Airbags and children: a spectrum of C-spine injuries

Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation

Children involved in car crashes can experience either direct trauma or inertial injuries resulting from interactions with external objects, such as other vehicles, or with the restraint system. Furthermore, improper use of restraint systems can lead to additional severe injuries. Recent reports from international institutions underscored the persistent prevalence of inadequate restraint systems utilization and this widespread issue increases children's vulnerability and risk of injuries.The aim of this study is to provide a systematic review of the literature on injuries sustained in children involved in road accidents describing and analyzing elements useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving pediatric passengers. A total of 69 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the accident was examined and discussed.The review highlights that in motor vehicle accidents involving children, the forensic evaluation of both the cause of death and accident dynamics needs to consider several factors, such as the child's age, the type of restraint system employed, and the specific passenger seat occupied. Considering the complexity of the factors that can be involved in this road accident, it is crucial that there is a comprehensive exchange of information between the judge and the medical expert.

Factors involved in the assessment of paediatric traffic injuries and deaths

Motor-vehicle collisions are the leading cause of unintentional injury and death in children in many parts of the world, including Europe, North America and Australia. The number of fatal collisions has decreased considerably in countries where safety measures such as child restraints, seat belts and air bags have been introduced, providing protection for children within vehicles, although it is recognised that there have been concomitant improvements in emergency responses and techniques, and in hospital treatments. Helmets and changes in external vehicle designs have been implemented to protect paediatric pedestrians and cyclists. However, despite the development of safety guidelines and technologies, injuries still occur. This paper provides an overview of the role of motor-vehicle collisions in paediatric morbidity and mortality to analyse the nature and aetiology of common fatal and non-fatal injuries in children that may present for forensic assessment as passengers, pedestrians or cyclists.

The role of seating position in determining the injury pattern among unrestrained children involved in motor vehicle collisions presenting to a level I trauma center

BACKGROUND AND OBJECTIVES

Seating position in motor vehicle collisions (MVC) plays a major role in determining the injury pattern in mainly restrained children. However, compliance with child seating and restraint laws is still suboptimal. The role of seating position in predicting injury patterns among unrestrained children has not been previously studied.

DESIGN AND SETTING

Retrospective review based on the trauma registry of a level I trauma center in Riyadh, Saudi Arabia. Data collection was restricted to unrestrained children involved in MVC.

PATIENTS AND METHODS

Between July 2001 and March 2010, 274 records were identified. Detailed information about the collision, child seating position and the use of restraints was cross-verified using parental phone interviews.

RESULTS

Of the 274 identified records, cross-verification was possible for 89 (32.4%) unrestrained children, 64 boys and 25 girls, with a mean (SD) age of 83 (40) months. Of these children, 41 (46.1%) were front seated (FS), and 48 (53.9%) were back seated (BS). There were higher rates of rollover (52.1% vs 24.4%, P=.02), ejection (41.7% vs 22%, P=.05), and occupant death ratio (14.8 vs 4, P=.04) among BS children. However, the two groups did not differ in pediatric trauma scores, Glascow coma scale score, or age distribution. FS children were more likely to present with isolated head, neck or facial injuries (HNFI) (51.2% vs 25%, P=.01), whereas BS children were more likely to suffer long bone or pelvic fractures (LPF) (60.4% vs 36.6%, P=.025).

CONCLUSION

Injury pattern can vary according to seating position among unrestrained children presenting at trauma centers after MVC. While FS children are more likely to present with HNFI, BS children more often sustain LPF. BS children had similar trauma severity compared with FS children despite the higher-impact nature of their MVCs. While highlighting the value of proper restraints use and seating position, these results can be valuable in the initial assessment of traumatized children involved in MVC.

Cervical spine injuries associated with the incorrect use of airbags in motor vehicle collisions

STUDY DESIGN

Retrospective database review and analysis.

OBJECTIVE

The purpose of this study is to determine the rate of cervical spine injuries with correct and incorrect use of front driver and passenger-side airbags. Summary of Background Data. Although there are abundant literature showing reduced injury severity and fatalities from seatbelts and airbags, no recent studies have delineated the affect of incorrect use of airbags in cervical spine injuries.

METHODS

The database from the Pennsylvania Trauma Systems Foundation was searched for drivers and front-seat passenger injuries from 1990 to 2002. The resulting records were then grouped into those using both seatbelt and the airbag, airbag-only, seatbelt-only, and no restraints. The data were then analyzed for frequency of cervical spine fractures with or without spinal cord injury and injury severity indexes.

