Child bicyclist injuries: are we obtaining enough information in the emergency department chart?

OBJECTIVE: The purpose of this study was to assess the range of information relevant to bicyclist injury research that is available on routinely completed emergency department medical records. METHODS: A retrospective chart review of emergency department medical records was conducted on children who were injured as bicyclists and treated at an urban level I pediatric trauma center. A range of variables relevant to bicyclist injury research and prevention was developed and organized according to the Haddon matrix. Routinely completed free text emergency department medical records were assessed for the presence of each of the targeted elements. In addition, medical records of seriously injured patients (for whom a more structured medical record is routinely used) were compared to free form records of less seriously injured patients to identify differences in documentation that may be related to the structure of the medical record. RESULTS: Information related to previous medical history (96% of records), diagnosis (89%), documentation of pre-hospital care (82%), and child traumatic contact points (81%) were documented in the majority of medical records. Information relevant to prevention efforts was less commonly documented: identification of motor vehicle/object involved in crash (58%), the precipitating event (24%), the location of the crash (23%), and documentation of helmet use (23%). Records of seriously injured patients demonstrated significantly higher documentation rates for pre-hospital care and child traumatic contact points, and significantly lower documentation rates for previous medical history, child kinematics, main body parts impacted, and location of injury event. CONCLUSIONS: Routinely completed free text emergency department medical records contain limited information that could be used by injury researchers in effective surveillance. In particular information relating to the circumstances of the crash event that might be used to design or target prevention efforts is typically lacking. Routine use of more structured medical records has the potential to improve documentation of key information.

Seat belt syndrome in children: a case report and review of the literature.

Characteristic patterns of injury to children in automobile crashes resulting from lap and lap-shoulder belts have been described for many years. These injuries are known as the "seat belt syndrome." We present a typical case of seat belt syndrome involving a 4-year-old boy and review the current literature on the topic, highlighting proposed mechanisms of intra-abdominal and spine injuries. In addition, recent research findings identifying a new pattern of injuries associated with inappropriate seat belt use in young children are reviewed. Emergency physicians must consider these seat belt-related injuries in the initial evaluation of any child involved in a motor vehicle crash who was restrained with the vehicle seat belt.

Factors influencing pediatric injury in side impact collisions.

BACKGROUND: Side impact collisions pose a great risk to children in crashes, but information about the injury mechanisms is limited. METHODS: This study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large, child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions. RESULTS: Ninety-three children in 55 side impact crashes were studied. Twenty-three percent (n = 22) of the children received an Abbreviated Injury Scale (AIS) score > or = 2 (clinically significant) injury. In these 22 children, head (40%), extremity (23%), and abdominal injuries (21%) were the most common significant injuries. Cases that illustrate body region-specific injury mechanisms are discussed. CONCLUSION: The cases revealed that serious injuries, particularly head injuries, occur even in minor crashes, and efforts should be made to make the interiors of vehicles more child occupant friendly. Lower extremity and abdominal injuries occurred because of contact with the intruding door. Design of vehicles to minimize crush should mitigate the occurrence and severity of these injuries.

Child occupant protection: a summary of current safety recommendations.

In 1998, 140 children younger than 1 year of age were killed in motor vehicle crashes, and nearly half of those children killed were restrained. Used correctly, child safety seats dramatically reduce a child's risk of death in a motor vehicle crash, but unfortunately, incorrect use of child seats is widespread. Obstetricians and gynecologists have a unique opportunity to counsel parents on the correct restraint for their infants and to provide recommendations for the proper restraint of older children as well. The recommendations for child occupant protection are updated with new information constantly. This article will provide an overview of the current recommendations for restraining children in motor vehicles and identify sources for up-to-date information for physicians and families.

The danger of premature graduation to seat belts for young children.

