Ejections of young children in motor vehicle crashes

PURPOSE: The purpose of this study was to report the incidence of ejection from the vehicle among children involved in motor vehicle crashes, and to describe a novel mode of ejection from child safety seats. METHODS: The U.S. National Automotive Sampling System General Estimates System and the Fatality Analysis Reporting System databases from 1995 through 1999 were analyzed. A prospective two-center study of children involved in severe car crashes in Canada was performed. RESULTS: Only 0.2% of 5.5 million children involved in crashes experienced ejection, but 1924 (29%) of 6570 child fatalities involved ejections. Only 2.2% of children experienced rollover crashes, but these contributed 1832 (28%) of 6570 child passenger fatalities. Among 56 crashes, 5 restrained young children were ejected, 4 in rollover crashes. Ejection of a toddler through the shoulder straps of a forward-facing child safety seat was the mechanism of ejection in three of the five cases. CONCLUSION: Ejection from the vehicle is common (29%) among fatally injured children. Shoulder straps alone (as found in T-shield or overhead shield child seats) may not prevent the ejection of toddlers from child safety seats during rollovers.     

Maxillofacial and ocular injuries in motor vehicle crashes

BACKGROUND: Injuries from motor vehicle crashes constitute a leading cause of death in the young and a high degree of morbidity and mortality in all age groups. Facial trauma has been consistently shown to be the single most common injury to the occupants of vehicles involved in crashes. This has been confirmed by more recent studies which have demonstrated a continuing high incidence of facial fractures amongst belted drivers. Airbags have been advocated as a supplemental restraint system. However, their deployment can cause injury particularly if the driver is of short stature, unrestrained or out of position within the vehicle. METHODS: The Crash Injury Research Engineering Network (CIREN) project aims to correlate the injuries received by occupants in vehicle crashes with the biomechanics of vehicle deformation. All cases of facial injury which presented to the University of Michigan Medical Center, USA in 1999 were retrospectively evaluated with reference to the methods of occupant restraint and to the correlation between the injuries sustained and vehicle deformation. RESULTS AND CONCLUSIONS: The case analysis confirmed the value of airbags to the safety of vehicle occupants but reinforced the conclusion that they must still be considered supplemental restraint systems. New generation airbags will minimise the risk of injury even to small stature or out of position occupants as they will prevent deployment in situations where they may have an adverse effect.     

Morbidity and mortality of children following motor vehicle crashes

HYPOTHESIS: The use of passenger compartment safety measures has not led to decreases in pediatric morbidity or mortality in our population of patients. DESIGN: Retrospective review. SETTING: University, tertiary care, level I trauma center. PATIENTS: All patients admitted to the Trauma Center at Louisiana State University Health Science Center School of Medicine in Shreveport between July 1, 1991, and December 31, 2000, who were younger than 16 years and involved in a motor vehicle crash. MAIN OUTCOME MEASURES: Intensive care complications, postoperative complications, and mortality. RESULTS: We reviewed the experience of all pediatric patients involved in motor vehicle crashes and transported to the Trauma Center at Louisiana State University Health Science Center School of Medicine in Shreveport from July 1, 1991, through December 31, 2000. A total of 191 patients met these criteria. There were 8 deaths, and only 1 of these patients was restrained. There were significantly more injuries in those patients who died compared with those who survived (Modified Injury Severity Score, 29 vs 9; P<.001). We compared the use of restraints in our cohort with the use of restraints in the US pediatric population. Only 20% of our patients were restrained vs 68% of the general pediatric population. This difference was significant (P<.001, chi2) test). CONCLUSIONS: In our population of patients, death was a relatively infrequent occurrence. All patients who died presented in extremis. No patient died as the result of a complication. The rate of seat belt use in our population of patients was low. The exact reason for why we were unable to detect any survival benefit with seat belt use is unclear and demands further investigation.     

Seat-belt injuries in children involved in motor vehicle crashes.

BACKGROUND: The efficacy of seat belts in reducing deaths from motor vehicle crashes is well documented. A unique association of injuries has emerged in adults and children with the use of seat belts. The "seat-belt syndrome" refers to the spectrum of injuries associated with lap-belt restraints, particularly flexion-distraction injuries to the spine (Chance fractures). METHODS: We describe the injuries sustained by 8 children, including 2 sets of twins, in 3 different motor vehicle crashes. RESULTS: All children were rear seat passengers wearing lap or 3-point restraints. All had abdominal lap-belt ecchymosis and multiple abdominal injuries due to the common mechanism of seat-belt compression with hyperflexion and distraction during deceleration. Five of the children had lumbar spine fractures and 4 remained permanently paraplegic. CONCLUSIONS: These incidents illustrate the need for acute awareness of the complete spectrum of intra-abdominal and spinal injuries in restrained pediatric passengers in motor vehicle crashes and for rear seat restraints that include shoulder belts with the ability to adjust them to fit smaller passengers, including older children.     

