A prospective study of children aged <16 years in motor vehicle collisions in Norway: severe injuries are observed predominantly in older children and are associated with restraint misuse

Close to zero preventable in-hospital deaths in pediatric trauma patients - An observational study from a major Scandinavian trauma center

BACKGROUND

In line with international trends, initial treatment of trauma patients has changed substantially over the last two decades. Although trauma is the leading cause of death and disability in children globally, in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system. To evaluate the performance of a major Scandinavian trauma center we assessed treatment strategies and outcomes in all pediatric trauma patients over a 16-year period.

METHODS

A retrospective cohort study of all trauma patients under the age of 18 years admitted to a single institution from 1st of January 2003 to 31st of December 2018. Outcomes for two time periods were compared, 2003-2009 (Period 1; P1) and 2010-2018 (Period 2; P2). Deaths were further analyzed for preventability by the institutional trauma Mortality and Morbidity panel.

RESULTS

The study cohort consisted of 3939 patients. A total of 57 patients died resulting in a crude mortality of 1.4%, nearly one quarter of the study cohort (22.6%) was severely injured (Injury Severity Score > 15) and mortality in this group decreased from 9.7% in P1 to 4.1% in P2 (p<0.001). The main cause of death was brain injury in both periods, and 55 of 57 deaths were deemed non-preventable. The rate of emergency surgical procedures performed in the emergency department (ED) decreased during the study period. None of the 11 ED thoracotomies in non-survivors were performed after 2013.

CONCLUSION

A dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention strategies to further decrease pediatric trauma related mortality.

Young adults in motor vehicle collisions in Norway: user safety errors observed in majority of cases with severe or fatal injuries

PURPOSE

We performed a multidisciplinary investigation of young adults involved in motor vehicle collisions (MVCs) to elucidate injury mechanisms and the role of passive safety equipment such as seat belts and airbags.

METHODS

MVCs resulting in death or serious injuries to the driver or passengers aged 16-24 years in southeastern Norway during 2013-2016 were investigated upon informed consent. We assessed the crash scene, the motor vehicle (MV) interior and exterior, and analyzed data from medical records, forensic autopsies and reports from police and civil road authorities.

RESULTS

This study included 229 young adult occupants involved in 212 MVCs. The Maximum Abbreviated Injury Scale (MAIS) score was ≥2 in 111 occupants, of which 22 were fatalities. In 59% (65/111) of the cases with MAIS score ≥2 injuries, safety errors and occupant protection inadequacies were considered to have contributed to the injury outcome. Common errors were seatbelt non-use and misuse, carrying insecure luggage, and the seat back being too reclined. MAIS score ≥2 head/neck injuries were observed in side impacts despite correct seatbelt use, related to older MVs lacking side airbag curtains. The independent risk factors for MAIS score ≥2 injuries included not using a seatbelt, driving under the influence of alcohol or drugs, nighttime driving, side impacts, heavy collision partner, and MV deformation.

CONCLUSION

User safety errors (not using a seatbelt, seatbelt misuse, excessive seat-back reclining, and insecure cargo) and a lack of occupant protection in older MVs resulted in young adults sustaining severe or fatal injuries in MVCs.

The effectiveness of booster seat use in motor vehicle collisions

BACKGROUND

Alberta remains the only province in Canada without booster seat legislation. To date, analyses of booster seat effectiveness compared with seatbelt only use have demonstrated mixed findings using observational data.

METHODS

This study uses Alberta police collision report data for the years 2010-2016, inclusive. Using a case-control study design, children aged four to eight years, who were reported by police to be injured (cases), were compared with uninjured controls for restraint use (seatbelt, booster seat or no restraint). Logistic regression was used to estimate the relation between booster seat use and injury with adjusted odds ratios (aORs) and 95% confidence intervals (CI), stratified by collision types.

RESULTS

There were 12,922 children involved in collisions, of whom 570 were injured. Approximately 62% of all children included in the analysis were in a booster seat or safety seat at the time of collision. Crude analysis indicates higher odds of injury for seatbelt wearers compared with booster seat use (OR = 1.21; 95% CI: 1.02-1.44). Front-end vehicle-vehicle collisions, demonstrated higher odds of injury for seatbelt wearers relative to those in booster seats (aOR = 1.46; 95% CI: 1.03-2.07).

