paediatric lap-belt injury: a 7 year experience

doi: 10.1111/j.1742-6723.2006.00809.x

Emergency Medicine Australasia

(2006)

18

, 57–63

© 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Blackwell Publishing AsiaMelbourne, AustraliaEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty Ltd20061815763Xxxx Xxxx

Paediatric lap-belt injuryM Shepherd

et al.

Correspondence: Dr James Hamill, Department of Surgery, Starship Children’s Hospital, Private Bag 92 024, Auckland, New Zealand.Email: [email protected]

Michael Shepherd, MBChB, Paediatric Emergency Medicine Fellow; James Hamill, MBChB, FRACS, Paediatric Surgeon; Elizabeth Segedin,MBChB, FRACP, FJFICM, Paediatric Intensivist.

P

AEDIATRIC

E

MERGENCY

M

EDICINE

Paediatric lap-belt injury: A 7 year experience

Michael Shepherd,

1

James Hamill

2,3

and Elizabeth Segedin

3,4

1

Children’s Emergency Department,

2

Department of Paediatric Surgery,

3

Starship Trauma Service, and

4

Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand

Abstract

Objective:

To highlight the injuries that result from lap-belt use and make recommendations forprevention, 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, withsignificant injury following involvement in a motor vehicle crash, while wearing a lap-belt. Patients were identified from two prospectively collected databases and dischargecoding data.

Results:

In total, 19 patients were identified over the 7 year period. The morbidity sustainedincludes 15 patients with hollow viscus injury, 13 laparotomies, 7 spinal fractures, 2paraplegia and 1 fatality. A total of 11 patients required laparotomy with a median delayof 24 h. Of patients in the present series, 58% were aged less than 8 years and thus wereinappropriately restrained.

Conclusions:

Lap-belt use can result in a range of life-threatening injuries or permanent disability inthe paediatric population. The incidence of serious lap-belt injury does not appear to bedecreasing. Morbidity and mortality could be reduced by the use of three-point restraints,age appropriate restraints and booster seats.

Key words:

child

,

injury

,

lap-belt injury

,

road traffic crash

,

seat-belt injury

,

wound

.

Introduction

The introduction of seat belts in the 1950s reducedfatalities from motor vehicle crashes for both adultand paediatric occupants.

1,2

Kulowski and Rost firstdescribed injuries from seat belts in 1956

3

and Garrettand Braunstein coined the term, ‘seat belt syndrome’ in1962.

4

The classic triad of abdominal wall echymosis,visceral injury and spinal injury is most frequentlyseen in occupants wearing two-point lap-beltrestraints.

5–7

Paediatric case reports of lap-belt injury have beendescribed previously.

8–15

Many of these reports includemultiple restraint types.

The present paper describes injuries from two-pointlap belts in children and reviews the relevant literature.

Methods

Retrospective review of children admitted to a regionalpaediatric trauma centre over the 7 year period, January

M Shepherd

et al.

58


1997–December 2003. Starship Hospital receivestrauma directly from two district hospitals, and coversa population of approximately 250 000 children. ThePaediatric Intensive Care Unit (PICU) provides servicesfor all New Zealand, a total population of around4 million people.

Cases were identified by: review of a prospectivelycollected PICU database (all PICU admissions); reviewof a prospectively collected trauma database (all traumaadmissions beyond the ED); discharge coding datausing the following ICD-9-CM and ICD-10-AM diag-noses – open or closed fracture of thoracic or lumbarspine with or without spinal cord injury; injury togastrointestinal tract; injury to other intra-abdominalorgans; injury to blood vessels of abdomen and pelvis;injury of intra-abdominal organs; injury of urinary andpelvic organs; injury of blood vessels at abdomen, lowerback and pelvis level.

Inclusion criteria were: age

≤

14 years; motor vehiclecrashes where the patient was restrained by a lap beltonly; admission to hospital beyond the ED (i.e. patientsseen in the ED and not admitted to another ward werenot included).

Exclusion criteria were: mechanism of restraintor injury unclear; injury limited to abdominal wallecchymosis.

Mechanism of injury, restraint type, demographic,clinical and injury details were obtained from a chartreview.

Abbreviated injury scores were calculated using Tri-Code coding software (Digital Innovation, Forest Hill,MD, USA) within a Collector trauma registry. Newinjury severity score (NISS) was calculated by summingthe squares of the highest three abbreviated injuryscores for each patient. NISS was chosen over the injuryseverity score because of its superior discriminatingpower in single body-region injuries (typical in lap-beltinjuries) and in children with severe injuries.