RESULTS

The drivers using the airbag-only had significantly higher rate (54.1%) of cervical fractures than those using both airbag and a seatbelt (42.1%). Overall, drivers using the airbag-alone were 1.7 times more likely to suffer a cervical spine fracture than those using both protective devices. Likewise, passengers using the airbag-alone were 6.7 times more likely to suffer from a cervical spine fracture with spinal cord injury than those using both protective devices. In addition, the injury severity indexes (Glasgow coma scale, Injury Severity Score, Intensive Care Unit stays, and Total Hospital days) were significantly worse in patients who used an airbag-only.

CONCLUSION

Airbag use without the concomitant use of a seatbelt is associated with a higher incidence of cervical spine fractures with or without spinal cord injuries. Airbag misuse is also associated with higher Injury Severity Score, lower Glasgow coma scale, and longer intensive care unit and total hospital stays, indicating that these patients suffer worse injury than those who use the airbag properly.

Pediatric cervical spine instability

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.

Cervical spine trauma in the pediatric patient

Injuries to the pediatric cervical spine occur infrequently. Numerous unique anatomic and biomechanical features of the pediatric spine render it much more flexible than the adult spine. These features give rise to significant differences in the presentation, diagnosis, treatment, and prognosis of pediatric cervical trauma compared with adults. Younger children more often suffer injury to the upper cervical spine with greater neurologic injury and fewer fractures. Once the child reaches the age of 10 years, he or she develops a more adult-type spine, and injuries are thus more similar to those seen in the adult population. The unique anatomic and biomechanical differences in the pediatric spine are discussed, along with the various common and unique injuries.

[Traumatic atlanto-occipital dislocation as part of a complex cervical spine injury. Case report in a 12-year-old girl]

Traumatic atlanto-occipital dislocation (AOD) appears to be an unusual and almost universally fatal injury. Although AOD is the cause of death in about 10% of fatal cervical spine injuries an increasing number of reports document cases of survival following this injury. Improved pre-hospital and in-hospital emergency care according to ATLS guidelines that include early cervical spine stabilization, effective diagnosis because of improved imaging after trauma including whole body multislice CT followed by expeditious reposition and adequate immobilization are reasons for this phenomenon. We report the case of a 12-year-old girl surviving an AOD accompanied by a distraction injury C6/7 with unilateral fixed spinal luxation. After a primary attempt at closed reduction and external stabilization with a halo vest, the injury was treated by a navigated dorsal spondylodesis C0-C1 using the CerviFix rod system and open reposition of the remaining subluxation C6/7 with laminar hooks. The literature was reviewed for diagnostic possibilities, management and prognosis of AOD.

Pediatric injuries: prevention to resolution

Despite improved education and prevention initiatives, trauma remains the leading cause of death in children. A variety of preventative measures have been developed to decrease the morbidity and mortality, and the financial burden on the health care system. This article discusses injury prevention strategies, issues in prehospital care, and key points of initial resuscitation. In addition, the major injury patterns are described with attention paid to the diagnosis and management of patients with multiple traumatic injuries.

Alar, transverse, and apical ligament strain due to head-turned rear impact

STUDY DESIGN

Determination of alar, transverse, and apical ligament strains during simulated head-turned rear impact.

OBJECTIVES

To quantify the alar, transverse, and apical ligament strains during head-turned rear impacts of increasing severity, to compare peak strains with baseline values, and to investigate injury mechanisms.

SUMMARY OF BACKGROUND DATA

Clinical and epidemiologic studies have documented upper cervical spine ligament injury due to severe whiplash trauma. There are no previous biomechanical studies investigating injury mechanisms during head-turned rear impacts.

METHODS

Whole cervical spine specimens (C0-T1) with surrogate head and muscle force replication were used to simulate head-turned rear impacts of 3.5, 5, 6.5, and 8 g horizontal accelerations of the T1 vertebra. The peak ligament strains during impact were compared (P < 0.05) to baseline values, obtained during a noninjurious 2 g acceleration.

RESULTS

The highest right and left alar ligament average peak strains were 41.1% and 40.8%, respectively. The highest transverse and apical ligament average strain peaks were 17% and 21.3%, respectively. There were no significant increases in the average peak ligament strains at any impact acceleration compared with baseline.

CONCLUSIONS

The alar, transverse, and apical ligaments are not at risk for injury due to head-turned rear impacts up to 8 g. The upper cervical spine symptomatology reported by whiplash patients may, therefore, be explained by other factors, including severe whiplash trauma in excess of 8 g peak acceleration and/or other impact types, e.g., offset, rollover, and multiple collisions.

