Stanford University Medical Center

Trauma: Case Presentation

Ronald Jou

19 March 2007

Ring Down

• 7year-old girl• Rear passenger• Lap belt restraint (shared)• Car traveling at freeway speeds• Tire blew out• Impact on median divider

Trauma Survey

• 1° survey:• Patient vomiting• No life-threatening injuries

• Vitals stable• Hx of abd pain and vomiting that AM• No medication allergies or PMHx• Patient had no complaints

Trauma Survey

• 2° survey:• Abdomen soft, non-tender• Abrasion over left iliac crest

• Repeat survey:• Somnolent• CT head: negative• Patient admitted to PICU

PICU Course

• Linear bruising across abdomen• Abdominal pain and tenderness

• CT abdomen/pelvis obtained

Operating Theater

• Diagnostic laparoscopy:• Moderate stool• Mild blood• Sigmoid perforation• Conversion to open laparotomy

Operating Theater

• Exploratory laparotomy:• Full thickness sigmoid perforation• No other injuries seen• Six hours had elapsed since injury

Operating Theater

• Treatment:• Resection of injury• Loop sigmoid colostomy

Seatbelts

• Sir George Cayley, ca. 1800• Implemented in aircraft, 1930s• Standard for U.S. automobiles, 1964• Rear belts standard in U.S., 1968

Seatbelt Innovations

• Three-point belt, 1958• Vehicle sensors• Pretensioners, 1981• Webclamps• Rip-stitching

U.S. Seatbelt Usage Rates

Year Usage rate

1980 10%

1984 15%

1990 50%

2003 75%

Please Wear Your Seatbelt

• No randomized controlled trials• Only cohort data is available• Seatbelt laws reduce fatality by 7-10%

Patterns of Injury

• Severe head injury• Facial injury• Solid organ injury• Long-bone fracture

• Hollow viscus injury• Sternal fracture• Lumbar spine

“Seatbelt Sign”

• Linear ecchymosis of the abdominal wall

“Seatbelt Sign”

• Seen in 60% of 112 adults in MVC• 64% v. 9% had abdominal injury• 36% v. 4% required operation• 35% v. 3% had hollow viscus injury

“Seatbelt Sign”

• MVCs in EAST multi-institutional study• 4.7-fold increase in small bowel

perforation in MVCs.

Problem

• Seatbelt injuries are difficult to diagnose• No ideal diagnostic test• Delays in diagnosis lead to morbidity

Solution

• Patients with seatbelt sign need workup• CT abdomen/pelvis• Serial examinations• DPL

Questions

• Chest seatbelt sign?• Does an abrasion count?

• Safer seatbelts?• Increasing usage in high-risk groups?