Hangman's fracture resulting from improper seat belt use

Diagonal seat belt application without accompanying lap belt closure may produce severe cervical spine injuries, including hangman's fracture and decapitation. Seat belts are effective in reducing injury, but they must be worn properly to do so. Passive restraint systems involving a diagonal seat belt may be hazardous if the motorist does not use the accompanying lap belt. We have presented a case in which the driver in a motor vehicle accident sustained a hangman's fracture (bilateral fracture of the pedicles of C-2) caused by use of a diagonal seat belt without accompanying lap belt closure. The mechanism of injury, as classically described in judicial hanging, is hyperextension and distraction, which occurred when the victim "submarined" under the diagonal seat belt and was caught at the neck.     

Airbag safety: Deployment in an automobile crash with a fall from height

Airbag restraint systems have demonstrated a significant reduction in mortality in motor vehicle crashes (MVCs). While airbag devices are effective primarily in frontal or near-frontal impacts, little is known about the efficacy of these devices in nonfrontal types of collisions. Moreover, there are reports of injuries specific to airbag deployment that have led some investigators to question the benefit of such devices. This article reports a rollover MVC with a considerable fall from height in which lap/shoulder belts were used in addition to airbag deployment that resulted in protection of the driver from injury. The outcome of this case continues to support the combination of belt and airbag restraint systems as the most effective occupant protection in both frontal and nonfrontal types of MVCs.     

An Emergency Department Intervention to Increase Booster Seat Use for Lower Socioeconomic Families

Objectives: To evaluate the effectiveness of booster seat education within an emergency department (ED) setting for families residing in lower socioeconomic neighborhoods.
Methods: This was a prospective, randomized study of families with children aged 4 to 7 years and weighing 40 to 80 lb who presented to a pediatric ED without a booster seat and resided in lower socioeconomic communities. Subjects were randomly assigned to one of three groups: 1) received standard discharge instructions, 2) received five-minute booster seat training, and 3) received five-minute booster seat training and free booster seat with installation. Automobile restraint practices were obtained initially and by telephone at one month.
Results: A total of 225 children were enrolled. Before randomization in the study, 79.6% of parents reported that their child was usually positioned in the car with a lap/shoulder belt and 13.3% with a lap belt alone. Some parents (16.4%) had never heard of a booster seat, and 44.9% believed a lap belt was sufficient restraint. A total of 147 parents (65.3%) were contacted for follow-up at one month. Only one parent (1.3%) in the control group and four parents (5.3%) in the education group purchased and used a booster seat after their ED visit, while 55 parents (98.2%) in the education and installation group reported using the booster seat; 42 (75.0%) of these parents reported using the seat 100% of the time.
Conclusions: Education in a pediatric ED did not convince parents to purchase and use booster seats; however, the combination of education with installation significantly increased booster seat use in this population.     

Paediatric lap-belt injury: a 7 year experience

Objective: To highlight the injuries that result from lap‐belt use and make recommendations for prevention, the recent experience of a regional paediatric trauma centre was reviewed. Methods: Retrospective review of admissions to Starship Children's Hospital from 1996 to 2003, with significant injury following involvement in a motor vehicle crash, while wearing a lap‐belt. Patients were identified from two prospectively collected databases and discharge coding data. Results: In total, 19 patients were identified over the 7 year period. The morbidity sustained includes 15 patients with hollow viscus injury, 13 laparotomies, 7 spinal fractures, 2 paraplegia and 1 fatality. A total of 11 patients required laparotomy with a median delay of 24 h. Of patients in the present series, 58% were aged less than 8 years and thus were inappropriately restrained. Conclusions: Lap‐belt use can result in a range of life‐threatening injuries or permanent disability in the paediatric population. The incidence of serious lap‐belt injury does not appear to be decreasing. Morbidity and mortality could be reduced by the use of three‐point restraints, age appropriate restraints and booster seats.     