Pediatric spine injuries

Pediatric spine injuries are rare, not only due to the plasticity of the pediatric spine, but also due to the difficulty of diagnosis and the usually severe, if not fatal, associated injuries. Mechanisms of injury, transportation, initial management, diagnostic exams, and management of such lesions are different from those of the adult, and an individualized approach to each case, looking for specific injury patterns, avoids misdiagnosis. The goal of this manuscripts is to summarize the specific spinal injury patterns of the pediatric population, as well as the present literature regarding their diagnosis and treatment.

Conservative management of priapism in acute spinal cord injury

OBJECTIVES

To perform a retrospective chart review of priapism as a complication of spinal cord injury and review the management and follow-up. Priapism is a known complication of acute spinal cord injury, but little has been written concerning the management of this condition.

METHODS

A retrospective chart review (1992 through 2002) was performed for all patients with a diagnosis of priapism. Of these patients, 6 had priapism in the setting of acute spinal cord injury without pelvic trauma. We reviewed the management of the priapism in these cases, and follow-up was attempted in each case.

RESULTS

Of the 6 patients with spinal cord injury-related priapism, 4 had spinal cord injury located at C5-C7, 1 at C5-C6, and 1 at T12. The prolonged erections were managed conservatively in 4 patients and irrigated with intracorporeal phenylephrine in 2. All patients with corporal blood gas measurement (n = 4) had nonischemic priapism. All 4 patients who underwent no intervention had the priapism resolve within 5 hours. Four patients (two treated conservatively and two who underwent irrigation) had recurrent episodes during the same admission that resolved spontaneously. Long-term outcomes were obtained by telephone from all 6 patients. Of the 6 patients, 5 had maintained spontaneous erections to date (range 3 to 10 years).

CONCLUSIONS

The results of our study have shown that priapism related to acute spinal cord injury is nonischemic and may be managed conservatively because of the high likelihood of resolution. Corporal blood gas measurement is important because the results can guide further management decisions. Our results suggests that conservative management of priapism related to spinal cord injury has a low rate of causing long-term erectile dysfunction.

The Effects of Depowered Airbags on Skin Injuries in Frontal Automobile Crashes

The purpose of this study was to determine the effects of depowered frontal airbags on the incidence of skin injuries. The National Automotive Sampling System database files from 1993 to 2000 were examined in a study including 2,246,524 occupants exposed to airbag deployment in the United States. There was no significant difference between full-powered and depowered airbags, with 60.2 percent of those exposed to a full-powered deployment sustaining a skin injury versus 59.5 percent of occupants exposed to a depowered airbag (p = 0.19). Whether occupants were exposed to a full-powered airbag (1,936,485 occupants) or a depowered airbay (310,039 occupants), the majority of skin injuries were to the upper extremity and the face. Regardless of airbag power, the overwhelming majority of the skin injuries were minor (99.8 percent). There was not a significantly greater risk of injury from any source for occupants exposed to a depowered airbag or a full-powered airbag (p = 0.87). The data suggest that the implementation of depowered airbags did not affect the number, seriousness, location, or source of skin injuries.

The effects of depowered airbags on eye injuries in frontal automobile crashes

The purpose of this study was to investigate eye injuries resulting from frontal automobile crashes and to determine the effects of depowered airbags. The National Automotive Sampling System database files from 1993 to 2000 were examined in a 3-part investigation of 22 236 individual crashes. Of the 2 103 308 occupants exposed to a full powered deployment, 3.7% sustained an eye injury compared to 1.7% of the 310 039 occupants exposed to a depowered airbag deployment. Occupants were at a significantly higher risk to sustain an airbag-induced eye injury when exposed to a full powered airbag compared with occupants exposed to a depowered airbag deployment ( P = .04). Approximately, 90% of the eye injuries in full powered airbag deployments were caused by the airbag, compared to only 35% of the depowered airbag eye injuries.

Acute hearing loss after airbag deployment

Hearing loss from airbag deployment after motor vehicle crashes has been documented multiple times in the adult population, but rarely in the pediatric population. We report a case of significant sensorineural hearing loss following airbag deployment in a pediatric patient who presented to the ED on the day of the crash. This report highlights the need for pediatric physicians to be aware of the potential of minor to significant hearing loss in patients who present for medical evaluation after airbag deployment in motor vehicle crashes and to be aware of the importance of follow-up in these children.

