Volume 173 Issue 4

Research Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis Anthony J Bell, Janet K Talbot-Stern and Annemarie Hennessy MJA 2000; 173: 179-182 For editorial comment, see Close & Glucksman Abstract - Methods - Results - Discussion - References - Authors' details - - More articles on Emergency medicine Abstract Objectives: To study older patients presenting to the emergency department after a fall -- factors associated with the fall, injuries sustained and outcome. Design: A retrospective analysis using the Emergency Department Information System (EDIS), the Trauma Registry and the patient information database (CCIS), in addition to the patient's emergency and inpatient medical records. Setting: Emergency department of a major inner city teaching hospital, 1 June - 30 November 1997. Patients: All patients over 65 years presenting to the emergency department (ED) after a fall, for whom complete medical records were available. Results: Of 803 patients over 65 years presenting to the ED after a fall, complete records were available for 733 (91.3%) (283 men and 450 women). Extrinsic (accidental) causes were implicated in more than a third of falls (313 patients [42.7%]). A high proportion of the patients were living at home (520; 70.9%) and walking unaided (389; 53.1%). Although absolute numbers of women increased with age, men were as likely as women to present after a fall. Many patients had fallen before -- 39% of the men (111/283) and 24% of the women (110/450). In 78 patients (10.6%), alcohol misuse may have been a direct cause of the fall. The overall injury rate was 70.5% (517/733 patients), the most common injury being an isolated fracture (269/517 patients; 52.0%). In all, 419 patients (57.2%) were admitted to hospital, 48% (200/419) with a fracture and 52% (219/419) for investigation of the medical cause of the fall. The median length of hospital stay was 6 days (mean, 10.4 days; range, 1-129 days); 35% (146/419) of patients were in hospital for more than 10 days. Conclusion: Older patients presenting to the ED after a fall had high injury rates, high admission rates and often prolonged hospitalisation. About a third had fallen before. Patients at risk can be identified in the ED and referred to falls prevention programs. Census data for 1996 show that 12.1% of Australians are aged 65 years or over.1 This proportion is expected to double in the next 40 years,2 with major implications for healthcare costs. Alone, the cost of falls in patients over 70 years in Australia was estimated to be $398 million in 1989.3In the United States, trauma causes a considerable proportion of presentations (and subsequent hospital admissions) of older patients. Falls account for most of these presentations.4 The annual incidence of all falls increases from 25% at age 70 years to 35% after the age of 75; the risk increases with age and is higher among those living in long-stay institutions.5 Up to 10%-15% of falls result in serious injury, of which at least half are fractures. Even falls not resulting in injury may have serious psychological consequences.5,6 The "postfall anxiety syndrome"7 and fear of falling leads to decreased activity,8 and ultimately an increased risk of future falls.9 Patients have reported continued disability two months after a fall.10 No Australian report has been published specifically about patients in this age group presenting to the emergency department (ED) after falls, although previous studies have looked at older people presenting to the ED.11,12 Our aim was therefore to focus on patients over 65 years who presented to our ED as a result of a fall. Several features were of interest: why the patients fell; what, if any, injuries were sustained; what proportion of patients required admission to hospital; and what morbidity and mortality resulted from the fall. Methods Royal Prince Alfred Hospital is a 700-bed tertiary referral centre with 60 000 admissions and 45 000 ED attendances per year. A retrospective review of attendances for the six-month period June - November 1997 was undertaken. All older patients who had fallen were eligible for the study. Patient data Data were obtained from the sources below and thereafter patients remained anonymous. EDIS: Patients eligible for the study were identified by a search of the EDIS (Emergency Department Information System) for "falls" in the age group chosen. EDIS is a computerised database in the ED with demographic information, presenting complaint, diagnosis and disposition for each patient. Medical records: A predetermined dataset was recorded from the medical record for each patient presenting to the ED. This included medical record number, age, sex, type of residence (home, hostel or nursing home), prefall mobility, nature of fall, alcohol misuse, recurrent fall, referral status, triage category, injury score, specific area of the body injured, fracture, admission, specialty, length of stay, mortality, and discharge disposition. Prefall mobility was further defined as unaided versus aided (use of a stick, frame, crutches, assistance by another person) versus unknown. Trauma Registry: Additional data were obtained from the hospital's Trauma Registry. An Injury Severity Score (ISS) is calculated for patients requiring admission after trauma. ISS is the sum of the squares of the highest Abbreviated Injury Scores (an anatomical system classifying injuries by body region on a scale of 1 [minor] to 6 [serious]) for the three most seriously injured body regions. ISS ranges from 1 (minor injury) to 75 (severe injury).13 CCIS: For patients transferred to an affiliated geriatric and rehabilitation hospital, the patient information database (CCIS [Central Sydney Area Health Service Clinical Information System]) was accessed for the length of stay. None of the patients in our study were transferred to non-affiliated geriatric and rehabilitation hospitals. Population data: The Australian Bureau of Statistics supplied population data for the hospital's catchment area.14 Definitions Fall: "Inadvertently coming to rest on the ground or other lower level with or without loss of consciousness."15 Extrinsic (accidental) causes: Environmental factors (eg, rugs, steps, uneven floors). Falls as a result of external trauma, such as motor vehicle accidents and violence, were excluded. Intrinsic (non-accidental) causes: Syncope, dizziness or vertigo, postural drop, central nervous system lesion (haemorrhage or infarct), drop attack, and balance or gait disturbance. Alcohol misuse: A history of alcohol misuse related temporally to the event, a record of alcohol on the breath, or a statement in the ED record about the patient's being intoxicated. Statistical analysis We used Minitab Statistical Software16 for statistical analysis and performed χ2 tests. Analysis was based on age group or sex and compared with a number of variables: presentation as a result of a fall, nature of the fall, outcome of a fracture, and admission status. A multivariate analysis was performed on four aspects of the falls considered to be related to place of residence or mobility: extrinsic cause, recurrent falls, fracture/no fracture and admission. Odds ratios (95% CI) were calculated for each of these groups. Multivariate analysis was also used to calculate odds ratios (95% CI) for whether alcohol use contributed to selected outcomes: admission (yes/no), extrinsic or recurrent falls versus other falls, and age under or over 80 years. Results Patient characteristics Of a total of 22 782 patients presenting to the ED during the six-month study period, 4489 (19.7%) were patients older than 65 years and 803 (17.8%) of these patients presented as a direct consequence of a fall. Of these patients, 733 (91.3%) had medical records available for review at the time of analysis and complete for the purposes of the dataset. Age and sex: The average age was 78.6 years (range, 65-101 years) and the median age was 79 years: 263 patients were aged 65-74 years, 279 were 75-84 years and 191 were 85 years or older. Increasing age of the patients was associated with presenting to the ED as a result of a fall (χ2 test for trend, P < 0.001) (Box 1). There were 283 men and 450 women. However, the number of men and women presenting to the ED after a fall reflected the age and sex distribution within the catchment population (Box 2). Thus, men were as likely as women to present as a result of a fall. Residence: At the time of the fall, 83% (211/253) of the 65-74 year olds, 74% (200/269) of the 75-84 year olds and 57% (109/191) of those over 85 years were living in their own homes. Thus, the proportion of those living in either a hostel or a nursing home increased with advancing age. In 20 patients residence could not be classified. Previous falls: 39% of the men (111/283) and 24% of the women (110/450) had fallen before. Mobility: Patients were classified according to mobility: walking aided or unaided. As expected, as the patients aged the use of a walking aid increased. Cause of fall Extrinsic or intrinsic: Overall, extrinsic causes for the fall accounted for 42.7% of patients presenting to the ED. In the age group 65-74 years extrinsic causes accounted for 49.4% of falls, which is more than expected when compared with the proportion in the older age groups (39.0% and 38.7%, respectively). Intrinsic causes were more likely with advancing age (χ2 test; P = 0.018) and accounted for 50.5% (95% CI, 45%-57%), 60.9% (95% CI, 55%-67%) and 64.2% (95% CI, 54%-68%) of falls in the respective age groups. The breakdown of all causes for falls presenting to the ED is shown in Box 3. Despite extensive review of the medical records we were unable to classify 23% of falls as either extrinsic or intrinsic. Alcohol misuse: This was documented in 78 patients (10.6%): 18% of the 65-74 year olds, 10% of the 75-84 year olds, and was not a factor in those over 85 years (χ2 test; P = 0.001). Sixty-five (83%) of these patients were living in their own homes. Multivariate analysis for alcohol misuse at the time of fall showed it to be significantly associated with an increased risk of both accidental and recurrent falls (Box 4). Outcomes Injury: 517 (70.5%) patients sustained an injury as a result of the fall: 73.3% (379/517) had an ISS of 4 or less (a score of 9 correlated with a femoral fracture); 13 patients had scores between 15 and 25, with all of these patients (except one with spinal cord compression) sustaining intracranial injury. The most common injuries were fractures (36.7%), soft tissue injuries (16%), lacerations and skin tears (14.5%). Fracture: 269 patients (36.7%) sustained a fracture: 36% (98/269) of which were neck-of-femur fractures, 16% fractured wrists, 12% fractured humeral neck and 5% pelvic fractures. The breakdown of fractures in each group is shown in Box 5. Women sustained both neck-of-femur and all fractures more frequently than men (χ2 test; P < 0.001): 64% (63/98) of femoral-neck fractures and 73% (125/171) of all other fractures (95% CI, 66%-80%). Interestingly, in women, the proportion of fractured neck of femur to all fractures was 33.5% (63/188) (95% CI, 27%-40%), whereas in men it was 43% (35/81) (95% CI, 32%-54%). Fracture rate overall was not found to be related to advancing age in either sex. Admission: The total number of patients admitted to hospital was 419, or 57.2% of all older patients with falls (representing 38% of all older patients admitted during the study period). Sixty-three per cent of those 85 years or older were admitted, compared with 60% of the 75-84 year olds and 50% of the 65-74 year olds (χ2 test; P = 0.009). Of the 269 patients with fractures, 200 (74%) were admitted. There was no statistically significant difference in the fracture admission rate across the age groups (χ2 test; P = 0.53). Of the 200 patients admitted, in 49% the cause of the fracture was intrinsic. Patients admitted to hospital after a fall had a mean length of stay of 10.4 days (95% CI, 10.2-10.6) and a median stay of 6 days (range, 1-129 days). Hospitalisation for more than 10 days was necessary in 35% (146/419) of patients. Deaths: Thirty-two patients died in hospital, representing 4.4% of all patients presenting to the ED after a fall: half of those who died were over 85 years of age and half were from nursing homes. In those who died, the cause of the fall was intrinsic rather than extrinsic (27/32), and the most common injury was a fracture of the neck of the femur (10/32). Data analysis: Multivariate analysis of place of residence or mobility and extrinsic cause, recurrent falls, fracture/no fracture and admission showed no significant interaction. Discussion We found that older patients presenting to the ED after a fall had a high injury rate (71%), high admission rates (57%) and often prolonged hospitalisation (> 10 days in about a third of those admitted). Our study complements others performed in Australia and elsewhere on older patients who fall, particularly those who present to an ED.11,12Some studies have found that women in the community fall more frequently than men,17 and others, as we did, found no difference.18 Institutionalised patients have been reported to have higher fall rates than patients living at home,17,19 but most of our patients lived at home and walked unaided. Falls may be caused by an environmental hazard alone or a simple syncopal event, or there may be a complex interaction of environment, physical illness, and type of activity. Changes in vision, vestibular function and proprioception affect physical stability, and musculoskeletal changes affect gait. Postural hypotension from dehydration, drug effects or autonomic dysfunction may be involved. Additionally, acute illness such as respiratory tract infection, arrhythmias, carotid sinus hypersensitivity,20 cardiac failure and neurological problems (eg, Parkinson's disease) may increase the risk of falling. All these intrinsic factors may be compounded by environmental hazards.5,6,17 We found gait disturbance, syncope, central nervous system lesion, postural hypotension and dizziness to be the most common intrinsic causes, and these were statistically more likely to be the underlying reason for a fall as age increased. The proportion of patients with falls in association with alcohol misuse contrasts with the findings of Adams et al.21 They surveyed older patients over an eight-week period for alcohol use, and found a negative relationship between alcohol use and falls. A high proportion of our patients with alcohol misuse lived at home, with perhaps easy access to alcohol. These patients had a greater risk of extrinsic and recurrent falls, a potential relationship that warrants further study. A UK study found that most falls in the community do not result in serious injury.17 We found that patients presenting to the ED after a fall have a high rate of injuries, consistent with previous reports,17,22 but the rate was significantly higher than that found by Tinetti et al.23 We found women to be statistically more likely to suffer a fracture than men. Grisso et al,10 in an older inner-city population in the United States, found that women generally had higher rates of fall injury than