I think we can all agree that seatbelts are wonderful inventions. Developed in the 1960s, these protective devices have been shown to cause a 45-60% decrease in fatal injury associated with motor vehicle collisions.
However, as with anything in life—there are risks. Seatbelts have been associated with patterns of injury in both adult and pediatric patients: specifically spinal chance fractures (extreme spine flexion with a fixed pelvis seen with lap belts without shoulder belt) and intraabdominal injuries. Children are specifically more vulnerable to intraabdominal injuries because lap belts are often misfitting and poorly applied.
The seatbelt sign is defined as continuous ecchymoses, abrasion or erythema across the abdomen demarcating location of seatbelt at time of impact. This external finding has been associated with a high rate of internal abdominal injury (65%!!!!), both solid organ and hollow viscous.
There is good evidence in the literature on scanning symptomatic patients with a seatbelt sign. How about asymptomatic? Specifically in the subgroup we are concerned about exposing to radiation—children?
Think for a moment, what would you do with a pediatric patient with a seatbelt sign who otherwise looks normal (no vital sign abnormality, no abdominal pain/tenderness, no nausea/vomiting)?
There was a large prospective multicenter study presented at the pediatric academic societies annual meeting in 2012 (not yet published) by Dr. Angela Ellison. The 20-center observational study looked at 4,706 children between May 200 and January 2010 aged less than 18 years who presented to the ED after blunt torso trauma in a motor vehicle collision. 874 patients were excluded due to additional trauma sustained, 3,832 patients were enrolled. 585 of these patients displayed the seat belt sign. Additionally, a subset of 196 of the 585 children who did not present with abdominal pain or tenderness were evaluated for their relative risk of intra-abdominal injury. CT scanning was left to the discretion of the MDs in the emergency department. 103 of the 196 asymptomatic children had an abdominal CT. 11 (10.7%) of these children had an intra-abdominal injury despite being symptom-free 4(2%) of these children required acute intervention for their injuries.
What can we say from this? In the words of Dr. Ellison: “Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients.”
There you have it, we have to take the seatbelt sign in children very seriously: asymptomatic does not mean injury-free.
References:
Chandler et al. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. 1997 Oct;63(10): 885-8.
Sokolove et al. Association between the “seat belt sign” and intra-abdominal injury n children with blunt torso trauma. Acad Emerg Med. 2005 Sep; 12(9): 808-13.
Pediatric News. “Seat-Belt Sign” Indicates Hidden Abdominal Injury Risk. www.pediatricnews.com. Accessed June 2014.
sadia.hussain
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Nice review. The question always comes up in the trauma literature what the outcome should be. Do we care about all injuries or just those that need intervention? I don’t think there will ever be agreement on this issue.