Review of the use of physical restraints and lap belts with wheelchair users

Wheelchair-related physical restraints, lap belts, and other alternatives are intended to provide safe and adequate seating and mobility for individuals using wheelchairs. Physical restraints and lap belts are also helpful for positioning people in their wheelchairs to reduce the risk of injury during wheelchair tips and falls. However, when used improperly or in ways other than intended, injury or even death can result. Although widely prescribed, little evidence is available to direct professionals on the appropriate use of these restraints and lap belts and for whom these restraints are indicated. The purpose of this study was to conduct a review of available literature from 1966-2006 to identify the risks and benefits associated with lap belts while seated in wheelchairs. Twenty-five studies that met the inclusion criteria were reviewed. Nine studies reported the frequency of asphyxial deaths caused by physical restraints, nine studies reported the long-term complication and indirect adverse effects of physical restraints and lap-belt use, and seven studies reported the benefits of physical restraints and lap belts with individuals using wheelchairs. Despite the weak evidence, the results suggest a considerable number of deaths from asphyxia caused by the use of physical restraints occurred each year in the U.S. The majority of the deaths occurred in nursing homes, followed by hospitals, and then the home of the person. Most deaths occurred while persons were restrained in wheelchairs or beds. Based on that, caution needs to be exercised when using restraints or positioning belts. In addition, other seating and environment alternatives should be explored prior to using restraints or positioning belts, such as power wheelchair seating options. Positioning belts may reduce risk of falls from wheelchairs and should be given careful consideration, but caution should be exercised if the individual cannot open the latch independently. Also, the duration of use of the physical restraint should be limited. Therefore, several factors should be considered when devising a better quality of physical-restraint services provided by health care professionals. These efforts can lead to improved safety and quality of life for individuals who use wheelchairs.     

Lap belt complex. Recognition & assessment of seatbelt injuries in pediatric trauma patients

That seatbelts save lives is irrefutable. Every health-care professional should advocate parents use proper restraint systems for their children. Resource guides are available from local, state and national organizations regarding proper restraint usage for the pediatric population. However, children restrained with lap belts are at risk of sustaining an occult injury. You must quickly stabilize the ABCs, immobilize the spine and get the patient en route to a trauma center while you perform a solid baseline assessment. The trauma team needs information on kinetics, type of restraints used, assessment findings and treatment rendered so they can accurately assess subtle changes in the patient's condition and initiate proper treatment.     

Strangulation associated with a passive restraint shoulder harness seatselt: case report

Diagonal shoulder harness restraint devices have been implicated as causes of neck trauma in motor vehicle accidents. This type of seatbelt is commonly used as an alternative to airbags in required passive restraint systems. A case of strangulation secondary to an automatically engaging diagonal shoulder harness used without the accompanying lap seatbelt is reported.     

Clinical Significance of the Seat Belt Sign as Evidence of a Compromised Occupant–Seat Belt Relationship

BackgroundSeat belt marks are seen frequently on occupants after motor vehicle accidents. Over the years, the clinical significance of these marks has changed as restraint systems have evolved. With modern restraint systems, signs of a compromised occupant–restraint relationship are an important and easily identified bedside finding.ObjectivesWe sought to learn to recognize seat belt marks that demonstrate an abnormal occupant–restraint system relationship and to cultivate an understanding of significant soft tissue biomechanical loading associated with marks caused by a compromised occupant–restraint relationship.DiscussionA review of case studies from the literature combined with forensic work demonstrate a strong correlation between significant injury and improper seatbelt use. When evidence of a compromised occupant–restraint relationship exists, incorporating computed tomography angiography and observation may be clinically indicated.ConclusionThe recognition of seat belt marks made by a compromised occupant–restraint relationship is an important finding that allows risk stratification of the patient at the bedside. Further investigation with a prospective trial at a trauma center is warranted.     

Visualization of C7-T1 on Portable Lateral Cervical Spine Radiographs Using a Lead-lined Acrylic Filter

Objective: To determine whether lead-lined acrylic cervical filters can improve the quality of portable lateral cervical spine (c-spine) radiographs for trauma patients.
Methods: Twenty trauma patients who required portable c-spine x-rays had these taken with a lead filter attached to the collimator of the portable x-ray machine to improve penetration and visualization of lower cervical structures without overpenetrating upper cervical structures. The radiographs of these patients were compared with the first portable c-spine radiographs without filters for 20 controls matched for gender and injury severity. The comparison of radiographs was done by an experienced emergency physician and a neuroradiologist blinded to whether the filter was used.
Results: The two groups were similar for demographic and clinical characteristics. There was a significant improvement in the ability to visualize the C₇-T₁ level for the filter group compared with the control group (65% vs 30%, p < 0.05). Agreement between the physicians was excellent (kappa = 0.79, 95% CI = 0.60-0.99).
Conclusions: Lead-lined acrylic filters improve the ability to visualize the lower c-spine in trauma patients.     

Update on restraint use in acute care settings.

This article will discuss alternatives to restraint use in the management of patients who have difficult behavior or an increased risk for injury in the acute care, surgical setting. A discussion of the efficacy and adverse effects of restraint use will be followed by review of new regulations established by HCFA and JCAHO and suggestions for care that minimizes restraint use.     

