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CHILD OCCUPANTS AND SIDE-IMPACT CRASHES:COMMENTARY Authors: Ediriweera Desapriya, PhD, Lionel Samayawardhena, PhD, Aruna Somasiri, PhD, and Ian Pike, PhD, Vancouver and Burnaby, British Columbia, Canada Section Editors: Tomi St. Mars, RN, MSN, CEN, FAEN, and Anna M. Valdez, RN, PhD, CEN, CFRN Earn Up to 8.5 CE Hours. See page 425. M ore than 10 million crashes involving passenger cars and light trucks occurred in the United States in 2005, resulting in 31,415 occupant deaths and 2,445,000 occupant injuries. 1 According to the National Highway Traffic Safety Administration, side- impact crashes account for 28% of all crash-related deaths, of which the majority involve brain and thoracic injuries. 2 Side-impact collisions represent a serious risk of injury for motor vehicle occupants. This type of collision provides less protection to the occupants and is associated with a specific pattern of injuries. 2,3 Having an understanding of side- impact crashes can assist the emergency nurse in caring for the patient and preventing this type of injury for others. Side-impact crashes are more dangerous for children and represent a challenge to injury prevention efforts. A recent study found that significant injury occurred in 41% of side-impact crashes, 15% of frontal impacts, and 3% of rear impacts involving child occupants. In addition, other studies have reported child mortality rates of 30% for side-impact crashes and 17% for frontal-impact crashes. 3-9 Because of the large size of the head in relation to the rest of the body, a childs head and neck are more vulnerable than those of an adult. Children have more head surface area and a lower-seated height, both of which increase the risk of contact with the interior door panel or pillars during side-impact crashes. Most recently, attention has been directed toward pre- vention of injuries in children and infants occupying rear seats of vehicles equipped with side-impact airbags. The National Highway Traffic Safety Administration has advised manufacturers of vehicles equipped with side air- bags to ship them deactivated unless the manufacturers have determined that the airbags pose no significant risk to children. 3 Children sitting in a forward-facing child restraint safety seat (CRS) are at higher risk of sustaining face, head, and lower extremity injuries when seated on the same side as the side of impact. 10,11 This finding was further sup- ported by work by Starnes and Eigen, 12 who found that in children aged 0 to 8 years, 61% of side-impact deaths involved those seated on the struck side whereas only 20% involved far-seated children. Because motor vehicle use is increasing, the amount of data available on side-impact crashes in rapidly motorized countries is limited. In 2002 deaths associated with side- impact crashes in China constituted about 27.5% of all traffic crashrelated deaths, whereas 30% of all crashes resulted from side-impact crashes. 13 These values are somewhat lower than but comparable to those in the United States (35% of deaths in 2005, according to the Fatality Analysis Reporting System 14 ). Hence, it is safe to assume that rapidly motorizing countries have a similar if not higher number of side-impact crashes. Airbags are a mixed blessing: they are protective for adults and dangerous for children. 15 Airbags inflate at high speeds, and they inflate before the occupant enters the deployment zone. 16 Some newer vehicle models are equipped with side airbags in both the front and the rear Ediriweera Desapriya is Research Associate, Department of Pediatrics, Faculty of Medicine, University of British Columbia, and Centre for Developmental Neurosciences and Child Health, British Columbia Injury Research and Pre- vention Unit, Vancouver, British Columbia, Canada. Lionel Samayawardhena is Research Associate, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Aruna Somasiri is Research Associate, Faculty of Medicine, University of Brit- ish Columbia, Vancouver, and Segal Graduate School of Business, Simon Fra- ser University, Burnaby, British Columbia, Canada. Ian Pike is Assistant Professor, Department of Pediatrics, Faculty of Medicine, University of British Columbia, and Centre for Developmental Neurosciences and Child Health, British Columbia Injury Research and Prevention Unit, Vancouver, British Columbia, Canada. For correspondence, write: Ediriweera Desapriya, PhD, Centre for Develop- mental Neurosciences and Child Health, British Columbia Injury Research and Prevention Unit, L408-4480 Oak St, Vancouver, British Columbia, Canada V6H 3V4; E-mail: [email protected]. J Emerg Nurs 2011;37:391-3. Available online 26 May 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.03.012 INJURY PREVENTION July 2011 VOLUME 37 ISSUE 4 WWW.JENONLINE.ORG 391