Air bags and the skin

Air bags, fitted in the majority of new automobiles, are safety devices activated when a sudden deceleration causes the ignition of a propellant cartridge containing sodium azide. The bag is inflated by nitrogen liberated during the combustion. Deployment releases various high-temperature gases, including nitrogen and carbon dioxide, and produces sodium hydroxide, a highly irritant alkaline substance. In about 7%-8% of cases, air bags cause dermatologic injuries such as traumatic lesions, irritant dermatitis, and chemical and thermal burns. Nondermatologic lesions, such as ocular damage (alkali keratitis, corneal abrasions), ear lesions, bone fractures, and contusive damage can also be caused by air bag deployment.

Atlanto-occipital dislocation: four case reports of survival in adults and review of the literature

Traumatic atlanto-occipital dislocation (AOD) is a rare cervical spine injury and in most cases fatal. Consequently, relatively few case reports of adult patients surviving this injury appeared in the literature. We retrospectively report four patients who survived AOD injury and were treated at our institution. A young man fell from height and a woman was injured in a traffic accident. Both patients survived the injury but died later in the hospital. The third patient had a motorcycle accident and survived with incomplete paraplegia. The last patient, a man involved in a working accident, survived without neurological deficit of the upper extremities. Rigid posterior fixation and complete reduction of the dislocation were applied in last two cases using Cervifix together with a cancellous bone grafting. Previously reported cases of patients surviving AOD are reviewed, and clinical features and operative stabilisation procedures are discussed.

Effects of airbag deployment: lesions, epidemiology, and management

Airbags are restraining safety devices, but their activation may sometimes induce injuries during road accidents. Rapid deceleration due to an impact causes the ignition of a sodium azide cartridge, which releases nitrogen gas to inflate the nylon rubber bag. Numerous high-temperature gases, sodium hydroxide, carbon dioxide, and various other metallic oxides are also released producing a corrosive alkaline aerosol. Cutaneous and extracutaneous injuries due to airbag deployment may occur. Cutaneous injuries are frequent, and consist of irritant dermatitis, and chemical and thermal burns. Furthermore, numerous kinds of traumatic lesions (abrasions, friction burns, and lacerations) may be observed. Extracutaneous damage may involve the eyes, ears, cardiovascular system, nerves, joints, and bones. The nature of airbag lesions, their frequency, and management are reported. Even though the majority of airbag lesions are minor and do not require hospitalization, correct diagnosis and the choice of the most suitable treatment are necessary.

Air bag injuries--a literature review in consideration of demands in forensic autopsies

Air bags have been implicated in saving lives and reducing morbidity associated with motor vehicle crashes since their introduction in the mid-1970s. However, there is increasing evidence showing that air bags can be a source of injury and even death in certain circumstances. As the number of air bag-equipped vehicles increases, air bag-related injuries have occurred more frequently. Thus, a greater awareness of air bag-related injuries is required in forensic autopsies. Here, we review thoroughly the literature concerning air bag-related injuries with special regard to their nature and causative mechanisms, and summarize air bag-related injuries observed in adults, children and infants.

The relationship between body weight and risk of death and serious injury in motor vehicle crashes

We sought to investigate the effect of increased body weight on the risk of death and serious injury to occupants in motor vehicle crashes. We employed a retrospective cohort study design utilizing data from the National Automotive Sampling System, Crashworthiness Data System (CDS), 1993-1996. Subjects in the study included occupants involved in tow-away crashes of passenger cars, light trucks, vans and sport utility vehicles. Two outcomes were analyzed: death within 30 days of the crash and injury severity score (ISS). Two exposures were considered: occupant body weight and body mass index (BMI; kg/m2). Occupant weight was available on 27263 subjects (76%) in the CDS database. Mortality was 0.67%. Increased body weight was associated with increased risk of mortality and increased risk of severe injury. The odds ratio for death was 1.013 (95% CI: 1.007, 1.018) for each kilogram increase in body weight. The odds ratio for sustaining an injury with ISS > or = 9 was 1.008 (95% CI: 1.004, 1.011) for each kilogram increase in body weight. After adjustment for potentially confounding variables (age, gender, seatbelt use, seat position and vehicle curbweight), the significant relationship between occupant weight and mortality persisted. After adjustment, the relationship between occupant weight and ISS was present, although less marked. Similar trends were found when BMI was analyzed as the exposure. In conclusion, increased occupant body weight is associated with increased mortality in automobile crashes. This is probably due in part to increased co-morbid factors in the more overweight occupants. However, it is possibly also due to an increased severity of injury in these occupants. These findings may have implications for vehicle safety design, as well as for transport safety policy.

Risk factors and predictors of mortality in children after ejection from motor vehicle crashes

PURPOSE

Mortality after ejection from a motor vehicle crash (MVC) has been studied extensively in adults. The magnitude of this problem in children is relatively unknown. We retrospectively examined fatalities resulting from ejection after MVC in the state of Pennsylvania to define risk factors and predictors of mortality in children.