Child safety seat counseling: three keys to safety

The number one cause of death for children younger than 14 years is vehicular injury. Child safety seats and automobile safety belts protect children in a crash if they are used correctly, but if a child does not fit in the restraint correctly, it can lead to injury. A child safety seat should be used until the child correctly fits into an adult seat belt. It is important for physicians caring for children to know what child safety seats are available and which types of seats are safest. Three memory keys will help guide appropriate child safety seat choice: (1) Backwards is Best; (2) 20-40-80; and (3) Boost Until Big Enough. "Backwards is Best" cues the physician that infants are safest in a head-on crash when they are facing backward. "20-40-80" reminds the physician that children may need to transition to a different seat when they reach 20, 40, or 80 lb. "Boost Until Big Enough" emphasizes that children need to use booster seats until they are big enough to fit properly into an adult safety belt.     

Does the position of restraint of disturbed psychiatric patients have any association with staff and patient injuries?

The aim of this study was to examine the risk of injury among patients and staff following involvement in a restraint episode in relation to restraint position (standing, supine or prone) and other aspects of the pre-incident behaviour including perceived causation. Mixed effects logistic regression was used to estimate the relative odds of injury to staff or patient in a series of 680 restraint episodes involving 260 patients in an adult mental health service in England between 1999 and 2001. There was no statistically significant association between patient injury and restraint position in this sample, but a prone restraint position was weakly associated with staff injury. Staff injury was most likely when an actual assault had occurred prior to the incident. Patient injury was more likely when the patient had self-harmed, had been abusing substances and had used a weapon prior to the incident, and less likely when the patient was showing signs of frustration with their environment. The use of prone restraint may be weakly associated with an increased risk of injury to staff. However, other aspects of the incident are stronger predictors and should be considered when planning training for front line staff.     

Pilot study of safety belt usability for vehicle occupants seated in wheelchairs

This study investigates the usability of wheelchair occupant restraint systems (WORS) that are used for crash protection of individuals seated in wheelchairs during motor vehicle transit. Ten independent adults with significant functional limitations who use wheelchairs for primary mobility were observed and interviewed while performing reach and manipulation tasks associated with WORS usage. Participants' opinions on ease of use and comfort-related factors were obtained for four occupant restraint scenarios. The study results show evidence of user problems with common WORS designs for use by wheelchair-seated individuals with significant functional limitations. Results from this pilot study suggest redesign of latch plates and buckles used in WORS to enable wheelchair-seated individuals with functional limitations to don and buckle belt restraints more easily and independently. Additionally, this study provides guidance to occupant-restraint manufacturers and wheelchair designers regarding belt-restraint usability. Improved WORS usability will complement other efforts to increase frequency of safety belt usage and lead to improved occupant safety.     

Patient injury and physical restraint devices: a systematic review

OBJECTIVE: To investigate physical restraint-related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury. DEFINITIONS: Injury in the context of this review was considered to be either direct injury, such as lacerations and strangulation, or indirect injury considered to be an adverse outcome such as increased mortality rates or duration of hospitalization. METHOD: A comprehensive search was undertaken that involved all major databases and the reference list of all relevant papers. To be included in the review studies had to involve people in acute or residential care settings and report data related to injury caused by restraint devices. A number of different types of research designs were included in the review. The findings of studies were pooled using odds ratio and narrative discussion. RESULTS: The search identified 11 papers reporting the findings of 12 observational studies. These studies were supplemented with the findings of a number of other types of studies that reported restraint-related data. The review highlights the potential danger of using physical restraint in acute and residential health care facilities. Observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined. DISCUSSIONS: Many of the findings highlight the urgent need for further investigation into the use of physical restraint in health care facilities. Further research should investigate the magnitude of the problem and specific restraint devices associated with injury. However, given the limited nature of the evidence, this association should be investigated further using rigorous research methods.     

Applying basic principles of child passenger safety to improving transportation safety for children who travel while seated in wheelchairs

Occupant restraint systems are designed based on knowledge of crash dynamics and the application of proven occupant-protection principles. For ambulatory children or children who use wheelchairs but can transfer out of their wheelchair when traveling in motor vehicles, there is a range of child safety seats that comply with federal safety standards and that therefore offer high levels of crash protection. For children who remain seated in wheelchairs for travel, the use of wheelchairs and wheelchair tiedown and occupant restraint systems (WTORS) that comply with voluntary industry standards significantly enhances safety. Revisions to the initial versions of these standards will further improve safety for smaller children who travel seated in wheelchairs by requiring wheelchairs for children between 13 and 22 kg (18 and 50 lb) to provide a five-point, wheelchair-integrated crash-tested harness similar to that used in forward-facing child safety seats. While wheelchair and tiedown/restraint manufacturers, van modifiers, transportation personnel, clinicians, and others involved with children who use wheelchairs have clearly defined responsibilities relative to providing these children with safe transportation, parents and caregivers should be knowledgeable about best-practice in wheelchair transportation safety and should use this knowledge to advocate for the safest transportation possible.     