Child Occupants and Side-Impact Crashes: Commentary

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Page 1: Child Occupants and Side-Impact Crashes: Commentary

CHILD OCCUPANTS AND SIDE-IMPACT

CRASHES: COMMENTARY

Authors: Ediriweera Desapriya, PhD, Lionel Samayawardhena, PhD, Aruna Somasiri, PhD, and Ian Pike, PhD,Vancouver and Burnaby, British Columbia, Canada

Section Editors: Tomi St. Mars, RN, MSN, CEN, FAEN, and Anna M. Valdez, RN, PhD, CEN, CFRN

Earn Up to 8.5 CE Hours. See page 425.

More than 10 million crashes involving passengercars and light trucks occurred in the UnitedStates in 2005, resulting in 31,415 occupant

deaths and 2,445,000 occupant injuries.1 According tothe National Highway Traffic Safety Administration, side-impact crashes account for 28% of all crash-related deaths,of which the majority involve brain and thoracic injuries.2

Side-impact collisions represent a serious risk of injury formotor vehicle occupants. This type of collision provides lessprotection to the occupants and is associated with a specificpattern of injuries.2,3 Having an understanding of side-impact crashes can assist the emergency nurse in caring forthe patient and preventing this type of injury for others.

Side-impact crashes are more dangerous for childrenand represent a challenge to injury prevention efforts. Arecent study found that significant injury occurred in41% of side-impact crashes, 15% of frontal impacts, and

3% of rear impacts involving child occupants. In addition,other studies have reported child mortality rates of 30% forside-impact crashes and 17% for frontal-impact crashes.3-9

Because of the large size of the head in relation to the restof the body, a child’s head and neck are more vulnerablethan those of an adult. Children have more head surfacearea and a lower-seated height, both of which increasethe risk of contact with the interior door panel or pillarsduring side-impact crashes.

Most recently, attention has been directed toward pre-vention of injuries in children and infants occupying rearseats of vehicles equipped with side-impact airbags. TheNational Highway Traffic Safety Administration hasadvised manufacturers of vehicles equipped with side air-bags to ship them deactivated unless the manufacturershave determined that the airbags pose no significant riskto children.3

Children sitting in a forward-facing child restraintsafety seat (CRS) are at higher risk of sustaining face, head,and lower extremity injuries when seated on the same sideas the side of impact.10,11 This finding was further sup-ported by work by Starnes and Eigen,12 who found thatin children aged 0 to 8 years, 61% of side-impact deathsinvolved those seated on the struck side whereas only20% involved far-seated children.

Because motor vehicle use is increasing, the amount ofdata available on side-impact crashes in rapidly motorizedcountries is limited. In 2002 deaths associated with side-impact crashes in China constituted about 27.5% of alltraffic crash–related deaths, whereas 30% of all crashesresulted from side-impact crashes.13 These values aresomewhat lower than but comparable to those in theUnited States (35% of deaths in 2005, according to theFatality Analysis Reporting System14). Hence, it is safe toassume that rapidly motorizing countries have a similar ifnot higher number of side-impact crashes.

Airbags are a mixed blessing: they are protective foradults and dangerous for children.15 Airbags inflate at highspeeds, and they inflate before the occupant enters thedeployment zone.16 Some newer vehicle models areequipped with side airbags in both the front and the rear

Ediriweera Desapriya is Research Associate, Department of Pediatrics, Facultyof Medicine, University of British Columbia, and Centre for DevelopmentalNeurosciences and Child Health, British Columbia Injury Research and Pre-vention Unit, Vancouver, British Columbia, Canada.

Lionel Samayawardhena is Research Associate, Department of Pediatrics,Faculty of Medicine, University of British Columbia, Vancouver, BritishColumbia, Canada.

Aruna Somasiri is Research Associate, Faculty of Medicine, University of Brit-ish Columbia, Vancouver, and Segal Graduate School of Business, Simon Fra-ser University, Burnaby, British Columbia, Canada.

Ian Pike is Assistant Professor, Department of Pediatrics, Faculty of Medicine,University of British Columbia, and Centre for Developmental Neurosciencesand Child Health, British Columbia Injury Research and Prevention Unit,Vancouver, British Columbia, Canada.