16

Results

Nineteen cases were identified and complete data wereable to be gathered on these cases. Two other possiblecases were excluded where the type of restraint was notdocumented clearly.

Demographics and mechanism

(Table 1)

In total, 19 children were admitted over the 7 yearperiod. More than half the children were aged less than

8 years including three who were under 5 years of age.Most children (84%) were sitting in the centre rear posi-tion of the motor vehicle. Three were sitting in the frontpassenger seat. The majority of injuries were sustainedin high-speed collisions (at least one vehicle thought tohave been travelling greater than 70 kph) on the openroad (74%).

Process of care

(Table 2)

Of patients in the present series 58% required inten-sive care admission (ICU). The median ICU stay was1 day, range 1–17 days. Total inpatient length of stayranged from 3 to 36 days, with median stay being11 days.

All patients in the present series had an abdominalCT scan, 18/19 of these on the day of presentation. Onepatient had a reportedly normal initial scan on day 1with subsequent scanning and laparotomy revealingsignificant bowel injury. Five patients had ‘free fluid’ astheir only abnormality on initial CT scan and all subse-quently required therapeutic laparotomy.

Of the 11 laparotomies performed, four took placeoutside our institution prior to transfer. All 11

Table 1.

Demographics and mechanism

n

(%)

Age (years)

<

5 3 (16)5–8 8 (42)8–14 8 (42)

SexMale 11 (58)Female 8 (42)

EthnicityNew Zealand European 9 (47)Maori 4 (21)Pacific Islander 2 (11)Other 5 (26)

Crash date1997–1999 7 (37)2000–2001 4 (21)2002–2003 8 (42)

Crash locationRural 14 (74)Urban 5 (26)

MechanismCar versus car 15 (79)Other 4 (21)

Position in vehicleCentre rear 16 (84)Other 3 (16)

Paediatric lap-belt injury


59

patients had a ‘therapeutic’ laparotomy with the dis-covery of hollow viscus perforation, ischaemic seg-ments, transection of bowel, or in one case ureterictransection.

Median time to laparotomy was 24 h. Five patientsproceeded to laparotomy more than 24 h after presenta-tion. Four of these five patients presented to our hospi-tal within 2 h of their injury.

Injuries, morbidity and mortality

(Table 3)

In total, 18 of 19 patients were documented to haveabdominal wall ecchymoses.

Of patients 79% (15/19) were found to have a hollowviscus injury (HVI), either on CT scanning or at lapa-rotomy. Many patients had multiple sites of intra-abdominal injury. Of patients with an HVI, 87% (13/15)had a jejunal or ileal injury as part of their injurycomplex.

In total, 11 hollow viscus perforations were found, 9involving jejunum or ileum, and 2 involving largebowel. All of the patients who proceeded to laparotomymore than 24 h after presentation were found to have ajejunal perforation at laparotomy.

Six of 15 patients with an HVI also sustained a spinalinjury.

Of all patients, 37% (7/19) sustained a thoracic orlumbar spine fracture, with two patients sustaining spi-nal cord injury. Six of these injuries were Chance frac-tures, with the other being a somewhat unusual fractureof T3. Four of the six patients with Chance fracturesrequired operative stabilization.

Other injuries were uncommon in the present series.Only one patient (7.5-year-old) sustained solid organinjury (liver and spleen). He was noted to have highabdominal wall ecchymosis suggesting a very highlap-belt position. One patient sustained major vesseldisruption in conjunction with hollow viscus andspinal injuries and subsequently died. One patientsustained injury to a ureter. No patients sustained asignificant head injury. One patient sustained a frac-tured limb.

Morbidity sustained by the patients included 17 lap-arotomies, 5 patients requiring total parenteral nutri-tion, 4 patients requiring spinal surgery and 2 patientswith paraplegia.

The median NISS was 10, range 5–45. The only mor-tality was in the patient with an NISS of 45.

Table 2.

Process of care

n

AdmissionsHospital days: median (range) 11 (3–36)Admissions to PICU 11PICU days: median (range) 1 (1–17)

CT scansDay 1 scan 18More than one scan 7

Initial CT scan reportNormal 5Free fluid only 5Free fluid

+

bowel injury 6Free air

±

other abnormality 3Laparotomy

Total patients 11Repeat laparotomies 2‘Non-therapeutic’ 0

Time to first laparotomyMedian: h 24

<

8 h 38–16 h 116–24 h 2

>

24 h 5

PICU, Paediatric Intensive Care Unit.

