SLIDE 1
The Occurrence of Occult Injuries 
in Crashes at the William Lehman Injury Research Center

Jeffrey Augenstein, Elana Perdeck, James Stratton, Jeffrey MacKinnon, Luis Labiste, Jerry Phillips

William Lehman Injury Research Center
A CIREN CENTER
Kennerly Digges, George Bahouth
The George Washington University

SLIDE 2
Saving Lives
Approx. 5-10% of all crash deaths are preventable with early recognition and improved triage
Evanco (2002), Best (2001)
CIREN is uniquely positioned to identify crash injury patterns and improve trauma systems
Continued education of providers is fundamental to system improvement-survival
Future systems will automate crash recognition, localization and prediction of injury

SLIDE 3
Education
Triage strategies to avoid missing patients with occult injuries

Optimized diagnostic and therapeutic 
 in-hospital decision making


SLIDE 4
Injuries
Occult Injuries (not easily recognized)
internal bleeding without external signs (liver, spleen)
heart and aortic injuries (damage without bleeding)
talk and die brain injuries


SLIDE 5
Trauma Criteria


SLIDE 6
Nearly 40% of all car crash victims who are brought to the Ryder Trauma Center under High Suspicion of Injury require no further treatment and are discharged shortly after arrival.


SLIDE 7
Added Criteria to Improve Triage Decisions
The SCENE Scale
The URGENCY Algorithm


SLIDE 8
Look Beyond The Obvious

SLIDE 9
The SCENE Scale
Proposed by WLIRC in 1993
Triggered by Unexpected Injuries at Low Delta-V
Significant Elements
Bent Steering Wheel  Lift & Look
Close-in Occupants
Excessive Energy in the Crash
Non-Use of Lap Belts
Eye-witness Observations On- scene

SLIDE 10
Evolution of the SCENE Scale
Added Low Frequency Events That Increase Injury Risk to Belted Occupants
Most Significant Events:
Multiple impact crashes
Narrow object impacts
Off-side crash direction
Unbelted rear seat occupants

SLIDE 11
The URGENCY Algorithm
Jones and Champion, Journal of Trauma, 1989  Damage Greater than 20 is indicator of severe injury - (1 Variable)
Malliaris  SAE 970393 Relationships Between Crash Casualties and Crash Attributes
Regression Analysis of NASS/CDS - (17 Variables) 
-Basis for the URGENCY Algorithm

SLIDE 12
Probability of AIS 3+ Injury Frontal Crash (Malliaris)

SLIDE 13
Factors that Increase of MAIS 3+ Probability over Shown Base (Malliaris)

SLIDE 14
Evolution of the URGENCY Algorithm
Selected Malliaris Factors Programmed in Excel, Briefing to NHTSA Administrator 3/11/97 (Digges & Champion)
Available to NHTSA Field Operational Test of ACN Systems (Jun 1997-Aug 2000)
Provided by NHTSA to Comcare - on Website

SLIDE 15
Original URGENCY (1997)

SLIDE 16
URGENCY + SCENE Added Data (1998)

SLIDE 17
URGENCY + SCENE (1998)

SLIDE 18
Exposure & Injury vs Crash Severity 

SLIDE 19
Injuries and Injury Risk vs Crash Severity

SLIDE 20
URGENCY and SCENE Scale
SCENE Scale - Predicts specific injuries
based on multidisciplinary analysis of 	injuries observed in low frequency 	crashes
URGENCY - Estimates injury risk 
	based on statistical analysis of injury frequency in real-world crashes

SLIDE 21
2nd Generation URGENCY and SCENE (2002)
URGENCY 
Separate Crash Modes
Include ACN Variables
Subdivide Data  Develop and Validate
Account for Multiple Injuries
SCENE
Continue to Document and Analyze Unexpected Severe Injuries

Slide 22
Continued Development & Application of the SCENE Scale

SLIDE 23
The Process
Learning from cases

SLIDE 24
Early recognition of crashes  with occult injuries 

SLIDE 25
Can Crash Patterns Leading to Occult Injuries be recognized early using the
 SCENE Scale?


SLIDE 26
CASE 1
2-Point Shoulder Belt Related
Non-Use of Lap Belt

Occult Liver Injury
-Fatality- 



SLIDE 27
CASE SUBJECT: 44 Y/O male driver
* 180 cm (72)
* 86.8 kg (191 lbs)
* 2-point shoulder belt restrained - lap belt not used
* No air bags available



SLIDE 28
NonUse of Lap Belt
Missed Opportunity

SLIDE 29
Case Vehicle
* 1990 Nissan Sentra
* PDOF: 11 Oclock
* Max crush: 55 cm (22)
* dV: 40 km/h (25 mph)


SLIDE 30
Case Facts
* Stated he was OK at scene
* Taken to Jail (DUI)
* 12 hours post-crash complained of extreme abdominal pain
* 14 hours post crash cardiac arrest  Died in ER

