A Small Family Was Traveling in Its Van and Had a Minor Accident
Tin J Surg. 2005 Oct; 48(5): 373–376.
Linguistic communication: English | French
Seat-belt injuries in children involved in motor vehicle crashes
Miriam Santschi
From the Departments of *Pediatrics and †Surgery, Kinesthesia of Medicine, Université de Sherbrooke, Sherbrooke, Que.
Vincent Echavé
From the Departments of *Pediatrics and †Surgery, Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Que.
Sophie Laflamme
From the Departments of *Pediatrics and †Surgery, Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Que.
Nathalie McFadden
From the Departments of *Pediatrics and †Surgery, Kinesthesia of Medicine, Université de Sherbrooke, Sherbrooke, Que.
Claude Cyr
From the Departments of *Pediatrics and †Surgery, Kinesthesia of Medicine, Université de Sherbrooke, Sherbrooke, Que.
Abstruse
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-chugalug syndrome" refers to the spectrum of injuries associated with lap-chugalug 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-indicate restraints. All had abdominal lap-belt ecchymosis and multiple abdominal injuries due to the mutual mechanism of seat-chugalug compression with hyperflexion and lark during deceleration. Five of the children had lumbar spine fractures and 4 remained permanently paraplegic.
Conclusions
These incidents illustrate the need for astute 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 suit them to fit smaller passengers, including older children.
Résumé
Contexte
L'efficacité des ceintures de sécurité pour réduire le nombre des décès causés par les collisions de véhicules à moteur est bien documentée. On a toutefois relevé une association particulière entre certains traumatismes et le port de la ceinture de sécurité chez les adultes et les enfants. Le «syndrome de la ceinture de la sécurité» désigne l'éventail des traumatismes associés aux ceintures ventrales, et en particulier les traumatismes de flexion-lark de la colonne (fractures de Gamble).
Méthodes
Nous décrivons les traumatismes subis par huit enfants, dont deux paires de jumeaux, dans trois accidents de véhicules à moteur.
Résultats
Tous les enfants prenaient place à l'arrière et portaient une ceinture ventrale ou à trois points. Tous ont subi une ecchymose causée par la ceinture ventrale et de multiples traumatismes abdominaux à cause du mécanisme usuel de compression par la ceinture de sécurité avec hyperflexion et distraction au cours de la décélération. Cinq des enfants ont subi une fracture à la colonne lombaire et quatre sont demeurés paraplégiques en permanence.
Conclusions
Ces incidents démontrent qu'il faut être vivement conscient du spectre complet des traumatismes intra-abdominaux et rachidiens, à la suite de collisions de véhicules à moteur, chez les enfants passagers attachés, ainsi que de la présence des ceintures arrières à baudrier et de la possibilité de les ajuster pour des passagers plus petits, y compris des enfants plus âgés.
School-aged children are a special grouping with respect to occupant restraint systems in motor vehicles. Four- to 9-year-old children outgrow the child condom seats designed for younger children and are often restrained in seat belts designed for adults.1 Compared with infants and younger children, school-aged children have a lower heart of gravity, and their trunk habitus differs from that of adults in 2 ways: the intra-abdominal organs are less protected by the bony thorax and pelvis, and the iliac crests are not fairly adult to serve as anchor points for the belt, allowing the belt to ride up over the abdomen.two
The efficiency of seat belts in reducing deaths from motor vehicle crashes is well documented.3 A unique association of injuries, all the same, has emerged in adults and children with the use of seat belts.4 , five , six , vii The "seat-belt syndrome," starting time described by Garrett and Braunsteinviii in 1962, referred to the spectrum of injuries associated with lap-chugalug restraints. These injuries include partial- and full-thickness abdominal injuries, mesenteric disruption, lumbar spine dislocation and fractures. The entire grade of seat-belt-related flexion-distraction injuries to the spine are ordinarily referred to as Chance fractures. These fractures are about likely caused past hyperflexion around a lap belt, with the belt acting as a fulcrum, subjecting the vertebrae to tension and distraction.9 This machinery of hyperflexion and lark would explain not simply these fractures but also the frequent association of intra-abdominal injuries as viscera are crushed between the lap chugalug and the spine. The spinal fractures are dissimilar in the pediatric population from those in adults. Children oftentimes accept a combination of bone and soft-tissue injury. Their spinal injuries commonly involve several levels, and paraplegia is seen more frequently. Several specific characteristics make children especially vulnerable to this kind of injury. They have a higher centre of gravity than adults, creating a greater distraction. Furthermore, because the iliac crests take not adult, the lap belt tends to be placed over the abdomen, contributing to the abdominal and spinal injuries during rapid deceleration.10 In this instance series we describe the different injuries sustained by viii children including two sets of twins in iii different motor vehicle crashes.
Case analysis
Eight children (4 girls, iv boys, ranging in age from 8–12 yr) involved in multiple-victim motor vehicle crashes were seen at the Centre Hospitalier Universitaire de Sherbrooke betwixt September 2000 and May 2001 (Table 1 eleven).
Table 1
The offset blow (crash 1 in Table i) included 3 siblings (1 girl and twin boys). The minivan in which they were passengers collided head-on with a calorie-free truck at high speed (100 km/h). The front seat passenger was killed on impact. The second blow (crash 2) involved twin girls riding in the rear seat of a passenger automobile. The vehicle collided head-on with another passenger automobile at loftier speed. The third accident (crash three) involved 3 children. The driver lost command of a minivan at high speed, and the van rolled over.
Case example
This 12-twelvemonth-quondam girl was restrained in the dorsum seat of a minivan at the time of a head-on collision. She had lost consciousness when emergency personnel arrived. On admission, her Glasgow Coma Scale score was 5. She was tachycardic (heart rate 150 beats/min) and hypotensive (blood pressure 70/palpable mm Hg). Her condition improved after 1-litre bolus of crystalloid.
