Seat Belt Sign Research Articles

Abdominal injury patterns in patients with seatbelt signs requiring laparotomy.

Aims:We analyzed our series of patients with seatbelt signs (bruising) that underwent laparotomy in order to correlate injury pattern with clinical course and outcome.Materials and Methods:Retrospective analysis of patients with seatbelt signs presenting to the level 1 Trauma Unit between 2005 and 2010 was performed. We evaluated the nature of injuries during laparotomy associated with seatbelt signs and their treatment and complications.Results:There were 41 patients, 25 (61%) male, with a median age of 26 years. Median injury severity score (ISS) was 25 (range 6–66) and overall mortality was 10% (four patients). Patients were classified into three groups according to time from injury to surgery. Median time to surgery for the immediate group (n = 12) was 1.05 h, early group (n = 22) was 2.7 h, and delayed group (n = 7) was 19.5 h. Patients in the immediate group tended to have solid organ injuries; whereas, patients in the delayed group had bowel injury. Patients with solid organ injuries were found to be more seriously injured and had higher mortality (P < 0.01) and morbidity compared with patients with the “classic” bowel injury pattern associated with a typical seatbelt sign.Conclusion:Our data suggest that there is a cohort of patients with seatbelt injury who have solid organ injury requiring urgent intervention. Solid organ injuries associated with malpositioned seatbelts lying higher on the abdomen tend to result in hemodynamic instability necessitating immediate surgery. They have more postoperative complications and a greater mortality. Seatbelt signs should be accurately documented after any car crash.

The Effectiveness of Focused Assessment With Sonography for Trauma in Evaluating Blunt Abdominal Trauma With a Seatbelt Mark Sign

Background: Specific injury patterns have been recognized from seatbelt use including hollow viscous, mesenteric, and musculoskeletal injuries. We aimed to evaluate if focused assessment with sonography for trauma (FAST) is a reliable screening tool for the initial evaluation of the blunt abdominal trauma patient with a seatbelt sign. Methods: A retrospective review of adult trauma patients with blunt abdominal trauma and a positive seatbelt sign were evaluated over a three-year period. Data collected included age, gender, Glasgow coma scale (GCS), presence or absence of abdominal tenderness, results of diagnostic studies, operative findings, missed injuries, and mortality. Results: A total of sixty-nine patients were evaluated. Fifty-eight ultrasound scans were interpreted as negative and 11 positive. Three of the 11 were taken immediately to the operating room. The remaining 8 underwent computerized tomography (CT) according to protocol and clinical management was altered in two. Sixteen patients with a negative ultrasound examination underwent CT. Our series revealed 11 true and no false positives, as well as 54 true and 4 false negatives. The sensitivity of utilizing FAST for detecting a clinically significant injury in this study is 73% with 100% specificity, a negative predictive value of 93%, positive predictive value of 100%, and accuracy of 94%. Conclusions: The use of FAST, not as a single diagnostic modality, but as a screening tool with selective use of CT, is a relatively reliable instrument for the initial evaluation of the blunt abdominal trauma patient with a seatbelt mark sign. J Curr Surg. 2014;4(1):17-22 doi: http://dx.doi.org/10.14740/jcs207w

