Three cervical seat belt signs. Now what?
After obtaining a CT-arteriogram on all three (no injuries) it was time to dig up that paper I came across a couple of years ago.
This paper, out of Emory University, looked at cervicothoracic seatbelt signs (SBS) and their association with vascular injury. The authors prospectively studies the results of their workup algorithm for SBS's, which consisted of an arteriogram or CTA for all patients with cervical SBS and those with a thoracic SBS who were symptomatic or suspected of having an aortic injury.
They identified 131/797 (16.4%) of trauma patients with a cervical and/or thoracic SBS, 3% of whom were found to have a vascular injury (mortality 50%).
Of the pediatric patients in that study, all of whom were appropriately restrained, 18.8% had a SBS. None of those patients had a vascular injury.
This study basically validated the safety of an algorithm where all patients with a cervical SBS undergo either a CTA or arteriogram (emergently in the presence of an abnormal neurovascular exam or GCS<14), while only those with a thoracic SBS and an abnormal neurovascular exam need further imaging (the rest should be ovserved and reexamined).
Interestingly, 2 of the 4 patients with carotid injury had an isolated thoracic SBS, suggesting the importance of shearing forces related to deceleration and hyper extension/flexion in carotid injury.
The absence of vascular injury in the pediatric population in this study should obviously not be considered a reason not to continue to image these patients, given that the number of pediatric patients in this study was small, and the potential consequence of missing an injury (rare as it is) is catastrophic.
Reference:
Rozycki et al. A prospective study fro the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. The Journal of Trauma injury, infection, and critical care (2002) 52:618-624
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