Author: Pamela Smith, RN, BSN, Charleston, SC

Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN

Pamela Smith is Clinical Nurse Leader, Childrens Emergency Services,Medical University of South Carolina.

For correspondence, write: Pamela Smith, RN, BSN; E-mail: smithpb@musc.edu.

J Emerg Nurs 2005;31:185-7.

0099-1767/$30.00

Copyright n 2005 by the Emergency Nurses Association.doi: 10.1016/j.jen.2004.11.010

Emergency N

Booster Seat Advocacy

Traumatic C

I N J U R Y P R E V E N T I O NApril 2005 31:2As I ran from my car, my first thought was to stabilize

the C-spine of the child being held. I encouraged the

bystander to place the child on the ground and showedMore than 2500 children died in 2003 as a

result of motor vehicle crashes, which are the

leading cause of death of children ages 4 to

14 years. An additional 28,000 children had incapacitating

injuries as a result of car crashes.1 Although advocates have

promoted booster seat use to protect children,2 booster

seat use remains low. According to a study conducted in

2000, 86% of children who should be restrained in car

seats or belt-positioning booster seats are inappropriately

placed in seat belts.3

My journey home from work includes a stretch of a

2-lane historical road that usually provides a pleasant ride.

On this day, however, as I came upon multiple cars pulled

over to the side, the journey became a very different, life-

changing experience. As I slowed, I saw a limp child in the

arms of an adult and a sport-utility vehicle (SUV) with its

rear against a tree. What I did not see was the presence of

emergency providers, and I realized I was the first provider

on the scene.

urse Urges

After Encounter at

rash Scenehim how to hold the childs head and neck properly. The

child was pale and had obvious seat belt marks across his

abdomen. I quickly ran to the vehicle to assess the number

of casualties and found the father of the child entrapped in

the drivers seat with the steering wheel pushed back into

his lap. He was pale, diaphoretic, and complaining of pain

in both legs and hips. When I returned to the child, he

began to retch. As we rolled him to his side, I noticed an

obvious deformity of his lumbar spine.

I realized I had 2 severely injured patients and few

resources at my immediate disposal. I was wishing that we

JOURNAL OF EMERGENCY NURSING 185

extremities. He was also beginning to have intermittent

peri ally

resp s. I

pray old

the f ly,

as w en-

ter w r. I

was ew

Sou ghs

mor ght

agai the

seat lt.5

Wit ilo-

I N J U R Y P R E V E N T I O N / S m i t hit put him that much closer to the trauma center and

more definitive treatment.

I later learned the details of the accident. My patient

had been restrained in the second seat of the SUV with

just a lap belt. The father was speeding on the wet roads

when he lost control and hit a tree on the passenger side.

After the initial impact, the speed and velocity of the

SUV caused it to go back across the road and hit another

tree. The father suffered multiple lower extremity

fractures and a pelvic fracture. The 5-year old boy had

a complete spinal cord injury at L2 as well as an injury tohis

186ods with gasping respirations. He was minim

onsive, other than to answer yes and no question

ed that the f light team would land quickly. I t

f light team on arrival that both patients needed to

e were more than 30 minutes from the trauma c

ithout any traffic congestion, and this was rush hou

happy to turn the child over to the f light team. I knwere in the controlled environment of the trauma center!

When the first sheriff s car arrived, I immediately asked

him to have a helicopter deployed to our location. The

dispatcher was hesitant to take the word of a bystander

until the officer became insistent that he had a trauma

nurse on scene asking for helicopter support. The county

EMS supervisor arrived and let me know the nearest

paramedic truck was 20 minutes away. We decided that I

would stay with the child, and she went to the father to

begin needed extrication and interventions.

As I slowed, I saw a limp child in thearms of an adult, and a sport-utilityvehicle (SUV) with its rear against atree. . . . .and I realized I was the firstprovider on the scene.

The fire department had supplied oxygen equipment.

My next priority was to establish IV access and begin to

reverse the shock state of this vulnerable little boy, who had

thready pulses and a distal capillary refill of 5 to 6 seconds.