Four Poems

Four Poems Cyril Wong (bio) a kind of hush Silent again, we begin to hearnoises in our heads, swelling to overwhelm the sound of ourbreathing. If we are silent for long enough, something would surfacefrom under the wind-troubled faces of murky pondsour minds have become. All at once, ripples would fleein a singular, outward direction— these questions of guilt or blame.Then what comes up for air would be a different quietwe keep drowning, pinning it underwater in our pride untilits legs stop kicking. Different because we may hearthe mirroring of fear and a time-sharpened dependencywithin it. Such a quiet we only hear when we do not hear:waking together, every meal, [End Page 95] sharing the same cab home.Listen. Listen. My hand swims into the bay area of your hand.If we are silent for long enough, we could start over. hotel In the cupboard, bare hangers are skeletonsfor future selves; a complimentary bathrobewaits like a new and better, even purer, skin;fresh pillows are the unformed bodiesof lovers yet to be born; bedroom slippersbecome footwear for shuffling upan airy flight of stairs free of this life.Open the fridge, lean past the overpricedchocolate and the smugly settled soft drinks,and tune in to voices from the god-realm,where beings reminisce, not unfondly, aboutpast desires and mistaken attachments.On the bed, our bodies stay unentwinedin rest because love is in a different roomin a faraway country; but beneath us,cowering children press ears to the floor,absorbing the footfalls of fathers retreating,heads lowered in shame or shaking with disgust;these trembling versions of us reachfor each other now, smaller hands taking hold.In reality, the air-con sighs as discreetlyas possible; behind translucent curtains, nightslowly lifts; nobody expects the morningto be spectacular; although my eyes arereluctant to close, still hungry for the ever-new;while another stranger beside me sleeps and sleeps. landing What death may be: a slow, close-to-weightlesstilt, like a burgeoning foetus turningslightly in the womb. The engine starts a lowgrowl like a stomach, the aircraft hungry to [End Page 96] land, to devour the space between itsfalling body and the ground, followed bythe slow lick of its wheels against the runway’sbelly: pressing down, then skating forward,only to decelerate, a sensual slow-mo,and the plane makes a soundlike the hugest sigh of relief. The seat-belt sign blinks off for the final time.We rise up from our seats like soulsfrom bodies, leaving bulky hand luggagein the overhead compartments, thenbegin a tense line down the aisle, awkwardlysmiling at each other, remaining few minutesalive with all kinds of ambivalences,or simply relief at having arrived, at long last,in that no-time zone of a countrywithout a name except the ones we give it;weeping, laughing, both at once. cigarette The redundancy of languagein a budget hotel, where muchcarries on behind us on the bedwe lean against, nakedon the floor. Offering to sharea cigarette, you play metechno remixes on your phone,the beats barely eclipsinga rough choir of moans andheavy breathing that, for now,excludes us. Smoke curlsaround our heads like unravellingnecklaces of unfinished thought.We exhale more of itbefore the last song is overand nod to ascend again,ready to insert ourselves backinto the chorus of bodiesbuilding to that unsurprising end;last wisps of smoke stubbornlydecorating the air; our cigaretteleft to expire on the lip of an ashtray. [End Page 97] Cyril Wong Cyril Wong is a poet and fiction writer. His poetry collections include Unmarked Treasure and Tilting Our Plates to Catch the Light. His poems have been anthologized in Language for a New Century and Chinese Erotic Poems. He is a recipient of the National Arts Council’s Young Artist Award for Literature and the Singapore Literature Prize. Copyright © 2014 University of Hawai‘i Press

Seatbelt Sign as an Indication for Four-vessel Computed Tomography Angiogram of the Neck to Diagnose Blunt Carotid Artery and Other Cervical Vascular Injuries

Computed tomography angiography (CTA) of the neck has become the most common modality for diagnosing blunt carotid artery injury (BCAI). The protocol at our institution includes CTA on trauma patients with a seatbelt sign. The purpose of this study is to evaluate whether a solitary seatbelt sign is an indication for CTA of the neck to diagnose BCAI. We conducted a retrospective review of patients from 2000 to 2010 who received CTAs as a result of a seatbelt sign performed at our Level I trauma center. Four hundred eighteen patients received CTAs based on the presence of a seatbelt sign. Two hundred twenty-six had skeletal injuries, obvious soft tissue injuries, and/or positive findings on imaging, including 11 positive vascular findings with two BCAIs found. Patients with noncarotid vascular injuries on CTA had a higher Injury Severity Score than patients with solitary seatbelt signs (11.4 ± 7.6 vs 3.4 ± 4.2, P < 0.01). The correlation between seatbelt sign and positive finding on CTA was weak (r = 0.007). Patients with vascular findings on CTA also had obvious hard/soft tissue injuries and/or positive findings on standard trauma imaging. This suggests that a protocol for CTA of the neck for patients with a seatbelt sign can be reserved for those with associated injuries on physical examination and/or findings on standard trauma imaging.

Dilemma of Blunt Bowel Injury: What are the Factors Affecting Early Diagnosis and Outcomes

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presentation. We aimed to study the predictors for early diagnosis and outcomes in patients with BBMI. Data were collected retrospectively from the database registry between January 2008 and December 2011 in the only Level I trauma unit in Qatar. Patients with BBMI were divided into Group A (surgically treated within 8 hours) and Group B (treated after 8 hours). Data were analyzed and χ2, Student's t test, and multivariate regression analysis were performed appropriately. Among 984 patients admitted with blunt abdominal trauma (BAT), 11 per cent had BBMI with mean age of 35 ± 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, respectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B (18 ± 11 vs. 13 ± 8; P = 0.02). Presence of pain and seatbelt sign (P = 0.02) were evident in Group B. Hypotension (P = 0.004) and hypothermia (P = 0.01) were prominent in Group A. The rate of positive Focused Assessment Sonography for Trauma was greater in Group A (P = 0.001). Among operative findings, bowel perforation was more frequent in Group B (P = 0.04), whereas mesenteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more frequent finding in Group A (P = 0.005). The overall mortality rate was 15.6 per cent. In patients with BAT, the presence of abdominal pain, hypotension, ISS greater than 16, hypothermia, pelvic fracture, and mesenteric hematoma might help in early diagnosis of BBMI. Moreover, base deficit and mean ISS were independent predictors of mortality. Delayed operative interventions greater than 8 hours increased morbidity rate but had no significant impact on mortality.