men. In addition, they found that injury rates increased with advancing age, a finding that we could not confirm. There were fewer hip fractures in older men than older women in our study, confirming previous findings.24 This is probably related to the higher prevalence of osteoporosis in women. Previous reports have shown that older men with hip fracture have higher mortality rates than age-matched women.23 The high admission rate in our study, which increased in older patients, is only slightly higher than that found by Richardson,11 but this was in patients over 75 years, in whom a higher admission rate is expected. A UK study found admission was needed in only 34% of patients.22 Admission rates for patients with a fracture did not vary significantly across our three age groups, nor were they different according to place of residence or prefall mobility. Length of hospital stay similarly did not depend on place of residence or prefall mobility, differing from the Richardson study, in which a significant relationship was found between accommodation status and outcome at 90 days.11 US studies report that 75% of deaths after a fall occur in patients over 65 years.6 We found that the single most important factor associated with death was hip fracture, a finding similar to that in previous studies.7,11 Modification of the environment and dealing with intrinsic problems such as drug side effects and gait dysfunction can reduce falls,25-27 prevent hospitalisation26 and shorten length of stay.15 If 95% of problems can be identified from the history and physical examination alone, as suggested by Rubenstein et al,15 the emergency physician is well able to identify those patients at risk of further falls. Intrinsic causes can be treated and the patient's general practitioner or specific falls prevention programs can then proceed to modify the risk of recurrence. References Australian Bureau of Statistics. Australia in brief (Census data, 1996). Canberra: ABS, 1998. <www.abs.gov.au> Davis JA. Older Australia: a positive view of ageing. Sydney: Harcourt Brace, 1994. Smith RD, Widiatmoko D. The cost-effectiveness of home assessment and modification to reduce falls in the elderly. Aust N Z J Public Health 1998; 22: 436-440. Spaite DW, Criss EA, Valenzuela TD, et al. Geriatric injury: an analysis of prehospital demographics, mechanisms and patterns. Ann Emerg Med 1990; 19: 1418-1421. Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med 1989; 320: 1055-1059. Nelson RC, Murlidhar AA. Falls in the elderly. Emerg Med Clin North Am 1990; 8: 309-324. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994; 121: 442-451. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls: a prospective study. JAMA 1989; 261: 2663-2668. Gostynski M, Ajdacic-Gross V, Gutzwiler F, Michel JP. Epidemiological analysis of accidental falls by the elderly in Zurich and Geneva. Schweiz Med Wochenschr 1999; 129: 270-275. Grisso JA, Schwarz DF, Wishner AR, et al. Injuries in an elderly inner city population. J Am Geriatr Soc 1990; 38: 1326-1331. Richardson DB. Elderly patients in the emergency department: a prospective study of characteristics and outcome. Med J Aust 1992; 157: 234-239. Stathers GM, Delpech V, Raftos JR. Factors influencing the presentation and care of elderly people in the Emergency Department. Med J Aust 1992; 156: 197-200. Baker SP, O'Neill B, Haddon W. The Injury Severity Score. J Trauma 1974; 14: 187. Needs Assessment and Health Outcomes Unit. A demographic profile of the Central Sydney Area Health Service from the 1996 Census. Sydney: Central Sydney Area Health Service, March 1998. Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL. The value of assessing falls in an elderly population: a randomised clinical trial. Ann Intern Med 1990, 113: 308-316. Minitab Statistical Software [computer program], version 12. State College, Pa: Minitab Inc, 1998. Blake AJ. Falls in the elderly. Br J Hosp Med 1992; 47: 268-272. Campbell AJ, Borrie MJ, Spears GF, et al. Circumstances and consequences of falls experienced by a community population 70 years and over in a prospective trial. Age Ageing 1990; 19: 136-141. Cummings SR, Nevitt MC. Falls [editorial]. N Engl J Med 1993; 331: 872-873. Ward CR, McIntosh S, Kenny RA. Carotid sinus hyersensitivity -- a modifiable risk factor for fractured neck of femur. Age Ageing 1999; 28: 127-133. Adams WL, Magruder-Habib K, Trued S, Broome HL. Alcohol abuse in elderly Emergency Department patients. J Am Geriatr Soc 1992; 40: 1236-1240. Davies AJ, Kenny RA. Falls presenting to the Accident and Emergency Department: types of presentation and risk factor profile. Age Ageing 1996; 25: 362-366. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319: 1701-1707. Diamond TH, Thornley SW, Sekel R, Smerdely P. Hip fracture in elderly men: prognostic factors and outcomes. Med J Aust 1997; 167: 412-414. Province MA, Hadley EC, Hornbrook MC, Lipsitz LA. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. JAMA 1995; 273: 1341-1347. Close J, Ellis M, Hooper R, Glucksman E. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93-97. Tinetti ME, Baker DI, McAvay G, Claus EB. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331: 821-827. (Received 10 Aug 1999, accepted 29 May 2000) Authors' details Department of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, NSW. Anthony J Bell, MB BS, Emergency Medicine Registrar. Janet K Talbot-Stern, MD, FACEM, FACEP, Director, Emergency Department; and Clinical Senior Lecturer, Department of Surgery, University of Sydney. Department of Medicine, University of Sydney, Sydney, NSW. Annemarie Hennessy, MB BS, PhD, Senior Lecturer. Reprints will not be available from the authors. Correspondence: Dr A J Bell, Department of Emergency Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. Make a comment 1: Patients presenting to the emergency department, by age group, June - November, 1997 65-74 years (n=2060) 75-84 years (n=1672) ≥85 years (n=757) Total (n=4489) Presentation after a fall Other presentations 295 (14.3%) 1765 317 (19.0%) 1355 191 (25.2%) 566 803 (17.9%) 3686 χ2 test for age trend (P<0.001). Back to text 2: Age and sex distribution of patients presenting to the emergency department after a fall compared with the catchment population 65-74 years 75-84 years ≥85 years Men Presentation after a fall Proportion of catchment population 124/263 (47%) 15415/32185 (47.9%) 107/279 (38%) 7251/18448 (39.3%) 52/191 (27%) 1650/6038 (27.3%) Women Presentation after a fall Proportion of catchment population 139/263 (53%) 15770/32185 (49.0%) 172/279 (62%) 11187/18448 (60.6%) 139/191 (73%) 4388/6038 (72.7%) Back to text Back to text 4: Multivariate analysis (logistic regression) of alcohol misuse and selected variables in older patients presenting to the emergency department after a fall Variable Alcohol misuse odds ratio (95% CI) Age at presentation 5.5 (2.8-10.6) Extrinsic cause of fall 1.72 (1.05-2.83) Recurrent falls 2.24 (1.35-3.72) Back to text 5: Fractures in older patients presenting to the emergency department after a fall, by age group (years) Fracture 65-74 (n=263) 74-85 (n=279) >85 (n=191) Total (n=733) Neck of femur 28 (11%) 37 (13%) 33 (17%) 98 (13.4%) Other 74 (28%) 59 (21%) 38 (20%) 171 (23.3%) No fracture 161 (61%) 183 (66%) 120 (63%) 464 (63.3%) Back to text

Anthony J Bell · Janet K Talbot-Stern · Annemarie Hennessy

