) were included in the final analysis. Most participants were amateurs (82.8%) participated in MMA for 6 or more years (26.6%) and trained 7-9 hours per week (32.7%). A total of 891 injuries were reported. The mean number of injuries reported were 3.0 (SD 4.6) and 58.4% of participants reported no injuries. The most common body parts injured were: head/face/neck (29.5%, n=263), leg/ankle/foot (20.2%, n=180), and upper extremity/arm (18.74%, n=167). The most common injury types were sprain/strain (23.3%, n=208), bruise/contusion (20.7%, n=184) and fracture (14.0%, n=125). Head injuries (concussion or knockout) represented 4.5% (40/891 injuries) of the total injuries, a rate of 1 head injury per 7.5 participants. A total of 195 injuries (22.2%) required immediate treatment or transport to the emergency department, 240 (34.1%) resulted in the inability to train for >1 week, and 5 (0.6%) of the injuries resulted in a permanent inability to train. Compared to all other injuries, head injuries trended towards more immediate treatment or transport to the emergency department (22.8% vs.42.5%; p=0.07; OR 1.8, 95% CI [0.95, 3.38]), but had no difference in the ability to train within 1 week or the permanent inability to train (14.6% vs. 12.5%; p=0.708; OR 1.2, 95% CI [0.45, 3.26]). There was no statistically significant difference for injury proportions by age, sex, height, weight, or time spent training. Professional athletes were 2.8 times more likely than amateur athletes to report an injury (p=0.0012, 95% CI [1.48, 5.28]). A total of 298 participants (97.6% male, median age of 30 years) were included in the final analysis. Most participants were amateurs (82.8%) participated in MMA for 6 or more years (26.6%) and trained 7-9 hours per week (32.7%). A total of 891 injuries were reported. The mean number of injuries reported were 3.0 (SD 4.6) and 58.4% of participants reported no injuries. The most common body parts injured were: head/face/neck (29.5%, n=263), leg/ankle/foot (20.2%, n=180), and upper extremity/arm (18.74%, n=167). The most common injury types were sprain/strain (23.3%, n=208), bruise/contusion (20.7%, n=184) and fracture (14.0%, n=125). Head injuries (concussion or knockout) represented 4.5% (40/891 injuries) of the total injuries, a rate of 1 head injury per 7.5 participants. A total of 195 injuries (22.2%) required immediate treatment or transport to the emergency department, 240 (34.1%) resulted in the inability to train for >1 week, and 5 (0.6%) of the injuries resulted in a permanent inability to train. Compared to all other injuries, head injuries trended towards more immediate treatment or transport to the emergency department (22.8% vs.42.5%; p=0.07; OR 1.8, 95% CI [0.95, 3.38]), but had no difference in the ability to train within 1 week or the permanent inability to train (14.6% vs. 12.5%; p=0.708; OR 1.2, 95% CI [0.45, 3.26]). There was no statistically significant difference for injury proportions by age, sex, height, weight, or time spent training. Professional athletes were 2.8 times more likely than amateur athletes to report an injury (p=0.0012, 95% CI [1.48, 5.28]). ConclusionsIn a national convenience sample of MMA athletes, injuries were common and most often represented sprains/strains and bruises/contusions to the head/face/neck and extremities. A small number of head injuries were reported; these did not result in more frequent immediate treatment or differ in recovery or disability rates. Professional athletes were more likely to report an injury than amateurs. In a national convenience sample of MMA athletes, injuries were common and most often represented sprains/strains and bruises/contusions to the head/face/neck and extremities. A small number of head injuries were reported; these did not result in more frequent immediate treatment or differ in recovery or disability rates. Professional athletes were more likely to report an injury than amateurs.