Injuries from motor vehicle crashes are the leading cause of mortality in children aged 5 years and older in the United States. This review discusses common injuries in children after motor vehicle trauma and examines the evidence regarding the evaluation and treatment of pediatric patients involved in motor vehicle crashes. Both prehospital and emergency department care are discussed along with a differential diagnosis of the injuries most commonly seen in motor vehicle crashes. The various options for imaging modalities are also discussed in this review. A critical appraisal of the existing guidelines for the management of motor vehicle trauma and for the use of appropriate child-safety restraints is presented. Emergency clinicians will be able to use the patient’s history and physical examination findings along with knowledge of common injuries to determine the most appropriate workup and treatment of pediatric patients who present with motor vehicle trauma.
Keywords: motor vehicle crash, motor vehicle injury, motor vehicle accident, motor vehicle trauma, motor vehicle collision, automobile accident, pedestrian injury, pedestrian-versus-automobile, pedestrian accident, car accident, blunt abdominal trauma, head injury, cervical spinal injury
You receive a call that an 8-year-old child who was in a motor vehicle crash will be arriving by air transport in 8 minutes. The child was the unrestrained passenger in the back seat of a sport utility vehicle that was involved in a high- speed collision on a busy freeway. The child was ejected from the vehicle. When EMS arrived on scene, the child was lying on the side of the road and was moaning in pain. He was noted to have abrasions on his abdomen and swelling of his left thigh. En route to the hospital, the child’s heart rate was 115 beats/min, respiratory rate was 24 breaths/min, and blood pressure was 90/42 mm Hg. While you are waiting in the trauma bay for the patient, you consider the injuries for which he is at risk and the interventions, laboratory studies, and radiographic studies he may require.
A 14-year-old girl is brought in by ambulance after a motor vehicle crash. She was a restrained passenger in the front seat of a car driven by her mother. When the car in front of them stopped suddenly, the patient’s car slammed into it and was then rear-ended by the car behind theirs. She was wearing both her lap and shoulder restraints, and there was no airbag deployment, passenger space intrusion, or damage to the windshield or windows. The girl denied any head injury or loss of consciousness. The girl was ambulatory at the scene, but when EMS arrived, she was placed in a cervical collar, positioned on a backboard, and brought to the ED. On arrival, she is alert and oriented but is complaining of neck and back pain. She has no other associated injuries. You wonder whether the patient’s cervical collar and backboard can be safely removed and what, if any, radiographic studies you should order.
An ambulance arrives with a 3-year-old girl who was involved in a pedestrian-versus-automobile accident. The child was playing in the front yard of her family’s home when the ball she was playing with rolled onto the driveway. She ran out to grab the ball just as her father was backing his car out of the driveway; he felt a “thump” as he backed over her. He immediately got out of the car and found his daughter lying on the driveway underneath the car between the front and rear wheels, crying. An ambulance was called, and the child was placed in a cervical collar and positioned on a backboard and brought to the ED. On arrival, the child is alert and awake with a Glasgow Coma Scale score of 15. Her head and neck examination is within normal limits, but she appears to have some abdominal tenderness and bruising on the lower portion of her abdomen. As you complete the remainder of your examination, you consider the injuries for which this patient is at risk, based on her mechanism of injury, and decide which imaging studies to order.
Motor vehicle crashes (MVCs) are the leading cause of morbidity and mortality among children in the United States, and they often present a diagnostic challenge for emergency clinicians, given the variety of injuries that may be sustained. In these situations, the emergency clinician must determine the most likely injuries and decide upon the appropriate workup for each patient. Given that a variety of laboratory and radiographic studies can be used to evaluate these injuries, determining the most appropriate workup for each patient is often a challenge. This issue of Pediatric Emergency Medicine Practice focuses on the evaluation and management of children injured in MVCs, using the best available evidence from the literature.
A PubMed search for articles pertaining to children aged < 18 years published since 1980 was performed using the search terms motor vehicle crash, motor vehicle injury, motor vehicle accident, motor vehicle trauma, motor vehicle collision, traffic accident, road traffic accident, traffic injury, automobile accident, automobile injury, pedestrian, pedestrian injury, pedestrianversus- automobile, pedestrian accidents, car accident, blunt abdominal trauma, head injury, and cervical spinal injury. More than 2200 articles were identified, and a total of 166 resources relevant to the topic of motor vehicle trauma are included in this review. Although several large prospective studies were included, the majority of studies are retrospective. No randomized controlled trials were identified. A search of the Cochrane Database of Systematic Reviews did not produce any reviews addressing the specific patterns of injury seen in MVCs or the workup and management of these patients.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Saranya Srinivasan, MD; Todd Chang, MD
August 1, 2013