Public Health Driveway motor vehicle injuries in children Andrew J A Holland, Rhea W Y Liang, Shailinder J Singh, David N Schell, Frank I Ross and Daniel T Cass MJA 2000; 173: 192-195 Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Paediatrics Abstract Objectives: To describe the frequency, nature and outcome of driveway injuries in children. Design: Retrospective case series of driveway-related injuries in children under 16 years of age admitted to the New Children's Hospital (NCH), New South Wales, from November 1995 to February 2000, and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry from January 1988 to December 1999. Main outcome measures: Circumstances of injury; type and number of injuries identified. Results: 42 children were admitted to our institution with driveway-related injuries over four years and four months. These represent 12% of all children admitted with pedestrian motor vehicle injuries. Fourteen deaths (including one of the children admitted to NCH) were reported to the NPTD Registry over 12 years, accounting for 8% of all paediatric pedestrian motor vehicle deaths reported to the registry. Typically, the injury involved a parent or relative reversing a motor vehicle in the home driveway over a toddler or preschool-age child in the late afternoon or early evening. Four-wheel-drive or light commercial vehicles were involved in 42% of all injuries, although they accounted for just 30.4% of registered vehicles in NSW. These vehicles were associated with a 2.5-times increased risk of fatality. In 13 of the 14 deaths, the cause was a severe head injury not amenable to medical intervention. Conclusions: Driveway injuries in children account for a significant proportion of paediatric pedestrian motor vehicle injuries and deaths in NSW. Prevention represents the only effective approach to reducing deaths from this cause. Trauma is the leading cause of death and disability in children after the first year of life.1 In children with major injuries (defined as an Injury Severity Score2 greater than 15), motor vehicle accidents have consistently been the most common cause of injury.3-6 Within this group, children as pedestrians frequently suffer the most severe injuries as a consequence of their small size in relation to motor vehicles.3,4,7 As paediatric pedestrian motor vehicle injuries predominantly involve young school-age children,8,9 conventional prevention campaigns have been directed toward these age groups.3,9,10A recognised clinical scenario in children is traumatic asphyxia with associated visceral injuries resulting from low-velocity compression of the torso.11,12 Typically, a motor vehicle reverses over a toddler or older pre-school child in a driveway or car park.7,13 In these cases, the pliability of a child's skeleton and soft tissues, together with the ability of the applied force to be distributed over the short time of the impact, often allows a good outcome.7,12,13 This clinical scenario has been variously termed the driveway, back over, crush, non-traffic or low-velocity motor vehicle injury in the United States, but has not been well described in Australia.4,6,13-18 We examined the experience of the New Children's Hospital, Westmead, (NCH) with driveway injuries, together with a review of cases reported to the New South Wales Paediatric Trauma Death (NPTD) Registry. Our objectives were to ascertain the extent of this problem, the nature of injuries, and the outcomes, in order to determine the optimal intervention strategy. Methods We performed a retrospective review of records of children younger than 16 years admitted to NCH or reported to the NPTD Registry with driveway injuries. Data were collected on the age of the child; the date, time and location of the injury; the vehicle type and driver of the vehicle; how the accident occurred, including documented safety features restricting access to the driveway; and the injuries identified, together with the surgical interventions, complications, and final outcome. The ethics committee of the NCH approved the study. Admissions to NCH: Data were collected from November 1995 (when the NCH opened) to February 2000. Patients were identified prospectively from the paediatric trauma database compiled by the trauma research nurse. In addition, a retrospective search was made of the case notes of all children admitted to NCH as a result of a pedestrian motor vehicle injury to ensure no cases had been missed. Patients were either admitted directly to NCH from its catchment area of Sydney's western suburbs or transferred via the New South Wales Newborn and Paediatric Emergency Transport Service from peripheral centres. NPTD Registry: The NPTD Registry records all deaths resulting from trauma of children under 16 years of age in NSW that are reported to the coroner. Data were available from inception of the database in January 1988 to December 1999. The police statement and coroner's report, together with the postmortem findings, were reviewed for children who had died following a driveway injury. Results Driveway injuries and deaths identified Box 1 summarises data on the 55 children injured or killed and the circumstances of the injuries, and Box 2 details an illustrative case. Admissions to NCH: There were 42 children admitted with injuries sustained as a result of a driveway motor vehicle injury, representing 12% of the 354 children admitted to NCH with pedestrian motor vehicle injuries. Thirteen patients had been transferred from another hospital. One of the children died. Twenty-six (63%) of the children who survived were under three years of age. Boys accounted for 74% of the children admitted. NPTD Registry: There were 14 deaths from driveway injuries, including one of the 42 children admitted to NCH, reported over the 12-year period. These deaths represented 8% of the 174 pedestrian motor vehicle deaths reported to the registry over the same interval. Children who died were generally younger than patients admitted to NCH. Boys were again over-represented (78%). Circumstances of the injuries and deaths Although 41 (82%) injuries occurred in the afternoon or evening (most between 4:00 pm and 7:00 pm), six (43%) of the fatalities occurred in the morning. There was no marked seasonal association, although 30% of the injuries took place in the summer months, when children would be more likely to be playing outside. A relative of the child or a family friend was the driver in 39 cases, including 12 of the 14 injuries leading to death. A four-wheel-drive (4WD) or light commercial vehicle (LCV) was involved in 34% of injuries in which the child survived, compared with 64% of those with a fatal outcome. Overall, these vehicles accounted for 42% of all injuries. They were associated with a 2.5-times greater risk of fatality compared with other motor vehicles. In 42 cases, the vehicle reversed over the child; 4WDs and LCVs accounted for 19 of these cases. Documentation of access limitation to the driveway was available in only three cases; in two this involved a front door only, and in one a fence gate, all of which had been left open. Nature of injuries Box 3 summarises the injuries identified. For 13 of the children who died, the cause of death was a severe, crushing head injury that involved at least one of the wheels of the vehicle passing directly over the child's head. All but one of the children with a severe head injury died either at the scene of the injury or in the emergency department of the receiving hospital. One child without a head injury died in transit as a result of hypovolaemic shock from a near-complete transection of the right lobe of the liver. In the children who survived, there was a lower incidence and severity of head and neck injuries and a greater incidence of limb trauma compared with children who died. In the surviving