Table 3.

Injuries, morbidity and mortality

n

New injury severity score: median 10Abdominal wall ecchymoses 18Hollow viscus injury

Total 15Duodenum 5Jejunum/ileum 13Large bowel 4

SpineVertebral fracture 7Chance fracture 6Paraplegia 2Spinal fusion 4

Major vessel injury 1Other injuries

Head injury 0Solid organ 1Limb fractures 1Pelvic fractures 1Urological injury 1

MorbidityInfection 3Respiratory 3Renal failure 1

Mortality 1

M Shepherd

et al.

60


Discussion

Lap belts cause an injury complex that can includeabdominal wall injury, visceral injury (bowel andmesentery), lumbar spine fracture (with potential forspinal cord injury), pelvic fractures and injury to thegreat vessels. Paediatric patients using lap beltsare particularly vulnerable to sustaining this injurycomplex.

Abdominal wall ecchymoses were seen in the major-ity of patients in the present series, but the study design(patients with abdominal wall bruising as their soleinjury were excluded) means we are unable to add tothe existing information on the value of abdominal wallecchymosis as a marker of serious injury. The incidenceof HVI seen in patients with abdominal wall ecchymosishas been 37%,

12

36%,

17

15%

18

and

<

5%.

19

Overall, thesestudies suggest that abdominal wall ecchymosis alone,whereas associated with small bowel injury, is not aspecific marker for significant injury.

The HVI that occurs in the lap-belt complex arethought to be caused by the transmission of shearingforces between two fairly rigid structures, the spinalcolumn and the seat belt at the anterior abdominalwall.

20

The most typical injury is the seromuscular tearwhere the submucosa is torn from the inner circularmuscle layer.

21

This can result in mesenteric bleedingand can progress to delayed perforation when the under-lying submucosa and mucosa subsequently lose viabil-ity. Other injuries that can occur include closed loopperforations and complete transection of the bowel.

21

This HVI is difficult to diagnose. Serial examinationin the non-head-injured paediatric patient has beenshown to be accurate in the diagnosis of HVI.

22,23

How-ever, time to laparotomy is likely to be increased usinga conservative approach. Ultrasound is not an appropri-ate modality for the diagnosis of HVI.

24

Many otherstudies also describe difficulty in making the diagnosisof HVI using CT scanning.

19,25–27

Sivit

et al

. have sug-gested improved specificity (96%) and sensitivity (95%)of CT scanning by looking for the presence of one ormore of (i) moderate-to-large amounts of unexplainedfree fluid; (ii) unexplained extraluminal air; (iii) bowelwall enhancement; (iv) bowel wall thickening; or (v)bowel dilatation.

28

Delay in the diagnosis of HVI and a delayed laparo-tomy might increase morbidity and mortality. Someseries have found worse outcomes in patients with alaparotomy more than 24 h post injury.

22,29,30

Some pae-diatric series have found no increase in morbidity andmortality with delayed laparotomy.

31,32

In our series five cases required their first laparot-omy more than 24 h post injury despite CT scanningand serial examination. On chart review this delaycould not be explained by a delay in presentation.Instead this delay reflects the difficulty in diagnosingHVI and the delayed perforation that can occur follow-ing seromuscular tears. In our small series thesepatients did not have a significantly longer hospitaladmission, and did not have measurably greatermorbidity.

Spinal column injuries caused by lap belts are causedby hyperflexion with distraction of the posterior spinalelements, and are relatively unique because the axis ofrotation is more anteriorly located.

33

This type of injurywas first identified by Chance in 1948.

34

A spectrum offlexion distraction injuries has since been describedwith classification systems developed.

35

These injuriesare often not detected by standard abdominal CT scan-ning, therefore, plain radiographs or CT saggital recon-structions of the lumbar spine are required. Spinalcolumn injuries significantly increase the risk of HVI(and vice versa), but they are not sensitive or specificpredictors of each other.

9–12,19

Lumbar compression fractures have also beendescribed in children wearing lap belts,

12,14

but nonewere seen in this series.

These lap-belt injuries continue to occur in NewZealand and elsewhere

11–13

despite a worldwide call fortheir replacement with three-point lap and shoulderbelts and age-specific restraints. More than half of thecases occurred in the last 3 years of the 7 year studyperiod suggesting that the incidence of these injuries isnot decreasing.

