Preventing the Disaster: Severe Abdominal Injury in Child Passengers of Motor Vehicle Accidents often indicate even more serious Trauma.
Authors: Spering Christopher , Lefering Rolf , Bieler Dan , Hackenberg Lisa , Dobroniak Corinna Carla , Müller Gerd , Lehmann Wolfgang , Rüther Hauke 
Published: June 2024

Purpose: The purpose of this study was to evaluate severe abdominal injury in child passengers of different ages of motor vehicle accidents and analyze the concomitant pattern of injury regarding injury severity, trauma management and outcome.
Method: Data acquisition was performed using the Trauma Register DGU® (TR-DGU) in a 10-years period (2010–2020) of seriously injured children (maximum AIS 2+ with intensive care) aged 0-15 years of age, as motor vehicle passengers (cMVP) (n = 1,035). Patients primarily treated in or transferred to a German Trauma Center were included. A matched pairs analysis with adult severely injured motor vehicle passengers (aMVP) (age 20-50 years, n = 26,218), matched 1:4 (child: adult), was performed to identify causes of mortality.
Results: The study group (cMVP) included 1,035 (10.6%) of 9,751 children, who were seriously injured in road traffic accidents. The mean age within the study population was 9.5 years, 50.5 % were male and the mean Injury Severity Score (ISS) was 18.7 points. Most of the patients (93.0%) were transported from the scene directly to the final trauma center, 7.0 % (n = 72) needed a transfer to another level of trauma care (Level 1 treated 71.0%, Level 2 23.4% and Level 3 5.6% of the children). The transferred patients showed a higher ISS (26 vs. 18 points), higher rate of severe traumatic brain injury (TBI) (AISHead ≥ 3; 49% vs. 33%), a prolonged time to reach the final treating hospital (221 vs. 68 min.), a higher rate of serious abdominal injury (AISAbdomen ≥ 2; 40% vs. 28%) and a higher mortality rate (12.5% vs. 7.4%). The overall mortality rate during hospital stay was 7.0%. About one third (29.3%, n = 303) of the patients showed serious abdominal injury (AISAbdomen ≥ 2). 58% of them showed liver contusions with hematoma, 36% liver lazerations, 36% contusions of the spleen with hematoma and 36% minor and 34% severe lazerations of the spleen. Small bowl contusions with perforation was found in 29%. Most of the severe abdominal injuries occurred after the third year of age with a first peak between 8 – 9 years of age and a second peak in the 14 – 15 years of age group. Serious injuries to the pelvis (AISPlevis ≥ 2) show a similar distribution but less often, the same applies to thoracical injuries but more often than abdominal injuries. Severe brain and head injuries show an antiproportional distribution to the age groups with the highest rate in the 0-1 year old (78%) and the lowest in the 14 – 15 year old (40%). The highest mortality rate was shown in the youngest age groups, related to TBI (AISTBI ≥ 3) 62% in 0-1 years of age. The matched pairs analysis shows a higher mortality rate of cMVP compared to aMVP within the first 24h after hospital admission and a significantly higher rate of patients in shock and unconsciousness, while the intubation rate is significantly lower. The proportion of patients at cardiac arrest is in cMVP higher than in their matched adults.
Conclusion: Child passengers of motor vehicle accidents are in need of a more specific and age-related attention towards security systems. The incident of a severe injury is a rare yet life threatening event leading to high mortality rates in the youngest population, especially caused by TBI. But also, severe abdominal and thoracic injuries and their concomitant trauma, need to be prevented and are indicators for even more severe injuries. The management of severely injured child passengers on scene seems to be less progressive than in adults. This also applies for the early diagnostic phase in the Trauma Resuscitation Unit (TRU). Although only 7 % of the children needed a secondary transfer to a higher level of care trauma center, it seems to be favorable for severely injured child passengers of motor vehicle accidents to be directly transported to designated special Level 1 Trauma Centers with sufficient capacity and competency to treat and manage severely injured children, to positively influence their outcome.