children, head injury was usually a consequence of a fall to the ground or cerebral oedema from traumatic asphyxia secondary to compression of the torso. Results of treatment Fourteen patients admitted to NCH required 18 procedures; most involved skin grafting or treatment of displaced fractures. One patient with cardiac tamponade secondary to myocardial injury had a non-therapeutic laparotomy at a country hospital for hypotensive shock that subsequently responded to pericardiocentesis. Final outcome was recorded as satisfactory or good for 34 of the 41 survivors, with a full return to normal activities and no significant physical or psychological sequelae. Active clinical and social problems were identified in seven patients (Box 4). Discussion Driveway injuries in children have usually been considered a minor public health problem,13 perhaps as a result of a combination of misclassification and the failure of non-fatal injuries to be reported to the police.7,8,14,16,19 The NSW Roads and Traffic Authority, which is responsible for compiling most motor vehicle injury statistics in NSW, does not collect data on driveway injuries because they occur on private land. Our figure of a frequency of more than 1 in 10 pedestrian motor vehicle accidents involving children that require admission seems representative of more recent data, although miscoding and under-reporting may have resulted in some cases being missed.6Of great concern was the number of fatalities associated with this injury mechanism: 8% of the total number of paediatric pedestrian motor vehicle deaths. Published figures range from 10.7% in New Zealand to 20% in the US, suggesting that our figure is representative.7,18 Male predominance is a feature of most traumatic injuries,4,8,13,14,16,19 and was particularly noticeable in our series, even below the age of five years. Our data suggest a marked difference between boys and girls in their exploratory behaviour that occurs from an early age.20 A family member or person known to the child was the driver in 86% of fatalities reported to the NPTD Registry; this high incidence is a feature of other series.7,14,17,18 Clearly, the psychological consequences must be devastating to the family, friends and neighbours.18 Our results suggested a link between fatal outcome, age of the child and the size and weight of the vehicle involved.14 Both 4WDs and LCVs accounted for a much higher number of the fatalities in our study than would be expected from their prevalence on the roads. They account for less than 30.4% of registered motor vehicles in NSW (Australian Bureau of Statistics, Motor Vehicle Census 1998, personal communication), but were involved in just under two-thirds of the deaths and were associated with a 2.5-times greater risk of fatality compared with other motor vehicles. Motoring and child safety organisations and health visitors should alert parents and relatives of young children to these findings to encourage greater awareness of the risks these vehicles pose to both toddlers and preschool children. Road safety organisations need to emphasise that the risk of injury appears to be particularly great when reversing in a driveway with this type of vehicle -- the increased ride height potentially reduces visibility and makes identification of a young child much more difficult, even with the use of convex mirrors or a wide-angle lens.15,16 In some prestige vehicles, a proximity-warning device, consisting of ultrasonic transceivers located in the bumpers, at an extra cost to the customer of between $900 and $1600, allows detection of objects within 50 cm to 70 cm of the bumper and above a height of 30 cm. Although the effectiveness of such devices has not been proven in this situation, their wider introduction in high-risk vehicles may help reduce the frequency of this injury.4,16 As nearly all the deaths involved massive head injuries not amenable to medical intervention, prevention represents the only effective approach to reducing fatalities.14-16,18 We suggest that an effective form of injury prevention is urgently required, particularly in view of evidence that this injury is often associated with shared driveways.21 The frequent subdivision of redeveloped residential blocks in urban areas might be expected to lead to an increase in these injuries.22 The optimal prevention would appear to be clear separation of the driveway and garage from the children's play area by a physical barrier such as a fence, wall or self-locking gate.16,21 There are risks to the inquisitive child not only from moving vehicles but also automatic garage doors and unattended vehicles.4,23 Although the construction of circular driveways might decrease the incidence of these injuries, such an approach would be impractical in most urban situations.4 The use of reversing alarms in passenger vehicles appears unlikely to be effective given that the group most at risk of injury, toddlers and preschool children, are too young to appreciate the significance of the alarm and act with appropriate speed.4,17 We recommend that the same degree of vigilance taken with regard to swimming pool safety should be applied to the driveway, and that legislation should be introduced to limit access to this area either by design or the use of temporary fencing.18,21 As an interim measure, we advocate extreme caution be exercised by parents, relatives and neighbours of young families when reversing out of driveways, particularly in vehicles with restricted rear view vision and at greater risk of causing fatal injury, such as four-wheel-drives, vans and trucks. Acknowledgements Mr A J A Holland is supported by a Surgeon Scientist Scholarship from the Royal Australasian College of Surgeons. Dr J Peat provided assistance with statistical analysis. References Meyer AA. Death and disbility from injury: a global challenge. J Trauma Injury Infect Critical Care 1998; 44: 1-12. Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-196. Tanz RR, Christoffel KK. Pedestrian injury. The next motor vehicle injury challenge. Am J Dis Child 1985; 139: 1187-1190. Winn DG, Agran PF, Castillo DN. Pedestrian injuries to children younger than 5 years of age. Pediatrics 1991; 88: 776-782. Roberts I, Norton R, Hassall I. Child pedestrian injury 1978-1987. N Z J Med 1992; 105: 51-52. Agran P, Winn D, Anderson C. Differences in child pedestrian injury events by location. Pediatrics 1994; 93: 284-288. Roberts I, Kolbe A, White J. Non-traffic child pedestrian injuries. J Paediatr Child Health 1993; 29: 233-234. Lapidus G, Braddock M, Banco L, et al. Child pedestrian injury: a population-based collision and injury severity profile. J Trauma 1991; 31: 1110-1114. Dunne RG, Asher KN, Rivara FP. Behavioural and parental expectations of child pedestrians. Pediatrics 1992; 89: 486-490. Roberts I, Norton R, Dunn R, et al. Environmental factors and child pedestrian injuries. Aust J Pub Health 1994; 18: 43-46. Campbell-Hewson G, Egleston CV, Cope AR. Traumatic asphyxia in children. J Accid Emerg Med 1997; 14: 47-49. Sarihan H, Abes M, Akyazici R, et al. Traumatic asphyxia in children. J Cardiovasc Surg 1997; 38: 93-95. Bell MJ, Ternberg JL, Bower RJ. Low velocity vehicular injuries in children -- "run-over" accidents. Pediatrics 1980; 66: 628-631. Brison RJ, Wicklund K, Mueller BA. Fatal pedestrian injuries to young children: a different pattern of injury. Am J Public Health 1988; 78: 793-795. Olson LM, Sklar DP, Cobb L, et al. Analysis of childhood pedestrian deaths in New Mexico. Ann Emerg Med 1993; 22: 512-516. Robinson P, Nolan T. Paediatric slow-speed non-traffic