SLIDE 31
Vehicle Damage

SLIDE32
Max Crush 55 cm (22")
dV: 40 km/h (25 mph)

SLIDE 33
Driver Area

SLIDE 34
Right Knee Contact

SLIDE 35
Restraint Loading - 2-point shoulder belt

SLIDE 36
Principle Other Vehicle - 1985 Chrysler Le Baron

SLIDE 37
Significant Injury
AIS-4   Right lobe of liver (major laceration)


SLIDE 38
Injury Mechanism
AIS 4  Right lobe of liver (major laceration)
 2-Point Shoulder restraint / direct 	loading


SLIDE 39
Injury 
No Obvious Indication of Severe Injury 
But Case Occupant Sustained a Liver Laceration
AIS 4


SLIDE 41
Using SCENE Scale

SLIDE 42
S C E N E  Non-use of Seatbelts

SLIDE 43
First Generation URGENCY

SLIDE 44
2nd Generation URGENCY
59.6% Risk of an AIS-3 or Greater Injury

Increased risk for non-use of lap belt


SLIDE 45
Poster Woman
2-point Belt - Success
* 93 Mazda Protege
* dV: 15 mph
* PDOF:  1 Oclock
* Max crush:  6.5

Vehicle to Vehicle Impact



SLIDE 46
Injury Recognized by Mechanism
40 Y/O Female driver
187 lb. , 6
Shoulder Belt Only
No Air Bag deployment
Injuries
* AIS-5 Major Liver Laceration
* AIS-2 Kidney Contusion
* Trauma Criteria  
	High Suspicion of Injury



SLIDE 47
Case 2
Close-in Occupant
Occult Liver Injury
-Survivor-
Single Vehicle Pole Impact


SLIDE 48
Case Subject: 40 Y/O Female Driver
* 163 cm (64),  61 kg (135 lbs)
* Lap/Shoulder restrained
* Driver air bag deployed

Initially Brought to ED


SLIDE 49
CRASH SCENE: 
crash occurred 09:47am
unknown reason for loss of control


SLIDE 50
CASE VEHICLE:
 1997 Jeep Wrangler
 PDOF: 12 Oclock
 Max crush: 81 cm (31.9)
 dV: 48 km/h (30 mph-est.)
 Left instrument panel intrusion: 
3 cm (1.2)
 Left toe pan intrusion: 
8 cm (3.1)
 Steering wheel deformation: 
12 cm (4.7)





SLIDE 51
Crash Facts
* Crash occurred	-09:47am
* Ground rescue takes driver to hospital ED	-10:37am
* Trauma resus arrival	-10:48am
* Hospital stay - 4 days



SLIDE 53
Vehicle Damage

SLIDE 54
Max crush 81cm (31.9")
dV: 48 km/h (30mph)


SLIDE 56
left side view of jeep

SLIDE 57
Steering Wheel Deformation 12cm (4.7")
close-in occupant

SLIDE 58
Restraint Loading

SLIDE 59
SIGNIFICANT INJURIES
AIS-4 Multiple rib fractures (bilateral 1-3) with hemothorax

* AIS-3 Liver laceration
* AIS-4 Brain hemorrhage
* AIS-3 Brain contusion
* AIS-3 Right lung contusion


SLIDE 60
INJURY MECHANISM
AIS-4 Multiple rib fractures (bilateral 1-3) - Driver air bag / Direct loading

AIS-3 Liver laceration
Lap/shoulder restraint / Direct loading

AIS-4 Brain hemorrhage
Seat back / Direct contact

AIS-4 Brain contusion
Seat back / Direct contact

AIS-3 Right lung contusion
Driver air bag / Direct loading


SLIDE 61
XRay of chest: bilateral rib fractures 1-3


SLIDE 62
Injury Mechanism
bilateral rib fractures 1-3: driver air bag loading

SLIDE 63
CT of liver: anterior right lobe of liver

SLIDE 64
Injury Mechanism
Liver lacertain - shoulder restraint loading

SLIDE 65
CT of Brain: Subarachnoid Hemorrhage

SLIDE 66
Mechanism of injury SAH to seat back


SLIDE 67
CT of Head:
right parietal region soft tissue swelling

SLIDE 68
Injury Mechanism:
- right parietal swelling
  rebound fright seat frame

SLIDE 69
INJURY MECHANISM
lap/shoulder loading

SLIDE 70
Applying SCENE Scale

SLIDE 71
S.C.E.N.E:
Steering wheel deformation Close-on occupant


SLIDE 72
First Generation URGENCY

SLIDE 73
2nd Generation URGENCY
72.27% risk of and AIS-3 or greater injury

Increased risk from impacts with strong narrow fixed objects


SLIDE 74
CASE 3
Lap/Shoulder Restraint Related 
Occult Liver Injury 
-Left Rear Passenger Fatality-
Vehicle to Vehicle Far Side Impact