Of patients in the present series 58% were aged lessthan 8 years, these children (and possibly others) wereinappropriately restrained in an adult seat belt only.Three patients were aged less than 5 years and weretherefore illegally restrained according to current NewZealand legislation. Current New Zealand legislationstates that children under 5 years of age must use anapproved child restraint, but children aged over 5 yearsare allowed to wear a seat belt if no child restraint isavailable.

The New Zealand motor vehicle fleet has a medianage of 10 years, with a high number of imported usedvehicles over the last 5 years. Most vehicles have lapbelts in the centre rear position, with lap/shoulderbelts in all other positions. Median vehicle age hasincreased somewhat over the last 10 years, probablyresulting in the persistence of centre lap belts in mostvehicles.



61

That seat belts save lives and reduce serious injuryhas been well demonstrated over many years.

1,2

It islikely that many patients in this series would havesustained more serious injuries if not restrained at all.However, three-point lap and shoulder belts, childseats and booster seats have an even greater ability toreduce morbidity and mortality than the two-pointlap belt.

36–38

Durbin

et al

. showed that belt-positioningbooster seats eliminated injuries to the spine andabdomen,

37

therefore age-appropriate restraint isessential.

We support recommendations for the introduction oflegislation to ensure two-point lap belts are rapidlyphased out. Similarly, legislation should require chil-dren who weigh less than 35 kg or whose height is lessthan 145 cm, to travel in a belt-positioning booster seat(age 8–12 years). There is evidence that the use ofappropriate legislation will improve restraint use.

39

The introduction of such legislation needs to be sup-ported by an education programme,

40

further enforce-ment of current seat-belt laws and initiatives to makechild restraints and booster seats more easily accessibleto the public.

The American Academy of Pediatrics has developedrecommendations for child seating and restraint inmotor vehicles.

41

They suggest seating children in theback seat where possible, using a child safety seatbefore progressing to a belt-positioning booster seat(with lap/shoulder belt). This should be used until ableto fit an adult seat and seat belt properly (usually at aweight greater than 35 kg). These recommendationsshould be familiar to all paediatric and emergency med-icine health workers.

The present review has limitations. Only cases sus-taining major injuries have been identified, this willserve to underestimate the morbidity sustained by ourstudy population.

Despite the use of two prospectively collected data-bases and discharge coding to find cases, it is possiblethat some cases of lap-belt injury were missed. Gener-ally, documentation of mechanism of injury andrestraint type by ambulance and ED staff was excellent;however, some cases were excluded where restrainttype was unclear. In addition, cases of lap-belt injurythat did not survive to hospital or beyond the ED havenot been included. These three limitations would serveto reduce the number of cases identified and thus onlyunderestimate the extent of this problem.

The present study excluded cases typical of ‘seat beltsyndrome’ where patients were wearing a three-point(shoulder and lap) restraint. These patients can sustain

a similar spectrum of injury, particularly in childrenaged less than 9 years, when the lap portion of the three-point restraint is often poorly positioned and the shoul-der portion might not be used correctly. These caseswere excluded in order to concentrate on issues sur-rounding two-point lap belts.

No cases in the present series were documented asusing a booster seat or car seat; however, some mighthave been missed in documentation at the crash scene.It is most likely however, that many of these patientssuffered their injuries because they were not placed inan alternative restraint.

Conclusions

Visceral injury (bowel and mesentery), lumbar spinefracture, pelvic fractures and injury to the great vesselsneed consideration when assessing patients restrainedby lap belts. The difficulty in diagnosing hollow viscusinjury should be recognized.

Lap belts continue to cause significant morbidity andmortality. The incidence of these injuries is not decreas-ing. This morbidity and mortality could be reducedby the use of three-point restraints, age-appropriaterestraints, booster seats and harnesses. Lap beltsshould be rapidly phased out, and resources directedtowards increasing the use of age-appropriaterestraints.

Acknowledgements

We would like to thank Dr Richard Aickin (ClinicalDirector, Children’s Emergency Department, StarshipHospital, Auckland) for reviewing the manuscript.

Author contributions

MS performed the chart reviews. MS and JH carried outdata analysis, literature review and preparation of themanuscript. ES designed the study and reviewed themanuscript.

Competing interests

None declared.

Accepted 8 September 2005

M Shepherd

et al.

62


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