METHODS

The records for all patients 0 to 16 years of age involved in an MVC and entered in the Pennsylvania Trauma Outcome Study between 1993 and 1997 were reviewed. We examined mortality, length of hospitalization, major injuries sustained, and impact of safety restraint devices. Significant differences were determined using chi2 test.

RESULTS

There were 2,298 children involved in MVCs during this period; 189 were ejected. A total of 77% of the ejected passengers were greater than 10 years of age, 16% were 0 to 4 years of age, and 7% were 5 to 9 years of age. Overall, 88% of the ejected occupants were unrestrained. Ejection nearly tripled the overall mortality rate and significantly increased the Injury Severity Score for each age group. Infants and children 0 to 4 years of age had the highest fatality rate despite having a lower Injury Severity Score than all other age groups. Head injuries accounted for the majority of deaths in all age groups. Children older than 10 years of age had a higher incidence of associated chest, abdominal, and pelvic injuries.

CONCLUSION

Our data show that most children ejected from MVCs were either unrestrained or improperly restrained. Head injuries were the most common cause of death in all age groups. Greater public awareness through educational programs targeting parents and children at risk may reduce this serious problem.

Part 9: pediatric basic life support. European Resuscitation Council

The epidemiology and outcome of pediatric cardiopulmonary arrest and the priorities, techniques, and sequence of pediatric resuscitation assessments and intervention differ from those of adults. Current guidelines have been updated after extensive multinational evidence-based review and discussion over several years. Areas of controversy in current guidelines and recommendations made by consensus are detailed. A large degree of uniformity exists in the current guidelines advocated by the AHA, Council on Latin American Resuscitation, Heart and Stroke Foundation of Canada, European Resuscitation Council, Australian Resuscitation Council, and Resuscitation Council of Southern Africa. Differences are currently based on local and regional preferences, training networks, and customs rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted.

Pediatric airbag injuries: the Ohio experience

BACKGROUND/PURPOSE

We sought to determine if properly restrained children, less than 13 years of age, placed in the front passenger seat are at greater risk for trauma from airbag deployment than unrestrained children.

METHODS

The charts of children treated at any of 3 regional pediatric trauma centers in Ohio were reviewed for airbag injuries sustained in motor vehicle crashes between January 1995 and September 1998. Injury Severity Scores (ISS) were compared with Mann-Whitney Rank Sum Test and outcome data with Fisher's Exact Tests. Statistical significance was set at P< or =.05.

RESULTS

Twenty-seven children aged 1 month to 12 years sustained airbag-related injuries. Sixty-one percent were girls. ISS ranged from 1 to 75 with a mean score (+/- SD) of 10 (14.5). All crashes were at reported speeds of less than 45 mph, and 64% were head-on collisions. No significant differences in the mean ISS (P = .074) occurred between groups. Both groups had similar closed head, ocular and facial injuries, extremity fractures, and number of deaths (P = 1.0). Abdominal organ injury was exclusive to the restrained group. Decapitation only occurred among unrestrained children.

CONCLUSION

Our data showed that airbags, with or without proper safety restraints, can lead to mortality or serious morbidity in children.

Atlanto-occipital dislocation: an unusual lethal airbag injury

Airbag-induced injury fatality is increasing in frequency. We present the case of a 6-year-old passenger who sustained a fatal atlanto-occipital dislocation associated with airbag deployment in a low-speed motor vehicle crash. The current literature regarding airbag fatalities and methods to ameliorate airbag-induced injury are reviewed.

Otologic injuries caused by airbag deployment

Airbags are clearly successful at mitigating injury severity during motor vehicle accidents. Deployment unfortunately has introduced new injury-causing mechanisms. A retrospective review of 20 patients who sustained otologic injuries resulting from airbag inflation was conducted. The most common symptoms were hearing loss in 17 (85%) and tinnitus in 17 (85%). Objective hearing loss was documented in 21 of 24 (88%) subjectively affected ears; this included unilateral and bilateral sensorineural, unilateral conductive, and mixed hearing losses. Ten patients (50%) had dysequilibrium. Four subjects (20%) had a tympanic membrane perforation; each required surgical closure. Ear orientation toward the airbag was found to be associated with hearing loss (P = 0.027), aural fullness (P = 0.039), and tympanic membrane perforation (P = 0.0004). A wide variety of airbag-induced otologic injuries occur and may have long-term sequelae. It is important for health care personnel to be aware of these potential problems.