Journal Reviews

Borglund ST, Hayes JS, Eckes JM. Florida’s bicycle helmet law and a bicycle safety educational program: Did they help? J Emerg Nurs 1999; 25:496-500.

After a mandatory law was passed in Florida for helmet use in bicycle riders under 18, helmet used increased, but remains too low, according to a study from Broward General Medical Center in Fort Lauderdale, FL. Researchers studied the effectiveness of Florida’s mandatory helmet law and a community bicycle safety program and found that helmet use rose from 5.6% to 20.8%. Children aged 10 to 12 years, who were targeted most heavily in the bicycle safety programs, had the greatest increase in helmet use (27%).

"Although this increase was significant, the fact remains that nearly 80% of the children admitted with injuries from bicycle crashes were not helmeted," say the researchers. "The number of nonhelmeted children remains much too high."

The type and extent of head injuries sustained in bicycle crashes also was evaluated, with injury severity scores higher for nonhelmeted children.

A community bicycle safety campaign promoting helmet use also contributed to increased helmet use, according to the study. The program was developed and implemented by ED nurses a year before the helmet law was enacted. In the ED, bicycle crash victims were given helmet safety packets, and a video about bicycle safety and helmet use was shown before discharge. If children indicated that they would wear a helmet if they could afford them, they were given helmets at no cost. Education programs increasing community awareness of the importance of bicycle helmet use among children, their parents, and other concerned adults remain an important adjunct to bicycle helmet laws, according to the researchers: "Nurses caring for bicycle crash victims and their families need to continue their efforts at the workplace and in the community to promote the use of bicycle helmets."

Grossman SA, Richards CF, Anglin D, et al. Caring for the patient with mental retardation in the emergency department.

Ann Emerg Med 2000: 35:69-76.

Many ED clinicians are uncomfortable interacting with patients with mental retardation, which has implications for assessment and management of those patients in the ED, according to this research from Brigham and Women’s Hospital in Boston and University of Southern California Medical Center in Los Angeles.

Because of de-institutionalization of patients with mental retardation, EDs are increasingly managing those patients; therefore, the comfort level should be increased to improve care, say the researchers. Here are key points of the guidelines for management of patients with mental retardation recommended by the researchers:

• In the ED, a concerted effort should be made to evaluate the patient in a quiet area with as few distractions as possible.

• When health care providers enter the room of patients with mental retardation, they should specifically introduce themselves to both the patients and their family or caregivers.

• During the physical examination, the patient should be assessed for signs of abuse, as these patients are at increased risk for abuse because of their dependency on their caregivers and the stressful demands placed on their caregivers. Also, patients may be incapable of comprehending, verbalizing, or even reporting abuse.

• Because patients with mental retardation already may have some baseline abnormalities in their neurologic function, indications for lumbar puncture and computed tomography might be subtle.

Invasive examinations, tests, and procedures, when performed on some apprehensive or anxious patients with mental retardation, might not be safe for the patient or the practitioner. Therefore, some form of sedation is often indicated. Examples include vaginal examinations, lumbar punctures, computed tomography scans, chest tube placement, peritoneal lavage, and dislocation or fracture reductions.

Hovanessian HC. New-generation anticoagulants: The low molecular weight heparins. Ann Emerg Med 1999; 34:768-779.

Low molecular weight heparins (LMWHs) are efficacious, safe, cost-effective, and easier to administer and monitor than standard heparin, according to this study from University Medical Center in Fresno, CA, and St. John’s Health Center in Santa Monica, CA. These new agents will be used in the ED instead of unfractionated heparin for unstable angina, non-Q-wave myocardial infarction, or thromboembolic disease. (For more information on LMWHs, see ED Nursing, July 1999, p. 113.)

In the ED, LMWHs soon will become indispen- sable tools, say the researchers. Currently, enoxaparin (Lovenox) and dalteparin (Fragmin, in combination with aspirin) are indicated for use in selected acute ischemic coronary syndromes — clinical situations that are managed on a daily basis in the ED, the study notes.

LMWHs are also efficacious in the treatment of venous thromboembolic disease, with evidence more compelling in the case of deep-vein thrombosis (DVT) than pulmonary embolism. Enoxaparin has recently gained Food and Drug Association approval for treatment of established DVT, as well as pulmonary embolism, note the researchers.

"As such, familiarity with this class of drugs is of paramount importance because treatment for venous thromboembolic disease is frequently initiated in the ED," the researchers say. The ease of administration of LMWHs, with once-daily dosing and no stringent requirements for monitoring, their relatively infrequent rate of complications, and their potential cost-effectiveness make those agents an attractive alternative to unfractionated heparin use.