fatalities: Victoria, Australia, 1985-1995. Accid Anal Prev 1997; 29: 731-737. Wright MS. Nonambulatory "pedestrians": infants injured by motor vehicles in driveways. Clin Pediatr 1998; 37: 515-517. Partrick DA, Bensard DD, Moore EE, et al. Driveway crush injuries in young children: a highly lethal, devastating and potentially preventable event. J Pediatr Surg 1998; 33: 1712-1715. Agran PF, Castillo DN, Winn DG. Limitations of data compiled from police reports on pediatric pedestrian and bicycle motor vehicle events. Accid Anal Prev 1990; 22: 361-370. Cass DT, Ross F, Lam LT. Childhood drowning in New South Wales 1990-1995: a population based study. Med J Aust 1996; 165: 610-612. Roberts I, Norton R, Jackson R. Driveway-related child pedestrian injuries: a case-control study. Pediatrics 1995; 95: 405-408. Australian Bureau of Statistics. Building approvals, New South Wales and Australian Capital Territory -- December 1999. Canberra: ABS, 2000. (Catalogue no. 8731.1.) Williams AF. Children killed in falls from motor vehicles. Pediatrics 1981; 68: 576-578. (Received 24 Mar, accepted 13 Jun, 2000) Authors' details New Children's Hospital, Royal Alexandra Hospital for Children, University of Sydney, NSW. Andrew J A Holland, BSc, FRCS, FRACS, Research Fellow and Clinical Lecturer, Department of Surgical Research; Frank I Ross, BAppSc(Nurs), MPH, Clinical Nurse Consultant, Department of Surgical Research; Daniel T Cass, PhD, FRACS, William Dunlop Professor of Paediatric Surgery; Rhea W Y Liang, MB, ChB, Surgical RMO, Department of Paediatric Surgery; Shailinder J Singh, FRCS (I), FRCS (Paed Surg), Clinical Fellow, Department of Paediatric Surgery; David N Schell, MB BS, FRACP, Consultant Paediatric Intensivist, Paediatric Intensive Care Unit. Reprints: Mr Andrew J A Holland, Department of Surgical Research, The New Children's Hospital, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, NSW 2124. AndrewH3ATnch.edu.au Make a comment 1: Summary of children injured and the circumstances of injuries* Survivors (n=41) Deceased (n=14) Age Median Youngest Oldest 23 m 13 m 13 y 1 m 18 m 8 m 3 y 1 m Sex Boys Girls 31 10 11 3 Time of day Morning Afternoon 8 33 6 8 Driver Parent/relative Friend/neighbour Other/unknown 30 7 4 9 3 2 Type of vehicle Car 4WD LCV Unknown 26 8 6 1 4 6 3 1 Direction of travel Forwards Reversing Both directions Unknown 9 30 1 1 2 12 0 0 *There were no statistically significant differences between survivors and deceased. 4WD=four-wheel-drive. LCV=light commercial vehicle. Back to text 2: Illustrative case of a typical driveway motor vehicle injury Unknown to his parents, a 20-month-old boy was playing in the driveway at home. The back door was open and there was no fencing restricting access to the driveway. The father was reversing his four-wheel-drive vehicle out of the garage when he felt a bump. He stopped and discovered his son underneath the vehicle between the tyres. The father pulled the child from underneath the vehicle and then called an ambulance. On arrival at the referring hospital, the child was alert but distressed and uncooperative. Clinical examination revealed bilateral conjunctival haemorrhages and facial petechiae characteristic of traumatic asphyxia (Figure). There was an abrasion of the lower chest and anterior abdominal wall, with a tyre mark on the left shin. Radiological investigations, including a computed tomography scan of the head, chest and abdomen, revealed mild cerebral oedema, pulmonary contusions of both lower lobes, a subcapsular splenic haematoma and a minimally displaced fracture of the upper third of the left tibia. The boy was transferred to the New Children's Hospital, where his injuries were treated non-operatively. He required intubation for worsening gas exchange, but was able to be extubated within 72 hours. He was discharged home 12 days after the injury and was completely well three months later. Both parents required extensive counselling by a social worker. They no longer own the vehicle. Back to text 3: Driveway motor vehicle injuries identified in children New Children's Hospital* (n=41) NPTD Registry† (n=14) Head and neck injuries Soft tissue injury Concussion Skull fracture Facial fracture Cerebral oedema/contusion Cerebral laceration Intracranial haemorrhage Avulsion cerebellum Retinal haemorrhage Cervical spine injury 18 (44%) 6 (15%) 1 (2%) 3 (7%) 1 (2%) 0 0 0 1 (2%) 0 9 (64%) 0 11 (79%) 1 (7%) 5 (36%) 6 (43%) 6 (43%) 1 (7%) 0 1 (7%) Totals 30 injuries in 24 patients 40 injuries in 13 patients Torso injuries Soft tissue injury Rib fractures Pneumothorax Pulmonary contusion/laceration Cardiac tamponade Mediastinal/retroperitoneal haematoma Splenic injury Hepatic injury Renal and pancreatic injuries Thoracic spinal injury Pelvic fracture 19 (46%) 1 (2%) 1 (2%) 2 (5%) 1 (2%) 0 1 (2%) 1 (2%) 0 1 (2%) 6 (15%) 6 (43%) 3 (21%) 0 7 (50%) 0 2 (14%) 1 (7%) 4 (29%) 2 (14%) 0 2 (14%) Totals 33 injuries in 27 patients 28 injuries in 13 patients Limb injuries Soft tissue injury: upper limb Soft tissue injury: lower limb Upper limb fractures Lower limb fractures 3 (7%) 10 (24%) 6 (15%) 8 (20%) 0 0 1 (7%) 0 Totals 27 injuries in 25 patients 1 injury in 1 patient *Injuries in children admitted to the New Children's Hospital with non-fatal injuries from November 1995 to February 2000. †Injuries in children reported to the New South Wales Paediatric Trauma Death (NPTD) Registry from January 1988 to December 1999. Back to text 4: Adverse outcomes among survivors of driveway motor vehicle accidents Incomplete spinal cord injury with lower limb weakness and neurogenic bladder Retinal haemorrhage with visual impairment Unequal leg length and gait disturbance from lower limb fracture Epiphora secondary to nasolacrimal duct injury associated with facial fracture Residual left ptosis secondary to closed head injury Significant varus deformity from upper limb fracture Prolonged social work and psychological counselling of one family Back to text

Shailinder J Singh · David N Schell · Frank I Ross · Daniel T Cass

Notable Cases Wasp sting mortality in Australia Forbes McGain, James Harrison and Kenneth D Winkel Wasp sting fatalities have rarely been reported in Australia. We used data from the Australian Bureau of Statistics and State coronial authorities to investigate deaths from wasp stings in Australia from 1979 through 1998. Seven cases were identified, all involving men in rural settings. Five of the seven victims had prior histories of wasp or bee venom allergy, or both, but none carried injectable adrenalin. All patients with a history of systemic Hymenoptera sting allergy should undergo assessment for immunotherapy and carry adrenalin. MJA 2000; 173: 198-200 Clinical records - Discussion - Acknowledgements - References - Authors' details - - More articles on Insects, bites and stings Australia has a diverse range of venomous creatures capable of causing lethal injuries. While most attention has been focused on deaths from snake and spider bite, arthropods such as jumper ants (Myrmecia pilosula),1 honey bees (Apis mellifera)2 and European wasps (Vespula germanica)3 can also inflict dangerous stings. Indeed, the widespread distribution of the hymenopterans (bees and wasps) means that their stings are a leading cause of mortality from bites and stings globally.4,5 The vast majority of deaths from Hymenoptera stings are caused by immediate hypersensitivity reactions to venom.4,5Despite the importance of fatalities from Hymenoptera stings internationally, little has been published on the circumstances and incidence of such deaths in Australia. For