AbdominopelvicAbdominopelvic InjuriesInjuries inin LateralLateral MotorMotor VehicleVehicle CrashesCrashes withwith SideSide Airbags:Airbags: AnotherAnother Bag?Bag?
October 8th, 2009 CIREN 2009 Public Meeting
Anne Rizzo, MD; Jeffrey Jenkins, BSME; Tayseer A Aldaghlas, MD, MS; Christine Burke; Robyn Richmond, MD; Margaret Griffen, MD Inova Fairfax Hospital Falls Church, VA OutlineOutline MorbidityMorbidity andand mortalitymortality ofof abdominalabdominal andand pelvicpelvic injuries:injuries: Solid organs Hollow Viscus Injuries (HVI) Pelvis FederalFederal MotorMotor VehicleVehicle SafetySafety StandardsStandards (FMVSS(FMVSS 214)214) CurrentCurrent sideside impactimpact airair bagbag coveragecoverage AnalysisAnalysis ofof sideside impactimpact airair bagsbags inin thethe CIRENCIREN databasedatabase DisclosuresDisclosures
NothingNothing toto DiscloseDisclose
Dude, I was texting my girl friend… I have my seatbelt on…? Abstract Accepted For 2010 Eastern Association for the Surgery of Trauma Annual Meeting, Phoenix, AZ BackgroundBackground Side impacts = 26% of all MVC’s 32% have AIS 3+ injuries Thorax and pelvis most likely to be injured in near-side impacts Thorax and pelvic injuries are associated with door intrusion NHTSA estimated head and torso SIAB reduce fatality in near side crashes by 24%
Samaha 2003 Lau 1991,Chung 1999,Samaha 2003 Department of Transportation, National Highway Traffic Safety Administration, “Federal Motor Vehicle Safety Standards; Side Impact Protection; Side Impact Phase-In Reporting,” Federal Register, Vol. 72, No. 175, Tuesday, September 11, 2007. Injury Distribution in Near Side Crashes with AIS>3 Injuries
Head 38%
Chest 64%
Abdomen 25%
Pelvis 32%
N=726 Aldaghlas 2009 AbdominalAbdominal PelvicPelvic ContentsContents
PeritonealPeritoneal organsorgans –– diaphragm,diaphragm, liver,liver, spleen,spleen, stomach,stomach, smallsmall bowelbowel andand transversetransverse coloncolon RetroperitonealRetroperitoneal –– aorta,aorta, venavena cava,cava, pancreas,pancreas, kidneys,kidneys, uretersureters andand portionsportions ofof duodenumduodenum andand coloncolon PelvisPelvis –– rectum,rectum, bladder,bladder, iliaciliac vessels,vessels, internalinternal genitaliagenitalia ofof womenwomen AbdominalAbdominal AnatomyAnatomy
Diaphragm Liver Stomach
Spleen
Kidney SolidSolid OrganOrgan InjuriesInjuries
SpleenSpleen mostmost commonlycommonly injuredinjured (60%),(60%), mortalitymortality 66--10%10% LiverLiver secondsecond mostmost commonlycommonly injured,injured, mortalitymortality 88--10%10% Mechanism:Mechanism: directdirect compression,compression, raterate ofof compression,compression, ribrib fractures,fractures, accelerationacceleration HollowHollow ViscusViscus InjuriesInjuries (HVI)(HVI)
Small bowel injury relatively uncommon (<1% of all trauma admissions) Intestine = 3rd most commonly injured abdominal organ in blunt trauma (5-15%) Mechanism: sudden rise in intraluminal pressure, compression, acceleration
East, J Trauma 2003 PelvicPelvic OrganOrgan InjuriesInjuries
PelvicPelvic structurestructure protectsprotects variousvarious organsorgans PelvicPelvic fracturesfractures :: GU,GU, GIGI andand vascularvascular injuriesinjuries Mechanism:Mechanism: directdirect compression,compression, acceleration,acceleration, lacerationlaceration fromfrom bonebone fragmentsfragments PelvicPelvic FracturesFractures Mechanism of Pelvic Ring Fractures
