A proposal for prospective evaluation of elderly subjects with low Glasgow Coma Scale

Table 1

Patient demographics and Assault characteristics.

Correspondence / American Journal of Emergency Medicine 37 (2019) 9721004


Linda Rossman1 Stephanie Solis1

YWCA West Central Michigan Nurse Examiner Program, United States




1862 (83.3%)

372 (16.7%)

Age of victim, mean (SD)

25.2 (11.1)

26.3 (13.2)

marital status (% single)



No prior history of sexual intercourse



Alcohol or drug use b24 h



Last consensual intercourse b72 h



Time interval to exam, mean hrs (SD)

17.4 (7.0)

18.0 (9.3)

Police report filed



Known assailant



Multiple assailants



Type of coercion

restraint used



Use of weapons



Victim sleeping/drugged?



Type of sexual assault Vaginal












Nongenital injuries (%)



Anogenital injuries (%)?



Anogenital injuries, mean (SD)?

2.3 (1.7)

1.6 (1.2)

* Indicates significance at the p b 0.001 level.

Crosby Rechtin2 Colleen Bush2 Barbara Wynn2 Jeffrey Jones*

Department of Emergency Medicine, Michigan State University College of

Human Medicine, Grand Rapids, MI, United States Department of Emergency Medicine, Spectrum Health Hospitals, Grand

Rapids, MI, United States

Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids, MI

49503, United States.

E-mail address: [email protected].

10 September 2018


greater prevalence of documented anogenital injuries (76% vs. 62%, p b 0.0001). The localized pattern of anogenital injuries was similar in both cohorts; typically involving the fossa navicularis, followed by the posterior fourchette, labia and hymen. The most common type of injury in all patients was lacerations; however, whites had a greater incidence of documented erythema (32% vs. 23%, p b 0.001).

Despite the use of colposcopy with nuclear staining and digital imaging, forensic examiners in this community-based study con- sistently documented fewer anogenital injuries in black women. Our study limitations include retrospective study design, a single urban clinical center, and the variability in skin pigmentation across and within races and ethnicities. Recognizing that whites do not necessarily have low amounts of skin pigmentation and blacks a high amount of skin pigmentation, our findings suggest that individuals with darker skin may be at a disadvantage for in- jury identification despite colposcopy and nuclear staining tech- niques. In a similar study of sexual assault cases, Cartwright found that white women of all ages had almost twice as frequent anogenital injuries as black women [4]. Sommers et al. also found a significant association between race (black vs white) and Genital injury in a community sample of sexual assault survivors and con- cluded that the odds for genital injury among whites was more than four times greater than blacks [5]. Coker and colleagues found that among male sexual assault survivors, their race (being white) was significantly associated with traumatic Physical injury [6].

An alternative explanation for our findings is that sexual assault

in white victims was associated with more Violent behavior. How- ever, the victim demographics were similar regarding weapon use, location, victim incapacitation, multiple assailants, or known assail- ant (Table 1). An alternative but less likely explanation is that differ- ences may exist that make skin of some populations more resistant to injury than other populations. This has not been well studied in the medical literature. Further prospective work is needed to under- stand the racial/ethnic differences in genital injury prevalence and to

Sommers MS, Zink TM, Fargo JD, Baker RB, Buschur C, Shambley-Ebron DZ, et al. Fo- rensic sexual assault examination and genital injury: is Skin color a source of health disparity? Am J Emerg Med 2008;26(8):857-66.
  • Baker RB, Fargo JD, Shambley-Ebron DZ, Sommers MS. Source of healthcare disparity: race, skin color, and injuries after rape among adolescents and young adults. J Foren- sic Nurs 2010;6(3):144-50.
  • Slaughter L, Brown CRV. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol 1992;166(1):83-6.
  • Cartwright P. Factors that correlate with injury sustained by survivors of sexual as- sault. Obstet Gynecol 1987;70(1):44-6.
  • Sommers MS, Zink TM, Baker RB, Fargo JD, Porter J, Weybright D, et al. Effects of age and ethnicity on physical injury from rape. J Obstet Gynecol Neonatal Nurs 2006;35 (2):199-207.
  • Coker AL, Walls LG, Johnson JE. Risk factors for traumatic physical injury during sexual assaults. J Interpers Violence 1998;13(5):605-20.
  • A proposal for prospective evaluation of elderly subjects with low Glasgow Coma Scale

    The favourable outcomes reported following Traumatic brain injury [1] will enhance optimisation of the management of patients of mean age 36 (Standard Deviation 14) with Glasgow coma scale (GCS) 4-5. The same will be true of patients of mean age 24 (Standard Deviation 23) with GCS 1-3. What we now need is a similar study to be conducted in patients aged 65-85 with traumatic brain injury. In a previous retrospective study which enrolled 66 patients with traumatic intracranial haematomas in that age group, all 18 patients with GCS of 4 or less, and all 22 patients with unilateral or bilateral non-reactive pupillary dilatation had a poor out- come. However, that study did not identify how many patients with bilat- eral fixed dilated pupils belonged to the category of GCS 4 or less [2].

    Thanks to increasing uptake of oral anticoagulants in nonvalvular atrial fibrillation [3] we should anticipate an increase in incidence of in- tracranial bleeding attributable to traumatic brain injury. The manage- ment of elderly patients who incur that complication will need to be informed by results from prospective studies which focus on elderly subjects with GCS 4 or less so as to validate or refute criteria for surgical intervention [2,4] used in those patients.