Life-altering outcomes after lower extremity injury sustained in motor vehicle crashes

BACKGROUND: Lower extremity injuries (LEIs) sustained in vehicular crashes result in physical problems and unexpected psychosocial consequences. Their significance is diminished by low Abbreviated Injury Scale scores. METHODS: Drivers who sustained LEIs were identified as part of the Crash Injury Research and Engineering Network (CIREN) and interviewed during hospitalization, at 6 months, and at 1 year. All were occupants of newer vehicles with seatbelts and airbags. RESULTS: Sixty-five patients were followed for 1 year. Injuries included mild brain injury (43%), ankle/foot fractures (55%), and bilateral injuries (37%). One year post-injury, 46% reported limitations in walking and 22% with ankle/foot fractures were unable to return to work. Depression (39%), cognitive problems (32%), and post-traumatic stress disorder (18%) were significant in the mild brain injury group. CONCLUSIONS: Long-lasting physical and psychological burdens may impede recovery and alter the lifestyle of patients with LEI. These issues need to be addressed by trauma center personnel.     

Children after motor vehicle crashes: Restraint utilization and injury severity

BackgroundAlthough injury patterns after motor vehicle crashes (MVCs) are well documented, association between adequate restraint and injury severity is unclear. We aimed to determine if improper restraint affects injury rates and severity.MethodsA retrospective chart review of 477 children hospitalized in Pediatric Trauma Center after MVC was performed. Injuries in various age groups (0–7, 8–12, 13–16, 17–18 years) with different restraint quality measures (proper [PR] and improper/unrestrained [IUR]) as well as injury severity score (ISS: mild [1–9], moderate [10–15], severe [16–25], and profound [> 25]) were evaluated and compared. Chi-square and Wilcoxon rank-sum tests were used for statistics.ResultsIn all age groups head/neck injuries were most common (55–63%), while abdominal and pelvic injuries were least likely except group 8–12 years where abdominal injuries ranked third (17.1%). Overall, 64.5% had PR and 35.5% IUR. Interestingly, that greatest proportion of IUR was in the youngest age group (0–7). It decreased with aging and children aged 17–18 years were significantly less likely to be IUR compared to those 0–7 years (OR[odds ratio] = 0.58; 95%CI[confidence interval] 0.35–0.94). We did not find significant differences in rates of various injuries between PR and IUR. However, ISS severity in IUR was significantly greater than in PR (median with interquartile range 6(2–14) and 5(1–9), respectively; P = 0.001). As a result, IUR compared to PR were less likely to have mild ISS (OR = 0.6, 95%CI 0.39–0.90) but more likely to have profound ISS (OR = 3.3, 95%CI 1.48–7.43).ConclusionRestraint quality has significant impact on injury severity in children after MVC.Level of EvidenceLevel III.     

Static stability as a predictor of overturn in fatal motor vehicle crashes

Fatal Accident Reporting System (FARS) files for the years 1981-1984 were examined for rollover crash involvement of 15 utility and passenger vehicle make-models for which static stability values (1/2 track width divided by height of center of gravity) were published. The values ranged from highs of 1.57-1.62 for the pre-1979 Ford LTD, the pre-1979 Chevrolet Nova, and the pre-1982 Pontiac Firebird to lows of 1.01-1.07 for the Jeep CJ-5 and CJ-7 and the pre-1978 Ford Bronco. Rollover as the first harmful event and as the most harmful event per 100,000 vehicles registered was strongly predicted by stability. Stability was unrelated to nonrollover crashes. The low-stability vehicles were much more likely to roll over on the road rather than after leaving the road. Other road, driver, and environmental risk factors recorded in the FARS files were not correlated to stability in such a way as to explain the high rollover of low-stability vehicles. Using Federal Highway Administration vehicle mileage estimates, calculations were made of the mileages under various conditions which the vehicles with low stability values would have to have been driven if mileage or hazardous-condition differences rather than stability differences accounted for their substantially higher fatal rollover fatal crash rates. This analysis indicates that fatal rollover rates of low-stability vehicles could not have occurred at reasonable mileage.     

