This issue includes 4 hours of ACEP/AMA category 1 CME credit.
 
Authors: John D. Cowden, MD and M. Denise Dowd, MD, MPH
Peer Reviewers: Stephen V. Cantrill, MD, FACEP and Michael Witt, MD, MPH, FAAP
Publication Date: October 1, 2007

Is injury prevention the responsibility of the emergency physician? To the emergency medicine establishment, the answer is clear. In policy statements, editorials, and reviews, emergency health care providers have repeatedly been called to join the injury prevention effort.[1-11] But medicine abounds with recommended practices that individual physicians do not follow because of disagreement, uncertainty, or perceived impracticality. For the practicing emergency physician, taking time to acquire new knowledge, to form new habits, and to use them in the busy acute care setting requires much more than a call to action. It requires confidence that the effort is worth it as well as the tools to do the job.

This issue of Pediatric Emergency Medicine Practice explores the challenge of implementing injury prevention in the acute care setting through an evaluation of evidence from the literature. The goal is to differentiate evidence-based methods from theoretical ones and to provide practical tools and advice to the practicing emergency care provider.

Excerpt from the issue…
A five-year-old boy arrives in the ED by ambulance from the scene of a motor vehicle crash. He was a back-seat passenger wearing a lap belt in a car that struck another car head-on. Both cars were traveling approximately 50 miles per hour. His seven-year-old brother, also wearing a lap belt, was pronounced dead at the scene. His parents, who were belted in the front seat, suffered minor injuries and are being treated at another ED nearby. The boy arrives tachycardic and in mild respiratory distress, with diminished breath sounds on the left, a linear ecchymotic area across the upper abdomen, and midline tenderness over the lumbar spine. Laboratory evaluation reveals a hemoglobin of 6.8 g/dL and hematuria on urinalysis. His chest x-ray is consistent with traumatic diaphragmatic hernia with the stomach bubble visible in the left chest, mediastinal shift to the right, and a pneumothorax on the left. Lumbar and thoracic spine radiographs show compression fractures of the first and second lumbar vertebrae. “All the hallmarks of ‘seat belt syndrome,’” the trauma surgeon points out to you. “We’ve got to teach parents that it’s not enough just to buckle their kids up,” he says, frustrated, as he heads to the operating room to explore and repair the boy’s internal injuries. You wonder what to say to the boy’s parents. Did they know that a booster seat might have prevented these injuries and might have saved their other son’s life? Maybe they think this was just an unlucky accident – awful, but unavoidable. Is this the right time to counsel them? Whose job is it to teach or ask families about safety? When is there time for injury prevention when the waiting room is full? And even if there was time, what works?

Conclusion to the above case study...
In addition to the traumatic diaphragmatic hernia seen on x-ray, surgeons discovered rent mesentery, torn colonic serosa, retroperitoneal hematoma, and ruptured spleen during laparotomy. These injuries were repaired, but a second laparotomy was required during recovery after adhesions caused bowel obstruction. Plain radiography of the spine showed compression fractures of the first and second lumbar vertebrae, which required only conservative, non-surgical treatment. As the surgeon told you before going to the operating room, the boy’s injuries were characteristic of severe “seat belt” or “lap belt” syndrome. Traumatic diaphragmatic hernia is an unusual and severe form of the intra-abdominal injuries seen in the seat belt syndrome, but significant morbidity is common when children are improperly restrained. The recognition of this problem has led to the design and use of booster seats, now required by law in most states. Booster seats re-position a child’s body so that the adult lap and shoulder belts fit appropriately. In this case, a booster seat might have allowed the boy to walk away from the accident without injury. They often do. The difficult decision for you as an emergency physician involves what to say to the family. With distraught parents concentrating on the well-being of their child, the encounter in the emergency room is not likely to feel like the right time to point out that they should have been using a booster seat.