For correspondence, write: Ediriweera Desapriya, PhD, Centre for Develop-mental Neurosciences and Child Health, British Columbia Injury Researchand Prevention Unit, L408-4480 Oak St, Vancouver, British Columbia,Canada V6H 3V4; E-mail: [email protected].

J Emerg Nurs 2011;37:391-3.

Available online 26 May 2011.

0099-1767/$36.00

Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2011.03.012

I N J U R Y P R E V E N T I O N

July 2011 VOLUME 37 • ISSUE 4 WWW.JENONLINE.ORG 391

Page 2: Child Occupants and Side-Impact Crashes: Commentary

seats. Side airbags were introduced in 1996 to reduce theimpact of lateral crashes on vehicle occupants, and theseairbags are designed to protect occupants who are heavierthan the fifth-percentile woman (105 lb).8,16,17

Currently, there are no standards or guidelines inNorth America for child restraints that include side-impactcrashes. The American Academy of Pediatrics “Car SafetySeats: A Guide for Families 2010” does not clearly stateprotection for transporting children in vehicles with sideairbags.18 The American Academy of Pediatrics 2010guidelines simply indicate that “Side air bags improvesafety for adults in side-impact crashes. Read your vehicleowner’s manual for more information about the air bags inyour vehicle. Read your car safety seat manual for guidanceon placing the seat next to a side air bag.”

In order to save the lives of children, we must gobeyond providing this type of simple advice to parentsand caregivers. The recent European Transport SafetyCouncil document (2003)19 highlighted frontal- andside-impact directives and consumer information fromthe European New Car Assessment Program (EuroNCAP). This has led to the most rapid developments invehicle occupant protection that Europe has ever experi-enced, although more can be achieved.

Proper installation of CRS and proper restraint ofchildren reduce the probability of an injury during a sideimpact, and parent and caregiver education have beencited as highly correlated to proper use of CRS in manycountries including the United States. Furthermore,improved law enforcement will lead to improved CRSuse and installation, and help to reduce the probabilityof traffic crashes.20,21

We know that vehicle body intrusion is an importantrisk factor for fatal child injuries, particularly when theCRS is positioned on the outboard nearside to the impactpoint.22 A child who is seated in close proximity to a sideairbag may be at risk of serious or fatal injury, especially ifhis or her head, neck, or chest is in close proximity to theairbag at the time of deployment.15 Parents and caregiversin developing countries do not have reliable information(because of a lack of research and resources) on child safetyseats, and they overtly depend on developed countries’advanced research- and evidence-based guidelines to pro-tect their children from motor vehicle-related injury. Thoseliving in countries producing and exporting cars to thedeveloping world must take responsibility for ensuringthe dissemination of correct evidence-based practice regard-ing child traffic safety.

The World Health Organization’s 2004 world reporton injury prevention23 urged highly motorized countries tohelp rapidly motorizing countries to prevent traffic injuries

by disseminating the best evidence of injury preventionstrategies, demonstrating the critical need to transferknowledge and proven strategies to developing countrieswhere crash-related deaths and injuries have alreadyreached epidemic levels. Developing countries should beencouraged to influence vehicle passive safety design stan-dards to meet local safety priorities, such as the protectionof vulnerable child occupants.

A properly designed and installed child restraint seatshould limit the movement of its occupant relative tothe vehicle interior in the event of a crash. There are sev-eral roles that the emergency nurse can participate in toprotect child passengers: 1) become trained as a certifiedchild safety seat technician; 2) teach families that all childmotor vehicle passengers should be seated in the mostappropriate place in the car that could prevent a directimpact or airbag system-related injury; 3) advocate topolicy-makers that there is an urgent need to protectchild occupants in vehicles incompatible with side-impactcrashes; and 4) be willing to advocate for and shareknowledge about child passenger safety with colleaguesand clients across the globe.

REFERENCES1. McMullin BT, Rhee JS, Pintar FA, Szabo A, Yoganandan N. Facial frac-

tures in motor vehicle collisions: epidemiological trends and risk factors.Arch Facial Plast Surg. 2009;11(3):165-70.

2. Consumer Reports. 2007. NHTSA accelerates new car safety rule.http://blogs.consumerreports.org/safety/2007/09/. Accessed January 7,2010.

3. National Highway Traffic Safety Administration. Consumer advisory onside air bags and child safety. National Highway Traffic Safety Admin-istration Web site. http://www.nhtsa.dot.gov/nhtsa/announce/press/ca101499.html. Accessed January 27, 2010.