Thornton 2009 PelvicPelvic FractureFracture ClassificationClassification
TileTile andand YoungYoung--Burgess:Burgess: BothBoth basedbased onon directiondirection ofof injuriousinjurious forceforce RelatesRelates toto typetype ofof treatmenttreatment requiredrequired andand prognosisprognosis YoungYoung--BurgessBurgess (YB)(YB) InjuryInjury TypesTypes BasedBased onon YBYB ClassificationClassification APAP compressioncompression BBasedased onon directiondirection ofof injuriousinjurious forceforce PubicPubic diastasisdiastasis withwith oror withoutwithout SISI jointjoint disruptiondisruption CausesCauses externalexternal rotationrotation ofof eithereither hemipelvishemipelvis oror bothboth ExternalExternal rotationrotation increasedincreased volume:volume: increasedincreased bleedingbleeding InjuryInjury TypesTypes BasedBased onon YBYB ClassificationClassification
Lateral compression Sacral buckle and horizontal pubic rami fractures Causes internal rotation of either hemipelvis or both Internal rotation creates decreased volume: less bleeding InjuryInjury TypesTypes BasedBased onon YBYB ClassificationClassification
VerticalVertical shearshear injuryinjury A vertical force to hemipelvis (by femur) Hemipelvis is displaced in a cranial direction ComplexComplex fracturefracture Forces applied > one primary vector MostMost MORBIDMORBID injuryinjury PelvicPelvic FracturesFractures MortalityMortality
AssociatedAssociated withwith highhigh mortalitymortality Overall mortality 16% Uncontrolled pelvic hemorrhage 39% Open fractures 45%
Grotz 2005 Dente 2005 PelvicPelvic FracturesFractures MorbidityMorbidity Infection,Infection, pain,pain, nervenerve damagedamage (10(10--15%),15%), malunionmalunion oror nonunion,nonunion, DVTsDVTs andand PEsPEs ComplicationsComplications inin women:women: urinaryurinary tracttract (21%),(21%), lowerlower GIGI symptomssymptoms (8%)(8%) LongLong termterm disability:disability: <50%<50% ofof patientspatients whowho areare operatedoperated returnreturn toto theirtheir preinjurypreinjury levellevel ofof functionfunction Mechanism:Mechanism: directdirect compression,compression, tension,tension, bending,bending, shearshear
Huittinen 1972 Weis 1984 TimelineTimeline ofof FederalFederal SafetySafety RulesRules
19661966 DOTDOT createdcreated 19681968 FrontFront seatseat shouldershoulder beltsbelts 19951995 PassivePassive restraintsrestraints inin allall carscars 19971997 DualDual frontalfrontal ABAB inin allall carscars 2000s2000s PerformancePerformance requirementsrequirements addedadded toto decreasedecrease injuriesinjuries inin sideside impactimpact crashescrashes FMVSSFMVSS No.No. 214214 Protect occupants in near side crashes Side impact requirements for passenger cars: October of 1990 Defined minimum requirements for thoracic and pelvic protection New requirements in 2010: criteria for abdominal and pelvic regions CurrentCurrent TestingTesting forfor SideSide ImpactImpact