OBJECTIVE: To determine the risk of significant injury associated with premature graduation of young (2- to 5-year-old) children to seat belts from child restraint systems (CRS). BACKGROUND: Advocates recommend use of child safety seats for children younger than age 4 and booster seats for children age 4 and older. Despite these recommendations, many children are prematurely taken out of these child restraints and placed in seat belts. Although data exist to support the use of child restraints over nonrestraint, no real-world data exist to evaluate the risk of significant injury associated with premature use of seat belts. DESIGN/METHODS: Partners for Child Passenger Safety includes a child-focused crash surveillance system based on a representative sample of children ages 0 to 15 years in crashes involving 1990 and newer vehicles reported to State Farm Insurance Companies in 15 states and the District of Columbia. Driver reports of crash circumstances and parent reports of child occupant injury were collected via telephone interview using validated surveys. Results were weighted based on sampling frequencies to represent the entire population. RESULTS: Between December 1, 1998, and November 30, 1999, 2077 children aged 2 to 5 years were included and were weighted to represent 13 853 children. Among these young children, 98% were restrained, but nearly 40% of these children were restrained in seat belts. Compared with children in CRS, children in seat belts were more likely to suffer a significant injury (relative risk: 3.5; 95% confidence interval: [2. 4, 5.2]). Children in seat belts were at particular risk of significant head injuries (relative risk: 4.2; 95% confidence interval: [2.6, 6.7]) when compared with children in CRS. CONCLUSIONS: Premature graduation of young children from CRS to seat belts puts them at greatly increased risk of injury in crashes. A major benefit of CRS is a reduction in head injuries, potentially attributable to a reduction in the amount of head excursion in a crash.

Factors influencing pediatric injury in side impact collisions.

Side impacts collisions pose a great risk to children in crashes but information about the injury mechanisms is limited. The heights and weights of children vary widely and as a result, the injury patterns may vary across the pediatric age range. This study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions. 93 children in 55 side impact crashes were studied. 23% (n = 22) of the children received an AIS > or = 2 (clinically significant) injury. In these 22 children, head (39%), extremity (22%), and abdominal injuries (17%) were the most common significant injuries. The cases revealed that serious injuries occur even in minor crashes. Cases that illustrate body region-specific injury mechanisms are discussed.

Development and validation of the injury severity assessment survey/parent report: a new injury severity assessment survey.

OBJECTIVE: To develop and pilot test a telephone-based survey instrument that enables parents to identify and characterize the body region and severity of childhood injuries using the Abbreviated Injury Scale (AIS) scoring system. DESIGN: A prospective cross-sectional survey. SETTING: The emergency department of an urban, tertiary care, pediatric trauma center. PARTICIPANTS: One hundred forty-seven parents of children younger than 18 years and seen in the emergency department for acute treatment of an unintentional injury. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The degree of agreement, measured as sensitivity, specificity, and kappa statistic, between medical record information and parents' responses to the telephone survey regarding the identification and characterization of clinically significant (AIS > or =2) injuries. RESULTS: The survey, known as the Injury Severity Assessment Survey/Parent Report, was developed via a systematic review of the AIS 1990 manual. Answers to questions were developed in a way that enabled automated coding of responses into AIS scores or ranges of scores. The sensitivity of the survey (its ability to detect injuries scoring 2 or more on the AIS that were documented in the medical record) varied somewhat by the body region of injury, ranging from 88% for head, face, neck, and spine injuries to 95% for extremity injuries. Intermediate sensitivity (92%) was noted for the detection of significant chest and abdomen injuries. The specificity of the survey (its ability to rule out the presence of a significant injury when one was not documented in the medical record) was more than 95% in each of the 3 body region groups. The kappa statistics for the 3 body region groups ranged from 0.89 to 0.92. CONCLUSIONS: A new telephone-based survey has been developed that enables parents to characterize their child's injuries by body region and to differentiate between minor injuries and more significant injuries using a well-established injury classification system. This survey has a significant advantage over previous telephone-based or written surveys of childhood injuries and may be particularly valuable in population-based (e.g., random-digit dial surveys) or multi-institutional studies of pediatric injuries.