Children in side-impact motor vehicle crashes: seating positions and injury mechanisms

BACKGROUND: This study aimed to describe the injury mechanisms of children involved in side-impact car crashes, particularly as these relate to seating position, and to estimate the danger of the near-side seating position. METHODS: A prospective two-center study of children involved in severe car crashes in Canada was conducted as well as a retrospective cohort study of children involved in crashes reported in the Fatality Analysis Reporting System (FARS) and the National Automotive Sampling System: Crashworthiness Data System (NASS CDS). RESULTS: Children sitting at the side the car was struck (near-side position) sustained severe head, trunk, and limb injuries. Many of these injuries were attributable to direct intrusion, but some occurred without direct damage to the occupant compartment. Center-seat and far-side occupants had severe injuries only when unrestrained. Injury severity scores were higher for children seated on the near side, and this was statistically significant (p = 0.024) The analysis of Fatality Analysis Reporting System data showed that the risk of fatality was higher for children seated in the near-side position than for those in the center-seat position. The fatality risk ratio was 2.53 (95% confidence interval [CI], 2.08-3.07) for restrained children and 1.84 (95% CI, 1.57-2.17) for unrestrained children. Analysis of the NASS-CDS data showed that for restrained children, severe injury (ISS > or = 16) was more common among those on the near side (7 per 1,000 children) than among those in the center seat (2 per 1,000) or on the far-side seat (1 per 1,000) (p < 0.001). CONCLUSIONS: Severe injuries to near-side occupants occurred in both the presence and absence of compartment intrusion. A typical pattern of head, chest, and extremity injury similar to that seen among child pedestrians was observed among near-side child occupants in side-impact crashes. The center seat was statistically safer than the near-side seat, particularly for restrained child occupants. Scene information may be useful to trauma teams for the prediction of injury type and location. Avoiding intrusion and preventing the occupant from striking the vehicle wall are both important to side-impact protection for children. Improvement of the vehicle safety cage may protect against intrusion injuries. Seating two child occupants in inboard seating positions may provide additional protection against intrusion injuries, and also may protect against nonintrusion injuries.     

Accounting for intubation status in predicting mortality for victims of motor vehicle crashes

BACKGROUND: Two of the important predictors of mortality for trauma patients are the Glasgow Coma Scale and the respiratory rate. However, for intubated patients, the verbal response component of the Glasgow Coma Scale and the respiratory rate cannot be accurately obtained. This study extends previous work that attempts to predict mortality accurately for intubated patients without using verbal response and respiratory rate. METHODS: The New York State Trauma Registry was used to identify 1994 and 1995 victims of motor vehicle crashes (MVCs). For the subset of patients who were not intubated, we developed two statistical models to predict mortality: one did not contain verbal response or respiratory rate, and the other contained a predicted verbal response. These were compared with a model that did include verbal response and respiratory rate. We also compared the predictive abilities of the first two models for all MVC patients (intubated and nonintubated) and determined the extent to which intubated patients were at increased risk of dying in the hospital after having adjusted for other predictors of mortality. RESULTS: For nonintubated patients, the statistical model without verbal response and the model with predicted verbal response had slightly better discrimination and worse calibration than the model that included verbal response and respiratory rate. Predicted verbal response did not improve the strength of the model without verbal response. For all MVC patients (intubated and nonintubated), predicted verbal response was not a significant predictor of mortality when used in combination with the other predictors. Intubation status was a significant predictor, with intubated patients having a higher probability of dying in the hospital than patients with otherwise identical risk factors. CONCLUSION: Inpatient mortality for intubated MVC patients can be accurately predicted without respiratory rate or verbal response. There appears to be no need for predicted verbal response to be part of the prediction formula, but intubation status is an important independent predictor of mortality and should be used in statistical models that predict mortality for MVC patients.     

Upper extremity fracture patterns following motor vehicle crashes differ for drivers and passengers

PURPOSE: Injury patterns of occupants in motor vehicle crashes are changing, with upper extremity injury becoming more common in patients treated at trauma centres. Although not life threatening, upper extremity injuries may result in long-term disability, including chronic deformity, neurovascular compromise and degenerative arthritis. The purpose of this study was to compare upper extremity injury in drivers and passengers using the Crash Injury Research Engineering Network (CIREN) database. METHODS: CIREN data were used to compare upper extremity skeletal injury patterns and sources for drivers and passengers in frontal and side impacts. Occupant variables (age, gender, co-morbidity, avoidance maneuvers and restraint use) and crash variables (direction of impact, delta V and vehicle crush) were considered in the analysis. RESULTS: Only 24.8% of all occupants in the CIREN database had upper extremity injuries. One-half of upper extremity injuries to drivers were forearm fractures compared to one-third for passengers. Occupants in side impacts were more likely (OR=5.05) to have clavicle fractures, even while controlling for driver versus passenger status and safety belt use. Air bags were more likely to be a source of forearm fracture (OR=2.31) when controlling for driver versus passenger status, direction of force, sex and age compared to other sources. Only 10% of driver fractures with air bag deployment in frontal impacts were associated with air bag fling. CONCLUSIONS: This study found that drivers and passengers have different upper extremity injury patterns but the direction of impact also plays an important role.     