example, an analysis of Australian bee sting fatalities during 1960-1981 was unable to obtain adequate clinical information about most of the fatalities during that period, and coronial records were examined for only one of the 27 fatalities identified in that study.2 Despite the increasing abundance of the introduced and aggressive European wasp (V. germanica),6 and consequent concerns about the increasing health risks posed by this vespid,3 even less information is available about fatalities from wasp stings in Australia than for those from bee stings. Indeed, only two minimally documented reports of fatal wasp stings exist in the Australian medical literature. In 1913, Cleland noted "oedema of the larynx and subsequent death occurred from a man being stung by a wasp. He had been drinking out of the spout of a waterbag in which the wasp was hiding".7 Lee also made reference to a fatal wasp sting in a 47-year-old man in southern Queensland in 1957.8 Analysis of fatalities can provide important information on the determinants of severe morbidity, which may be useful in injury prevention. Thus, we investigated, in detail, wasp sting related fatalities that occurred in Australia over the past two decades. This period was coincident with the arrival and dispersal of V. germanica on the Australian mainland.6 In the absence of national coronial data for this period, we used State-based coronial information systems. In particular, we aimed to identify the contribution of allergy versus venom toxicity (envenomation), and the likely contribution of V. germanica to the mortality burden. Clinical records We identified seven wasp sting fatalities, which occurred between 1 January 1979 and 31 December 1998, from the following data sources: the Australian Bureau of Statistics mortality dataset; State and Territory Registrars of Births, Deaths and Marriages; State and Territory coronial authorities; and in one instance, from the family physician of the deceased. These data allowed us to analyse the circumstances of the wasp stings, the likely wasp species involved, and any history of Hymenoptera sting allergy and its management. This project was approved by the University of Melbourne Health Sciences human ethics subcommittee. The seven fatalities identified during the 20-year period correspond to a mean annual incidence rate of 0.02 deaths per million population per year. The deceased were all men living in northern New South Wales, or in Queensland (from the southeast to the far north coast). They were aged between 39 and 73 years (mean age, 54 years). Five of the seven deaths occurred during December and February, and the remaining two deaths occurred in April and May. In no year was there more than one death from wasp sting. All stings occurred in rural areas and four of the deceased were described as farmers in the coronial reports. The details of each case are summarised in Box 1. Discussion More than one thousand species of wasp have been recognised in Australia,9 but most are solitary, and rarely come into contact with humans. The most medically significant wasps belong to the family Vespidae.9 The genera Vespula, Polistes and Ropalidia, illustrated in Box 2, comprise the most important subfamily of vespids, the Vespinae. These social wasps cooperate in the construction and provisioning of their nests and have a propensity for interaction with humans. For example, European wasps are great scavengers and are usually found around areas of human habitation and activity, thus posing a particular hazard. In Europe4,10 and the United States,11 relative proportions of deaths from wasp and bee stings are different from those in Australia. In Sweden, these proportions are 90% for wasps and 10% for bees;4 corresponding figures for Denmark are 63% for wasps and 37% for bees,10 while, in the US, wasp and bee sting fatalities occur with approximately equal frequency.11 By contrast, our finding of a wasp sting fatality rate of 0.02 per million population per year is only a quarter of the reported Australian bee sting fatality rate of 0.086 per million population per year.2 This may reflect the relatively recent arrival in Australia of the European wasp6 compared with the European honey bee. Although our study was precipitated by concern about the health impact of European wasps, and we looked at a period that coincided with their arrival and spread on the mainland, we identified no fatalities attributable to this wasp. All of the wasp-sting deaths occurred outside the known range of V. germanica.6 This may change as increasing numbers of people become sensitised to its venom. Further research is required to ascertain whether the arrival of V. germanica has altered sting-related morbidity patterns in Australia. As in previous studies,2,4,10 in the deaths we examined we found that the reponsible wasp was rarely formally identified. Nonetheless, it seems likely that at least one case was attributable to a Polistes species. This is consistent with reports of severe allergic reactions to stings by Polistes and Ropalidia species in Queensland.12 Moreover, given the distribution of the various vespid wasps,9 it seems likely that all seven fatalities were caused by Polistes and Ropalidia species. This adds impetus to the call for purified Ropalidia venom to become available for immunotherapy,12 as, currently, only imported Polistes and Vespula venoms are available. The absence of wasp sting mortality outside Queensland and NSW contrasts with the nationwide occurrence of deaths from bee stings.2 It is possible that the wasp species found in Queensland and NSW possess greater allergenic potential than those found elsewhere in Australia. No systematic research has yet been undertaken on this question. The formal identification of the wasp species implicated in future fatalities would facilitate such research. Consistent with previous analyses of bee and wasp sting mortality internationally,2,4,5 we found a low number of stings, rapid onset of symptoms, no child fatalities and over-representation of middle-aged men among those who died. It has been proposed that pre-existing heart disease might explain the increased risk for men aged over 40 years;2,4 certainly, this may have contributed to death in two of our cases. However, our findings differ from these other reports in the high frequency of autopsy examinations and low rates of underlying cardiorespiratory disease. Venom toxicity is rarely reported in Hymenoptera-related fatalities,2,4,10,11 and we found no fatal massive envenomations. In all cases death was attributable to anaphylaxis (although ideally mast cell tryptase and IgE level measurements should be made to confirm this diagnosis). In contrast with previous international reports, most of the victims in our study had either previously diagnosed allergy to wasp stings or a clear history of systemic reactions indicating severe allergy. Thus, most of these deaths might have been prevented by specific immunotherapy, early treatment with adrenalin or both. However, patients and their families should be aware that vulnerability to venom-induced anaphylaxis persists at least until maintenance doses of immunotherapy are attained. As with Australian bee sting fatalities,2 most deaths occurred in the summer months when human-wasp interaction is most likely. The rural setting of these fatalities highlights concerns about the acute shortage of specialist allergists and clinical immunologists in rural areas,13 although it is unclear whether such shortages contributed to the fatal outcomes. Nevertheless, this underservicing, combined