CONCLUSION

This analysis indicates a protective effect of booster seats that varies depending on the type of collision and impact location. These regionally-specific injury data may encourage and inform policy on the use of booster seats. Moreover, stratification by collision type may be necessary to inform analyses on booster seat effectiveness.

Serious motor vehicle collisions involving young drivers on Norwegian roads 2013-2016: Speeding and driver-related errors are the main challenge

Objective: Motor vehicle collisions (MVCs) are a leading cause of death and acute disability among young adults worldwide. We performed a prospective study of young drivers involved in severe MVCs, investigating the critical events leading up to a collision with an emphasis on driver-related factors and collision culpability. Methods: A study was conducted in southeastern Norway of all drivers younger than 25 years who were involved in high-energy MVCs resulting in immediate hospitalization during 2013-2016. Collision investigators evaluated the exterior and interior of the motor vehicle (MV) within 24 h. Complementary information was obtained from interviews of collision victims, ambulance personnel and witnesses, from police reports, and medical records.Results: There were 145 young drivers included during a 3-year study period, representing an estimated incidence of 29 per 100,000 drivers with registered driving licenses. Ninety-two percent (133/145) were considered culpable of initiating the MVC, and only 2% of the critical factors preceding the collision were not related to the driver. There were 74% (108/145) males, the median MV (motor vehicle) age age was 14 years, and 86% (125/145) of the MVs were passenger cars. The MVCs predominantly occurred on rural roads (90%, 130/145). Among the culpable drivers, speeding behavior was the main predisposing factor in 80% (106/133) of the collisions. Driving at excessive speed was associated with single-vehicle collisions (87%, 74/85) and the presence of passengers (89%, 56/63). Compared to nonculpable drivers, culpable drivers were more often younger than 21years (66% vs 33%, p = 0.031), had obtained their license less than 2 years previously (68% vs 20%, p = 0.004), and were more likely to have been drinking or using drugs (27% vs 0%, p = 0.039). The overall rate of seatbelt use was 79% (114/145).Conclusion: The vast majority of injury-causing MVCs involving young drivers are initiated by those drivers. These incidents are characterized by male drivers with little driving experience who are operating old cars on rural roads at excessive speeds. Driving under the influence of alcohol or drugs is also not uncommon. These issues should be targeted in future preventive measures.

Restraint Factors and Child Passenger Deaths in New South Wales, Australia

Inappropriate or incorrect use of child restraints can influence crash injury outcome. This study examined the role of restraint factors in child passenger deaths and the effect of legislation requiring appropriate restraint systems up to 7 years old. Data for child (0–12 years) passenger deaths occurring in New South Wales (NSW) from 2007 to 2016 were collected by the child death review team including photographs, reports of in-depth crash investigation, witness reports and medical reports. Restraint use, type of restraint, appropriateness of the restraint for the age of the child and correctness of restraint use were examined. The primary contributor to death was determined in each case. Sixty-four child passengers died in NSW during the data period. Twenty-nine (29/64, 45%) were properly restrained. Thirteen children (13/64, 20%) were unrestrained. In 20 cases (20/64, 31%), children were using a restraint that was either inappropriate for their age (6) or not used correctly (14). Restraint factors were a primary contributor in 22 (22/64, 34%) child deaths. Compared to pre-legislation, appropriate restraint use was more common post-legislation (13/22. 59% vs. 30/42, 71%). However, incorrect use was also greater (3/22, 14% vs. 11/42, 26%). Interventions targeting increasing restraint use and reduction of common ‘use’ errors are needed to prevent further restraint factor-related deaths.

Increased risk of fatal paediatric injuries in rural Northern Norway

Background

Finnmark, Northern Norway, had a mortality rate for paediatric injury in 1998‐2007 that was more than twice the national average. We investigated whether this rate had decreased in 2008‐2015 after improvements in emergency care. We also compared the mortality rate to rates of non‐fatal injury and trauma team activation both regionally and in Norway.