SLIDE 75
Case Subject: 
* 12 Y/O Female 
* Left Rear Passenger
*  165 cm (65),  71 kg (156lbs)
*  Lap/Shoulder restrained

Occupant does not go to ED



SLIDE 76
Crash occurred 07:00pm

SLIDE 77
CASE VEHICLE:
 1997 Lexus LS 400
 PDOF: 2 Oclock
 Crush measurements N/A
 dV: 24 km/h (15 mph)



SLIDE 78
CASE FACTS:
* Crash occurred	-07:00pm
* Vehicle occupied by driver, RF passenger and 2 rear seat passengers 
* Right rear passenger taken to local ED, accompanied by her daughter (case subject)
* Case subject complains in ED of stomach pains
* Case subject goes to bathroom, drinks water, gets dizzy and goes into respiratory arrest
* Case subject expires in ED 4 hours post crash -10:45pm


SLIDE 80
MAX CRUSH: UNKNOWN 
DV: 24km/h (15mph)

SLIDE 81
Right Side Damage - intrusion unknown

SLIDE 82
Perpendicular right side damage


SLIDE 83
Left Rear Seat
exemplar

SLIDE 84
Occupant Exemplar
5'5", 156lbs


SLIDE 86
Principle Other Vehicle:  1987 TOyota Tercel

SLIDE 87
SIGNIFICANT INJURIES
AIS-5    Right lobe of liver major laceration

* AIS-4    Bilateral lung contusion
* AIS-3    Endocardium contusion 
* AIS-2    Left lobe of liver contusion


SLIDE 88
Injury Mechanisms
AIS 5  Right lobe of liver major laceration
Lap Shoulder restraint / Direct loading

* AIS 4  Bilateral lung contusion
Lap Shoulder restraint / Compression

* AIS 3  Endocardium contusion 
Lap Shoulder restraint / Compression

* AIS 2  Left lobe of liver contusion
Lap Shoulder restraint / Direct loading



SLIDE 89
Lessons Learned
* URGENCY and SCENE currently not applied to rear seat occupants

* Certain far side crashes may be hazardous to  belted occupants

* Need to update our thinking on rear seat occupants!


SLIDE 90
CASE 4
Rear Seat Loading
Occult spleen injury - survivor
Frontal Narrow Pole Impact

SLIDE 91
Case Subject
* 20 Y/O Female  
* Right Front Passenger
* 168 cm (66), 54 kg (120lbs) 
* Lap/Shoulder restrained
* Right front passenger air bag deployed

Sharing the rear right seat are two occupants that load the right front seat back during impact


SLIDE 92
SCENE - showing CV trajectory; driver distracted by vehicle occupants


SLIDE 93
CASE VEHICLE
 1995 Ford Mustang
 PDOF: 12 Oclock
 Max Crush: 62 cm (24.4)
 dV: 40 km/h (25 mph est.)
 No Intrusion

Initially brought to ED



SLIDE 94
CRASH FACTS:
* Crash Occurred	- 03:42am 
* Ground rescue takes RF passenger to hospital ED -04:42am 
* Trauma resus arrival 06:22am 
Hospital stay -9 days



SLIDE 96
max crush 62cm (24.4")
DV: 40 km/h (25mph)

SLIDE 97
photos right front passenger area (post-crash)

SLIDE 98
restraint usage indicated


SLIDE 99
* Left rear seat was in down position when crash occurred
* right rear seat was occupied by 2 unrestrained occupants


SLIDE 100
* AIS-3 Spleen laceration
* AIS-3 Left rib fractures with pneumothorax
* AIS-3 Left lung contusion
* AIS-2 Pelvic fracture


SLIDE 101
* AIS-3 Spleen laceration
Lap/Shoulder restraint / Compression

* AIS-3 Left rib fractures with pneumothorax
Lap/Shoulder restraint / Direct loading

* AIS-3 Left lung contusion
Lap/Shoulder restraint / Direct loading

* AIS-2 Pelvic fracture
Lap/Shoulder restraint / Direct loading



SLIDE 102
CT Spleen

SLIDE 103
Rib Fractures with Pneumothorax

SLIDE 104
CT of Pelvis 

SLIDE 105
Mechanism of Injury

SLIDE 106
1st Generation URGENCY

SLIDE 107
2nd Generation 
URGENCY
46.86% risk of an AIS-3 or greater injury

Increased risk from impacts with strong narrow fixed objects and extent of crush

No factor for unrestrained rear seat occupants

SLIDE 108
Using SCENE SCALE
NOTE: Rear Seat Occupant Loading
Predicts specific injuries based on multidisciplinary analysis of injuries observed in low frequency crashes

SLIDE 109
Thank you
For Recognizing the Importance of Education
*	NHTSA  CIREN 
	*	Live lectures
	*	Web-based
	*	Under development