Pertinent physical findings included an surface area of ecchymosis just above the umbilicus, abdominal amplification and guarding. Rectal sphincter tone was absent. The lower extremities were flaccid, and deep tendon reflexes were absent bilaterally.
Because of her hemodynamic instability, she was taken chop-chop to the operating room, and a damage command approach was used. An incision was fabricated from the xiphisternum to the pubis. Immediate bleeding control was necessary, and this was initially accomplished with iv-quadrant packing with multiple large abdominal packs. Renal injury with an expanding hematoma was dealt with by right nephrectomy. Haemorrhage liver injuries were treated with big hemostatic sutures and packing. A big correct diaphragmatic laceration was closed. Bleeding mesenteric and mesocolon lacerations were sutured. Aortic control was necessary at this stage and was achieved at the diaphragmatic hiatus by aortic cross-clamping. The duodenum was found to be transected 1 cm distal to the papilla of Vater with a v-cm duodenal gap distal to the injured area. The proximal duodenum was closed temporarily, carefully preserving the papilla, with adequate external drainage. The distal duodenum was closed proximal to the ligament of Treitz. Packing to control nonarterial hemorrhage allowed the girl to exist transferred to the intensive intendance unit of measurement to go along resuscitation and correct her coagulopathy and hypothermia. Abdominal closure was rapid and temporary. Only the skin was airtight with multiple towel clips.
The patient was actively warmed. Perfusion was restored by intravenous infusion of warmed crystalloid, administration of blood and inotropic support. Coagulopathy was treated by giving fresh frozen plasma, cryoprecipitate and platelets, and correcting hypothermia and acidosis.
The spine was visualized past evidently movie radiography, which showed a Run a risk fracture at T12–L1 (Fig. 1). Open reduction and posterior stabilization of the spine were washed. There was no neurologic recovery.
FIG. 1. Plain film of the lumbar spine shows a Adventure fracture at T12–L1.
20-four hours after, the remaining small intestine was completely feasible. Cholecystectomy, gastrostomy and pyloric exclusion were performed with adequate drainage of the duodenal stump, and a feeding jejunostomy was established. After full recovery of nutritional status, 4 months after injury, a gastrojejunostomy and a Roux-en-Y jejunoduodenostomy were performed to re-establish duodenal continuity. Her general status improved and no major abdominal complication was noted at follow-up. The patient returned habitation later undergoing treatment in a rehabilitation centre.
Discussion
The children in this series demonstrate that, with the common mechanism of seat-belt compression with hyperflexion and distraction during deceleration in a motor vehicle crash, the md should consider the complete spectrum of spinal and intra-abdominal injuries when a school-anile kid has been restrained by a seat belt and been involved in such a motor vehicle crash. The impact of a relatively high-riding restraint compresses the fixed duodenum against the lumbar spine, leading to a high rate of injury.
Crash 1 resulted in a family disruption; i of the parents died and the 3 surviving children were paraplegic. The prevalence of this syndrome may be rare (0.four%), but the burden of injuries is of great importance.2
The hallmark indicator of the seat-belt syndrome is abdominal wall ecchymosis, suggesting the blueprint of a lap belt.12 Many children with intestinal injury caused by blunt trauma have equivocal or absent physical findings. Peritoneal signs may be missed in presence of the associated tender rectus muscle hematomas or contusions. All of the children in our series had abdominal wall ecchymosis, and six of the 8 had hollow-viscus injuries. Repeated physical examinations of the abdomen are mandatory equally the signs of peritoneal irritation can be missed when the child arrives at the infirmary. Furthermore, diagnosis of hollow-viscus injury in children is difficult even with CT and merely a close clinical follow-upward can help identify children with these injuries.12 , 13 , 14
In contrast to abdominal wall ecchymosis, Run a risk fractures are more than readily catalogued considering the radiologist often acts as a second screen in identifying such fractures.
In our patients, all 5 children with a Chance fracture had hollow-viscus injury. Albanese and associates15 reported a 17% incidence of Chance fractures with a hollow-viscus lesion in children just did non include the frequency of Take chances fractures for all blunt trauma patients during the study period. Examining the epidemiologic characteristics of seat-belt-associated injuries, Anderson and assemblyii constitute that x of 16 patients (62%) with Gamble fractures had hollow-viscus injury.
To our noesis, this is the offset case serial that reports on twins with seat-belt syndrome. It is also one of few reports of multiple pediatric victims with seat-chugalug syndrome.16 These incidents illustrate the need for back-seat restraints that include shoulder belts and the ability to adapt them to fit small people, including older children. Near of the children described hither were properly restrained in the back seat with lap belts only or 3-point belts. None of them was restrained in a booster seat. Adult seat belts practice not provide protection equivalent to child condom or booster seats. In examining the relationship betwixt type of restraint used (lap chugalug v. lap belt with shoulder harness) and injury pattern, Anderson and associates2 showed that lap belts were associated with an increased risk of hollow-viscus injury as well as Chance fractures. The proper fitting of lap belts and the addition of shoulder harnesses, or utilise of booster seats when advisable, may affect this injury pattern and reduce the injuries described hither.
Notes
Presented in part at the annual meeting of the Canadian Paediatric Lodge, Toronto, Ont. June 12–sixteen, 2002.
Competing interests: None alleged.
Correspondence to: Dr. Miriam Santschi, Département des Soins Intensifs, Hôpital Ste-Justine, 3175, ch. Côte Ste-Catherine, Montréal QC H3T 1C5; fax 514 345-7731; moc.oohay@ihcstnasmairim
Accepted for publication Aug. 23, 2004.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211905/
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