HICHIC (Head(Head InjuryInjury Criterion)Criterion) TTITTI (Thoracic(Thoracic TraumaTrauma Index)Index) MaximumMaximum PelvicPelvic AccelerationAcceleration CriteriaCriteria (130g)(130g) NoNo currentcurrent abdominalabdominal criteriacriteria AirAir BagBag DeploymentDeployment ReviewReview 726726 nearnear sideside crashescrashes reviewedreviewed 586586 nearnear sideside crashescrashes withoutwithout SIABSIAB installedinstalled 2828 SIABSIAB diddid notnot deploydeploy 112112 vehiclesvehicles withwith SIABSIAB deploymentdeployment 6161 deploymentsdeployments withwith headhead coveragecoverage 111111 deploymentsdeployments withwith thorax/abdomenthorax/abdomen coveragecoverage 44 deploymentsdeployments withwith pelvicpelvic coveragecoverage TypesTypes ofof SideSide ImpactImpact AirAir BagsBags Torso and head: Roof rail and door mounted TypesTypes ofof SideSide ImpactImpact AirAir BagsBags Torso and head: roof rail and seat mounted HeadHead InjuriesInjuries TypesTypes ofof SideSide ImpactImpact AirAir BagsBags Torso: seat and door mounted ChestChest InjuriesInjuries AbdominalAbdominal InjuriesInjuries TypesTypes ofof SideSide ImpactImpact AirAir BagsBags Torso and pelvis: seat mounted PelvicPelvic InjuriesInjuries HeadHead injuryinjury vs.vs. SIABSIAB coveragecoverage
No SIAB
Minor Injury = At least one AIS ≤ 2 for Head Severe Injury = At least one AIS ≥ 3 for Head
SIAB with SIAB without Head Coverage Head Coverage ChestChest injuryinjury vs.vs. SIABSIAB coveragecoverage
No SIAB
Minor Injury = At least one AIS ≤ 2 for Chest Severe Injury = At least one AIS ≥ 3 for Chest
SIAB with SIAB without Chest Coverage Chest Coverage AbdominalAbdominal injuryinjury vs.vs. SIABSIAB coveragecoverage
No SIAB
Minor Injury = At least one AIS ≤ 2 for Abdomen Severe Injury = At least one AIS ≥ 3 for Abdomen
SIAB with SIAB without Abdomen Coverage Abdomen Coverage PelvicPelvic injuryinjury vs.vs. SIABSIAB coveragecoverage
No SIAB
Minor Injury = At least one AIS ≤ 2 for Pelvis Severe Injury = At least one AIS ≥ 3 for Pelvis
SIAB with SIAB without Pelvis Coverage Pelvis Coverage Injury Distribution in Severe Near Side Crashes with AIS>3 Injuries
With Air Bags Without Air Bags 2% 47%
6% 66%
4% 21%
<1% 38%
N=726 ConclusionConclusion CurrentCurrent sideside airair bagbag coveragecoverage focusesfocuses onon thethe headhead andand torsotorso SIABSIAB (head,(head, chest,chest, abdomen)abdomen) extendextend protectiveprotective benefitsbenefits toto otherother bodybody regions:regions: EXCEPTIONEXCEPTION Pelvis Lesser extent abdominal organs FewFew SIABSIAB extendextend toto thethe pelvicpelvic region,region, leavingleaving pelvispelvis unprotectedunprotected inin aa majoritymajority ofof crashescrashes ConclusionConclusion FutureFuture HorizonsHorizons
AdditionalAdditional datadata variablesvariables describingdescribing sideside airair bagbag coveragecoverage zoneszones inin crashcrash researchresearch databasesdatabases wouldwould enableenable researchersresearchers toto focusfocus moremore specificallyspecifically onon reductionreduction inin injuriesinjuries toto thethe APAP regionregion ConclusionConclusion FutureFuture HorizonsHorizons TheThe newnew injuryinjury criteriacriteria forfor FMVSSFMVSS 214214 inin 20102010 forfor thethe protectionprotection ofof APAP regionsregions willwill reducereduce injuriesinjuries andand disabilitiesdisabilities fromfrom sideside impactimpact crashescrashes Recommendations:Recommendations: PelvicPelvic ABAB coveragecoverage Structural Integrity Change LimitationsLimitations
LimitedLimited detailsdetails onon SIABSIAB coveragecoverage areaarea availableavailable forfor researchresearch SmallSmall samplesample sizesize ofof currentcurrent pelvicpelvic SIABSIAB AbdominalAbdominal organorgan mechanismsmechanisms ofof injuryinjury needneed moremore studystudy Questions?Questions?