    In the latter retrospective study of 112 consecutive patients aged 65 or more with traumatic intracranial haematoma (TIH), surgery was per- formed in 70. Multivariate logistic regression analysis revealed that GCS of 5 or less was significantly (P b 0.001) associated with unfavourable out- come. Nevertheless, patients undergoing surgery were significantly (P b

    determine if these differences are related to lack of sensitivity of the

    current forensic exam procedures or innate differences in the prop- erties of the skin.

    1 MSN, 25 Sheldon Blvd. SE, Grand Rapids MI 49503, United States.

    2 15 Michigan St NE Suite 701, Grand Rapids, MI 49503, United States.

    976 Correspondence / American Journal of Emergency Medicine 37 (2019) 9721004

    0.001)less likely to have an unfavourable outcome (52.9% vs 95.2%) at 6 months after injury compared with patients managed conservatively [4].


    I have no funding and no conflict of interest.

    Oscar M.P. Jolobe, MRCP(UK)

    Manchester Medical Society, Simon Building, Brunswick Street, Manchester

    M13 9PL, United Kingdom

    Flat 6 Souchay Court, 1 Clothorn Road, Manchester M20 6BR, United


    E-mail address: [email protected].

    4 September 2018


    1. Sadaka F, Jadhav A, Miller M, Saifo A, O’Brien J, Trottier S. Is it possible to recover from traumatic brain injury and a Glasgow Coma Scale score of 3 at emergency department presentation? Am J Emerg Med 2018;36:1624-6.
    2. Jamjoon A, Nelson R, Stranjalis G, Wood S, Chissell H, Kane N, et al. Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly. Br J Surg 1992;6:27-32.
    3. Cowan JC, Wu J, Hall M, Orlowski A, West RM, Gale C. A 10 year study of hospitalised atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation. Eur Heart J 2018;39:2975-83.
    4. Wan X, Liu S, Wang S, Zhang S, Yang H, Ou Y, et al. Elderly patients with severe trau- matic brain injury could benefit from surgical treatment. World Neurosurg 2016;89: 147-52.

      Unsupervised toothbrushing: Risk of airway injury in young children

      Despite being an important personal hygiene tool, the toothbrush has the ability to cause significant injury. Oral airway injuries from im- palement can be the most serious and even life-threatening [1,2]. Youn- ger children are often injured [3-5] and the severity of the injuries may require multiple medical specialties. Several recent visits to our emer- gency department where children were injured by improper use of toothbrushes have occurred. One in particular required rapid surgical management due to carotid artery proximity.

      A literature search was performed in PubMed as described by Olivera et al. except limiting the results to publications since 2014, which returned 12 results [5]. PubMed was queried with the following search terms: “(toothbrush*) AND ((“2014/01/01” [PDat]: “2018/12/ 31″ [PDat]))” returning 1324 results (performed 03/2018). These were imported to EndNote (Clarivate Analytics, Philadelphia, PA). Titles and keywords were queried with the following terms: injur*, trauma, for- eign, case, adverse, airway, and pharyn* returning 171 publications. These publications were manually screened by title and abstract. Bibli- ographies were screened for additional reports. The majority of the resulting 29 publications contained reports of damage to the airway [1-4,6-16] from toothbrush injury (Fig. 1). Other major contributors were ingestion [17-25], epilepsy [26,27], and others [28-30]. The me- dian age of case reports involving oral/airway injuries from a toothbrush was 2.1 years old (range: 1 year to 45 years old).

      The National Electronic Injury surveillance System (NEISS) database

      was used to query oral airway injuries involving toothbrushes present- ing to the ED. This included cases from January 1, 2006 – December 31, 2016 (search performed 03/2018). The search included a product codes of 1608 (“powered toothbrush or oral irrigator”) and 1629 (“nonelectric toothbrush”), or a screening of “toothbrush,” “brushing teeth,” “brushing his teeth,” or “brushing her teeth” in the free-text narrative.

      Fig. 1. Pubmed database search outcomes of toothbrush injuries resulted in 4 major categories of reports after literature selection.

      Fig. 2. The NEISS estimated emergency department visit for toothbrush injury from 2006 to 2016 (95% confidence limits shaded).

      The NEISS database revealed a nationwide estimate of 8566 oral/air- way injuries (95% confidence interval: 6988-10,144) in the ten years queried based on 257 incidences reported by the NEISS database (Fig. 2). There was a steep drop in incidences beginning in 2011. This de- cline should not be interpreted as a drastic change to injury rates or a vast nationwide-improvement of oral hygiene routine supervision.

      Table 1

      The demographics of the NEISS database query are summarized, along with information about discharge information.

      N (%)

      Sex Male

      124 (48.2)


      133 (51.8)

      n.s. (P = 0.57)

      Age 0-4

      162 (63.0)


      42 (16.3)


      45 (17.5)


      8 (3.1)

      (P b 0.001)

      Race White

      115 (44.7)


      40 (15.6)


      17 (6.6)


      6 (2.3)


      7 (2.7)

      Not stated

      72 (28.0)


      Treated in ED and released

      225 (87.5)

      Treated in ED and admitted 26 (10)

      Treated in ED and transferred 1 (0.4)

      Held for observation 1 (0.4)

      Left without being seen 4 (1.6)

      Fatality 0

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