4. National Highway Traffic Safety Administration. 49 CFR part 571(docket No. 02-12151). RIN 2127-AI83. Federal motor vehiclesafety standards; child restraint systems. http://www.nhtsa.dot.gov/Cars/rules/rulings/CPSUpgrade/CPSSide/Index.html. Accessed January17, 2010.

5. Arbogast K, Chen I, Durbin D, Winston F. Child restraints in sideimpacts. In: Proceedings of the International Conference on the Bioki-netics of Impact. Graz, Austria.

6. Chipman ML, Lebovic G, Desapriya E, Gane J. Lateral damage andpoint of impact in intersection crashes: implications for injury. InsurRisk Manag. 2006;73(4):429-42.

7. Desapriya EBR, Pike I, Kinney J. The risk of injury and vehicle damageseverity in vehicle mismatched side impact crashes in British ColumbiaCanada. IATSS Res. 2005;29(2):60-6.

8. Arbogast KB, Kallan MJ, Durbin DR. Front versus rear seat injury riskfor child passengers: evaluation of newer model year vehicles. Traffic InjPrev. 2009;10(3):297-301.

9. Braver ER, Kyrychenko SY. Efficacy of side air bags in reducingdriver deaths in driver-side collisions. Am J Epidemiol. 2004;159(6):556-64.

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10. Arbogast KB, Ghati Y, Menon RA, Tylko S, Tamborra N, Morgan RM.Field investigation of child restraints in side impact crashes. Traffic InjPrev. 2005;6(4):351-60.

11. Kallan MJ, Durbin DR, Arbogast KB. Seating patterns and correspond-ing risk of injury among 0- to 3-year-old children in child safety seats.Pediatrics. 2008;121(5):e1342-7.

12. Starnes M, Eigen AM. Fatalities and Injuries to 0-8 Year Old Passen-ger Vehicle Occupants Based on Impact AttributesNHTSA reportDOT HS 809 410. Washington, DC: National Highway TrafficSafety Administration; 2002.

13. Dong G, Wang D, Zhang J, Huang S. Side structure sensitivity topassenger car crashworthiness during pole side impact. Tsinghua SciTechnol. 2007;12(3):290-5.

14. Fatality Analysis Reporting System. 2006. FARS encyclopedia. http://www-fars.nhtsa.dot.gov. Accessed January 7, 2010.

15. Wittenberg E, Nelson TF, Graham JD. The effect of passenger airbagson child seating behavior in motor vehicles. Pediatrics. 1999;104(6):1247-50.

16. National Highway Traffic Safety Administration. National StandardizedChild Passenger Safety Training Program Curriculum Instructor Guide.Washington, DC: National Highway Traffic Safety Administration; 2004.

17. Olshaker J, Jackson C, Smock WS. Forensic Emergency Medicine.New York, NY: Lippincott Williams & Wilkins; 2007.

18. American Academy of Pediatrics. Car safety seats: information for familiesfor 2010. http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Families-2010.aspx?nfstatus=401&

nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token.

19. European Transport Safety Council. 2003. Priorities for EU motorvehicle safety designs. http://www.etsc.be/oldsite/rep_road7.htm. AccessedJanuary 21, 2010.

20. Desapriya E, Fujiwara T, Scime G, Babul S, Pike I. Compulsory childrestraint seat law and motor vehicle child occupant deaths and injuries inJapan 1994-2005. Int J Inj Contr Saf Promot. 2008;15(2):93-7.

21. Desapriya EB, Joshi P, Subzwari S, Nolan M. Infant injuries from childrestraint safety seat misuse at British Columbia Children’s Hospital.Pediatr Int. 2008;50(5):674-8.

22. Howard A, Rothman L, McKeag AM, Pazmino-Canizares J, Monk B,Comeau JL, et al, Children in side-impact motor vehicle crashes: seatingpositions and injury mechanisms. J Trauma. 2004;56(6):1276-85.

23. Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al,eds.World Report on Road Traffic Injury Prevention. Geneva: WorldHealth Organization; 2004.

Submissions to this column are encouraged and may be sent toTomi St. Mars, RN, MSN, CEN, [email protected] Maria Valdez, RN, PhD, CEN, [email protected]

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