By the time the paramedic unit arrived, the first f luid

bolus was in, but the child continued to look pale, his

abdomen was firm, and he had no movement of his lowermesenteric vessels. The family owned a booster seat,

Jgrams, this child did not meet either of these criteria.

This scenario is not unique. The National Highway

Traffic Safety Administration (NHTSA) recently revealed

findings from a 2003 national random survey of 6000 per-

sons. About 85% of the parents and caregivers of young

children had heard of booster seats. Among those who

were aware of booster seats, 60% said they only used them

at some time with their children.6

Emergency nurses should urge policy makers at local,

state, and national levels to enact and fund legislation

and education regarding child restraint in automobiles.

NHTSA recommends the adoption of comprehensive

child occupant protection laws to cover all children up to

age 16 in all seating positions and encourages the en-

forcement of all child occupant protection laws, in-

cluding penalties. Further information can be found at

the NHTSA Web site at www.nhtsa.dot.gov. ENA also

provides training opportunities to enable emergency

nurses to teach and advocate in the community through

the Emergency Nurses Care (ENCARE) program (www.

ena.org).

Among those who were aware of boosterseats, 60% said they only used themat some time with their children.

ED staff members need to be aware of the child

restraint laws in their state and use every opportunity

possible to provide education to our parents and children.

Increasing funding for education and continuing to lobby

for strict policies and enforcement of legislation related to

child restraint in cars could help to decrease the incidenceof th

OURth Carolina, if a child less than 6 years of age wei

e than 80 pounds, or can sit with his back strai

nst the seat back cushion with his knees bent over

edge, then the child may use an adult safety be

h his small stature and estimated weight of 25 kbut it was in the third row of the SUV and was not used

to restrain the child.

The use of a lap belt as the only method of restraint in

small children has been associated with injuries such as

severe f lexion distraction injuries of the lumbar spine,

abdominal wall bruising, and hollow viscous injury.4 Inese very devastating injuries.

NAL OF EMERGENCY NURSING 31:2 April 2005

When I thought about whether my future in this

endeavor would include teaching about booster seats in

the community, all I needed to do was to remember those

big, brown eyes looking up at me, and my decision was

very easy.

Acknowledgment

The author gratefully acknowledges the guidance and edits of JENSection Editor Angela Hackenschmidt, RN, MS, CEN

REFERENCES

1. National Highway Traffic Safety Administration. Traffic SafetyFacts 2003: Children. Available at: URL: http://www-nrd.nhtsa.

seats and reduction in risk of injury among children in vehicle

I N J U R Y P R E V E N T I O N / S m i t hcrashes. JAMA 2003;289:2835-40.

5. Car seat regulations for zone 4 website. Available at: URL: http://www.inventiveparent.com/lawsreg4.htm. Accessed October 15, 2004.

6. Parents/caregivers report 21 percent of children ages 4 through8 using booster seats. Available at: URL: http://www.nhtsa.dot.gov/people/injury/traffic_tech/2004/TrafficTech294/index.html .Accessed October 15, 2004.

Contributions for this column are welcomed and encouraged.Submissions should be sent to:

Gail Pisarcik Lenehan, RN, EdD, FAANc/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002

800 900-9659, ext 4044 . awbkelly@comcast.netdot.gov/pdf/nrd-30/NCSA/TSFAnn/TSF2003EarlyEdition.pdf.Accessed October 15, 2004.

2. Winston F, Durbin D. BUCKLE UP! is not enough: enhancingprotection of the restrained child. JAMA 1999;281:2070-2.

3. Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger ofpremature graduation to seat belts for young children. Pediatrics2000;105:1179-83.

4. Durbin DR, Elliot MR, Winston FK. Belt-positioning boosterApril 2005 31:2 JOURNAL OF EMERGENCY NURSING 187

Emergency Nurse Urges Booster Seat Advocacy After Encounter at Traumatic Crash SceneAcknowledgmentReferences