Methods

The study was based on 4 national registries. Mortality and injury rates were calculated per 100 000 persons per year. The study population was divided into age groups; 0‐5, 6‐10, 11‐15 and 16‐17 years.

Results

Between 1998‐2007 and 2008‐2015 there was an overall decrease in paediatric mortality rate due to external causes in Norway in total from 7.1 to 4.0. Despite this, in 2008‐2015, the mortality rate remained 2.5 times higher in Finnmark than in Norway (9.7, RR = 2.5 CI 1.4‐4.3, P = 0.001), similar to findings for 1998‐2007. Finnmark had half the rate of non‐fatal injuries in 1999‐2007 (5052, RR = 0.6, 95% CI 0.6‐0.7, P < 0.001) and in 2008‐2015 (3893, RR = 0.5, 95% CI 0.5‐0.6, P < 0.001) as in Norway. The rate of trauma team activation was similar in Finnmark and Norway.

Conclusions

The risk of injury‐related death remained significantly higher, while the overall risk of non‐fatal injury was significantly reduced for children in rural Northern Norway. Thus, injuries in this rural area seem to be less frequent but more severe. There is a need for detailed examination of each death to determine possible preventive measures.

The impact of booster seat use on child injury and mortality: Systematic review and meta-analysis of observational studies of booster seat effectiveness

OBJECTIVE

To determine through systematic review and meta-analysis of observational studies if booster seats, compared to seatbelts alone, reduce injury and mortality from motor vehicle collisions among child passengers four to eight years of age.

METHODS

A comprehensive search of several data sources (including Medline, Embase, and PsycINFO) was conducted from inception to December 2016, to retrieve relevant publications in any language and from any geographic region. Data extraction was completed by two independent reviewers, capturing: study details, population characteristics, exposure (booster seat compared to seat belt use), outcomes (injury and fatality), and all associations reported between the exposure and outcomes. Risk of bias assessment was completed by two reviewers using the QUIPS tool. Meta-analysis of sufficiently similar studies was conducted using random effects models.

RESULTS

Eleven observational studies were included in qualitative syntheses. The systematic review and meta-analysis found no association between booster seat use, compared to seatbelts, and reduced injury (4 studies, OR 1.03; 95% CI 0.53-1.99) or fatality (2 studies, OR 0.91; 95% CI 0.73-1.13).

CONCLUSIONS

Evidence on booster seat effectiveness to protect against injury and mortality in real-world conditions is limited. This review identified the need for high quality studies assessing the effects of different models of booster seats on children of varying ages and weights.

Has Child Restraint System Use Increased among Parents of Children in Shantou, China?

OBJECTIVE

to examine parents' use of child restraint systems (CRS), and determine if parents' knowledge of, attitude toward, and use behavior of child restraint systems have improved following enactment of child restraint use laws in other cities.

DESIGN

Observations and a cross-sectional survey of drivers transporting children 17 years and under were conducted at the gate of the schools and parking lots of hospitals in Shantou. Observers recorded the seating location of child passengers, the type of restraint, and appropriate use of CRS and safety belts based on the observation. Knowledge of and attitudes towards use of CRS were reported by the driver following observation.

RESULTS

Approximately 6.6% of passengers aged 0-12 were in CRS; rate of forward-facing CRS in children aged 3-5 (9.9%) was higher than rear-facing CRS for children aged 0-2 (1.1%) and booster seat use among children aged 6-12 (0.1%). Children younger than four years old (OR = 3.395, 95% CI = 2.125-5.424), drivers having a college or higher lever education (OR = 2.908, 95% CI = 1.878-4.500) and drivers wearing seatbelt (OR = 3.194, 95% CI = 1.605-6.356) had greater odds of CRS use. Over half (56.6%) of parents might or would use CRS if they could rent CRSs with fees.

CONCLUSIONS

The rate of CRS is still low in Shantou. Comprehensive public education programs supported by legislation might be an effective way to improve child passenger safety. Renting CRSs to parents could be a new approach to encourage use.