Mental health. Ethical standards and human rights.

In an earlier article in Nursing Standard (1), the author discussed the use of control and restraint techniques when dealing with violent or potentially violent situations. Here, he offers a nurse's perspective on the ethical and human rights issues which confront staff who are trying to cope with the challenging behaviours of their patients and who, as a last resort, may have to use physical restraint to prevent injury occurring. In intervening physically, nurses, he argues, must be aware of the legal and ethical boundaries of their practice.     

Toward Development of Effective Custom Child Restraint Systems in Motor Vehicles

Traveling safely in motor vehicles can be challenging for many families who have young children with physical disabilities. Harnesses, simple adaptations, and special child restraint systems are available, but sometimes these devices do not adequately meet the unique postural support requirements of children with complex seating needs. Faced with no alternative, parents may choose to use the custom seating system from a wheeled mobility device to support their children in the family car. Transporting children in this way can increase the risk of motor vehicle–related injury because custom seating systems are not designed to meet the requirements of federal motor vehicle safety regulations. We studied whether assistive technology suppliers could build custom child restraint systems that met the crashworthiness requirements of a safety standard for production child restraint systems. We provided technical instructions to 10 suppliers from different parts of North America so they could each build a custom restraint system using a transit frame that we designed. This approach allowed suppliers to make custom seats that could be attached to the transit frame using special connection hardware. We crash tested the 10 custom child restraint systems to evaluate the effectiveness of our transit frame design and fabrication instructions. Six custom restraint systems met the dynamic performance requirements of the stringent Canada Motor Vehicle Safety Standard 213.3. The remaining four systems did not meet the compliance criteria due to the failure of postural belt assemblies or seat securement hardware. We recommend that future research include similar effectiveness studies to support the introduction of technical requirements for adaptive seating systems that improve occupant safety and are practical for wheelchair users, their families, and assistive technology professionals to implement.     

Toward development of effective custom child restraint systems in motor vehicles

Traveling safely in motor vehicles can be challenging for many families who have young children with physical disabilities. Harnesses, simple adaptations, and special child restraint systems are available, but sometimes these devices do not adequately meet the unique postural support requirements of children with complex seating needs. Faced with no alternative, parents may choose to use the custom seating system from a wheeled mobility device to support their children in the family car. Transporting children in this way can increase the risk of motor vehicle-related injury because custom seating systems are not designed to meet the requirements of federal motor vehicle safety regulations. We studied whether assistive technology suppliers could build custom child restraint systems that met the crashworthiness requirements of a safety standard for production child restraint systems. We provided technical instructions to 10 suppliers from different parts of North America so they could each build a custom restraint system using a transit frame that we designed. This approach allowed suppliers to make custom seats that could be attached to the transit frame using special connection hardware. We crash tested the 10 custom child restraint systems to evaluate the effectiveness of our transit frame design and fabrication instructions. Six custom restraint systems met the dynamic performance requirements of the stringent Canada Motor Vehicle Safety Standard 213.3. The remaining four systems did not meet the compliance criteria due to the failure of postural belt assemblies or seat securement hardware. We recommend that future research include similar effectiveness studies to support the introduction of technical requirements for adaptive seating systems that improve occupant safety and are practical for wheelchair users, their families, and assistive technology professionals to implement.     

新型约束工具的使用特征及护理现状

[目的]分析重症监护病房(ICU)病人身体约束现状,探讨管理对策。[方法]对2011年1月—2011年6月我院ICU使用新型约束工具(安全背心、约束手的球拍手套、双保险约束带)的案例进行调查分析。[结果]身体约束的人群主要是老年人,病种是神经外科疾病占30.50%,约束的方式是以双上肢双保险约束带约束加穿球拍手套为主,护理人员对约束相关知识掌握不全,告知落实欠到位,主要引发的并发症为非计划性拔管,占27.84%。[结论]ICU身体约束使用规范不明确,约束知识及告知缺乏,应加强约束知识教育,规范操作流程,正确处理约束引起的并发症,能有效减少不良事件的发生。     

Continuous passive motion in the management of heterotopic ossification in a brain injured patient

We report a man admitted to inpatient rehabilitation 6 wk after traumatic brain injury, who presented with bilateral knee heterotopic ossification. In addition to conventional physical therapy, we applied a continuous passive motion device during 4 wk increasing the range of motion of the knees. On the basis of the limited current literature and this case, we suggest that the use of continuous passive motion devices for heterotopic ossification may be effective and safe and should be the subject of further study.