Risk factors and predictors of mortality in children after ejection from motor vehicle crashes

PURPOSE: Mortality after ejection from a motor vehicle crash (MVC) has been studied extensively in adults. The magnitude of this problem in children is relatively unknown. We retrospectively examined fatalities resulting from ejection after MVC in the state of Pennsylvania to define risk factors and predictors of mortality in children. METHODS: The records for all patients 0 to 16 years of age involved in an MVC and entered in the Pennsylvania Trauma Outcome Study between 1993 and 1997 were reviewed. We examined mortality, length of hospitalization, major injuries sustained, and impact of safety restraint devices. Significant differences were determined using chi2 test. RESULTS: There were 2,298 children involved in MVCs during this period; 189 were ejected. A total of 77% of the ejected passengers were greater than 10 years of age, 16% were 0 to 4 years of age, and 7% were 5 to 9 years of age. Overall, 88% of the ejected occupants were unrestrained. Ejection nearly tripled the overall mortality rate and significantly increased the Injury Severity Score for each age group. Infants and children 0 to 4 years of age had the highest fatality rate despite having a lower Injury Severity Score than all other age groups. Head injuries accounted for the majority of deaths in all age groups. Children older than 10 years of age had a higher incidence of associated chest, abdominal, and pelvic injuries. CONCLUSION: Our data show that most children ejected from MVCs were either unrestrained or improperly restrained. Head injuries were the most common cause of death in all age groups. Greater public awareness through educational programs targeting parents and children at risk may reduce this serious problem.     

Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes

Background

Both solid and hollow visceral abdominal injuries have been associated with the use of seat belts in children involved in motor vehicle crashes. The relationship between the types of restraint used and the pattern of abdominal injury is unknown.

Methods

A probability sample of restrained children involved in crashes was enrolled in an ongoing crash surveillance system (1998 through 2002) linking insurance claims data to telephone survey and crash investigation data. Significant abdominal injuries were considered when the Abbreviated Injury Scale (AIS) score was ≥2 and were defined as hollow visceral (HV; intestine, bladder), or solid visceral (liver, spleen, pancreas, kidney). Restraint type was categorized as optimal restraint (OR) or suboptimal restraint (S-OR) based on the child’s age and size.

Results

For the 33 months of review, interviews were obtained for 13,558 restrained children aged 0 to 15 years, of which, 56% were OR (n = 7,591) and 44% were S-OR (n = 5,967). A significant abdominal injury was recorded in 78 children. A hollow visceral injury was recorded in 38 (9 OR and 29 S-OR), and a solid visceral injury in 32 (18 OR and 14 S-OR). Both hollow and solid visceral injuries were present in 8 children (2 OR and 6 S-OR). Suboptimally restrained children had a higher risk for hollow visceral injury when compared with optimally restrained children (Odds Ratio, 4.14 [95% Confidence Interval 1.33 to 13.22, P < .01]).

Conclusions

Among restrained children with intraabdominal injuries, those who were suboptimally restrained were 4 times more likely to have a hollow visceral than a solid visceral injury when compared with those who were optimally restrained. This suggests that the mechanism of injury for hollow viscus may be directly related to the improper positioning of the restraint.     

Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes

BACKGROUND: The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated. METHODS: Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10927 crashes involving 17132 restrained children, representing 210926 children in 136734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale >or=2 severity. RESULTS: Among all restrained children, optimal was noted in 59% (n = 120473) and suboptimal in 41% (n = 83555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87-6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds. CONCLUSIONS: Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.     

The relative influence of alcohol and seatbelt usage on severity of injury from motor vehicle crashes

Seatbelt usage has been consistently documented to decrease mortality and injury severity from motor vehicle crashes (MVC); however, conflicting results are available comparing mortality and injury severity, and blood alcohol positivity. Prospective testing on all MVC admissions showed that 51.5% of the non-belted, and 22% of the shoulder-belted drivers had a positive blood alcohol content (p less than 0.001). A comparison of belted and non-belted MVC drivers revealed a significantly higher mean length of stay (LOS) (p less than 0.05) and Injury Severity Score (ISS) (p less than 0.01) for the non-belted drivers. A comparison of groups positive and negative for blood alcohol revealed no significant differences in LOS or ISS, suggesting that these parameters are related to seatbelt use and not alcohol consumption.