with the lack of Ropalidia,12Myrmecia1 and other venoms for immunotherapy, increases the importance of anaphylaxis emergency kits and education14 for those with life-threatening allergy to insect stings and their families. The fact that most of the deceased were reported to be farmers is consistent with the fact that rates of work-related deaths in agriculture are among the highest in Australia.15 Information on bites and stings should therefore be incorporated within injury prevention programs such as those developed by Farmsafe Australia.15 As noted in previous investigations of bee sting mortality,2 dependence on a single data set is likely to lead to an underestimation of the total injury burden. It is possible that additional wasp sting deaths occurred during the study period but were not recorded because of miscertification, misattribution as bee sting, or other inadequate or inaccurate recording. We found that the wasp sting diagnosis was almost wholly dependent on the presence of a witness and absence of retained bee sting on autopsy. Clearly, unwitnessed wasp sting deaths could be attributed to other causes, and our findings should be considered an underestimate of wasp sting mortality. Acknowledgements This study was supported by grants from the Victorian Department of Human Services, Snowy Nominees, the BHP Community Trust and Bayer Healthcare Australia. We acknowledge the assistance of Ms Malinda Steenkamp, Mr Stan Bordeaux, of the Research Centre for Injury Studies, Flinders University; Mr Peter Burke and Mr David Jayne, of the Australian Bureau of Statistics, Brisbane, as well as the various state and regional coronial authorities, hospitals and individual clinicians involved. We also thank Assistant Professor Nadine Levick, of Johns Hopkins Medical Institutions, and Associate Professor Gordon Smith, of the School of Public Health, Baltimore, Maryland, USA, for helpful advice. Dr Gabrielle Hawdon and Associate Professor James Tibballs, Australian Venom Research Unit, as well as Dr Jo Douglass, Department of Allergy, Asthma and Clinical Immunology, The Alfred Hospital, critically reviewed the manuscript. Dr Ken Walker, of Museum Victoria, and Dr Justin Schmidt, of the Carl Hayden Bee Research Center, Tucson, Arizona, USA, provided photographs and entomological advice. References Clarke PS. The natural history of sensitivity to jack jumper ants (Hymenoptera formicidae Myrmecia pilosula) in Tasmania. Med J Aust 1986; 145: 564-566. Harvey P, Sperber S, Kette F, et al. Bee sting mortality in Australia. Med J Aust 1984; 140: 209-211. Levick NR, Winkel KD, Smith GS. European wasps: an emerging hazard in Australia. Med J Aust 1997; 167: 650-651. Johansson B, Eriksson A, Ornehult L. Human fatalities caused by bee and wasp stings in Sweden. Int J Legal Medicine 1991; 104: 99-103. Langley R, Morrow W. Deaths resulting from animal attacks in the United States. Wild Environ Med 1997; 8: 8-16. Spradbery JP, Maywald GF. The distribution of the European or German wasp in Australia, past, present and future. Aust J Zool 1992; 40: 495-510. Cleland JB. Insects and their relationship to disease in man in Australia. Trans 9th Aust Med Congress Sydney 1911; 1: 548-552. Lee DJ. Arthropod bites and stings and other injurious effects. Sydney: School of Public Health and Tropical Medicine. The University of Sydney, 1975. Naumann ID. Hymenoptera. Chapter 42. In: CSIRO. The insects of Australia. 2nd ed. Melbourne: Melbourne University Press, 1991: 916-1000. Mosbech H. Death caused by wasp and bee stings in Denmark 1960-1980. Allergy 1983; 38: 195-200. Barnard J. Studies of 400 Hymenoptera sting deaths in the United States. J Allergy Clin Immunol 1973; 52: 259-264. Solley G. Allergy to stinging and biting insects in Queensland. Med J Aust 1990; 153: 650-654. O'Hehir RE, Douglass JA. Stinging insect allergy. Med J Aust 1999; 171: 649-650. Douglass JA, O'Hehir RE. Peanut allergy. Education, avoidance and adrenaline are the mainstays of management. Med J Aust 1997; 166: 63-64. Fragar L. Agricultural health and safety in Australia. Aust J Rural Health 1996; 4: 200-206. (Received 6 Mar, accepted 21 Jun, 2000) Authors' details Australian Venom Research Unit, Department of Pharmacology, University of Melbourne, VIC. Forbes McGain, MB BS, Honorary Fellow; Kenneth D Winkel, MB BS, FACTM, Director. Research Centre for Injury Studies, Mark Oliphant Building, Flinders University, Bedford Park, SA. James Harrison, MB BS, MPH, Director. Reprints will not be available from the authors. Correspondence: Dr K D Winkel, AVRU, Department of Pharmacology, University of Melbourne, VIC 3010. k.winkelATpharmacology.unimelb.edu.au Make a comment 1: Summary of the circumstances and features of wasp sting fatalities in Australia from 1 January 1979 to 31 December 1998 Case Medical history Allergy treatment Circumstances Autopsy results Wasp identification 1 Previously well. No significant reactions to previous bee or wasp stings. Unknown Witnessed sting to the neck after disturbing a wasp nest while working outdoors. Collapsed with convulsions and died within minutes. Two puncture marks to the neck, severe laryngeal oedema, no coronary atherosclerosis. Identified by a professional entomologist as "paper wasps" (genus Polistes). 2 Previously well. Allergic to both bees and wasps (degree uncertain). Nil Witnessed sting to the scalp while outdoors, followed by rapid collapse, cyanosis and death. Single puncture to the occipital scalp, gross laryngeal oedema, no coronary atherosclerosis. Not formally identified. 3 Previously well. No known history of bee or wasp sting allergy. Unknown Single witnessed sting to the hand while gardening; initial marked local reaction only, followed by collapse, cyanosis and death within an hour. Erythematous left hand, glottic oedema and moderately severe coronary atherosclerosis. Not formally identified. 4 Previously well, but with a history of systemic reactions to wasp stings. Nil Single witnessed sting to the thigh after disturbing a wasp nest while working outdoors; dyspnoea, cyanosis, collapse and death within 30 minutes. Single puncture to the thigh, epiglottic oedema and no coronary atherosclerosis. Not formally identified. 5 Severe wasp sting allergy and a prosthetic mitral valve; otherwise well. Unspecified allergy treatment by family doctor and "specialist". Victim did not carry adrenalin. Single witnessed sting to the ear while gardening, followed by collapse, convulsions and death within minutes. Aryepiglottic oedema; moderate coronary atherosclerosis. Not formally identified. 6 Previous anaphylactic reaction to either a bee or wasp sting. Nil Single witnessed sting while gardening; developed urticaria, cyanosis and cardiac arrest within 15 minutes. No autopsy; death not reported to the coroner. Not formally identified. 7 Previous life threatening allergic reactions to "paper wasp" stings. Nil Multiple witnessed stings, while walking in a national park; collapsed with convulsions and died. Angioneurotic truncal oedema, laryngeal and tracheal oedema, no coronary atherosclerosis. Described as "paper wasps" by victim's son, who witnessed the stings. Back to text 2: Representative examples of the three most medically significant wasp genera found in Australia The European wasp (Vespula germanica). Photograph courtesy of Dr J Schmidt, Carl Hayden Bee Research Center, Tucson, Arizona, USA. Paper Wasp: Polistes humilis (left) and Ropalidia gregaria (right). Photographs courtesy of Dr K Walker, Department of Entomology, Museum Victoria. Back to text

Forbes McGain · James Harrison · Kenneth D Winkel