CT scan-detected pneumoperitoneum: An unreliable predictor of intra-abdominal injury in blunt trauma

IntroductionFree intra-peritoneal air in blunt trauma is a classic sign associated with hollow viscus injury, traditionally mandating laparotomy. In blunt abdominal trauma, the CT scan has become the diagnostic modality of choice. The increased sensitivity of CT scans may lead to detection of free intra-peritoneal air that is not clinically significant. ObjectiveTo characterize conditions and findings that allow for the safe observation of blunt trauma patients with free air and to propose a patient management algorithm to decrease rates of non-therapeutic laparotomy. DesignA retrospective review of 5877 blunt trauma patients who had an abdominal CT scan upon admission to our hospital from 2003 to 2011. A secondary CT review was performed by a single radiologist to further characterize the CT findings in the 74 patients with free air reported on initial scan. Management and hospital course were reviewed in these patients. ResultsOf the 74 patients with intra-abdominal free air, 36 patients with a benign clinical picture were observed and 38 patients underwent urgent exploratory laparotomy. Eleven patients received a non-therapeutic laparotomy. The majority (61%) of patients, 45 of 74, had free air and no significant injury suggesting the presence of benign free air. Patients who had intra-abdominal injury also typically had other clinical or radiologic signs of injury. Findings that were highly predictive of intra-abdominal injury in the setting of free air were free fluid (P<0.001), radiographic signs of bowel trauma (P<0.001) as well as clinical and/or radiographic seatbelt sign (P=0.004). ConclusionsCT scans may detect free air that is not always clinically significant. Free fluid, seatbelt sign or radiographic signs of bowel trauma in the presence of pneumoperitoneum is highly predictive of injury and these patients should be explored. Based on the results of our study, we created an algorithm to aid in identifying those patients with intra-abdominal free air who may be observed safely.

Post-Traumatic Stress Disorder: A Less Visible Sign of War

On a beautiful sunny morning last fall, my family and I boarded a flight at Washington Reagan Airport in the nation's capital, where we reside. Our destination was Miami for a weeklong vacation with our son, Michael, before his upcoming active duty military deployment to Afghanistan. A departure flight from Washington, DC, commonly includes traveling military service members, some in uniform on official business and others in civilian clothing en route to some other destination. On this early Saturday morning, the flight contained an abundance of both. We settled into our seats and proceeded to an on-time departure. Shortly after reaching the altitude at which the seat belt sign is turned off, a nervous sounding announcement was made over the loudspeaker by a flight attendant asking for a doctor or nurse to please provide medical assistance. Looking back from my seat up front, some commotion was visible in the rear section of the plane. A second nervous call for medical assistance quickly followed. I and another woman stood and identified ourselves as registered nurses and then followed a flight attendant to the person needing assistance. Joni M. Brady, MSN, RN, CAPA, is an International Perianesthesia Nursing Consultant and Pain Management Nurse, Nursing Administration, Inova Alexandria Hospital, Alexandria, VA.

Interobserver Agreement in the Clinical Assessment of Children With Blunt Abdominal Trauma

The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement. A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.

Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries

We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Seat belt sign and its significance

Safety belts are the most important safety system in motor vehicles and when worn intend to prevent serious injuries. However, in unusual circumstances (high velocity motor vehicle collisions) these safety measures (seat belts) can be the source and cause of serious injuries. The seat belt syndrome was first described as early by Garrett and Braunste in but the term “seat belt sign” was discussed by Doersch and Dozier. Medical personnel's involved in emergency care of trauma patients should be aware of seat belt sign and there should a higher index of suspicion to rule out underlying organ injuries.

Seat-belt induced bladder rupture in a car accident: A case report

Injury to the lower urinary tract is relatively uncommon in the setting of blunt trauma. Identification of serious intra-abdominal injury is often challenging. Bladder injuries occur most often from external force and are often associated with pelvic fractures. Typically, these patients have a history of pelvic trauma, which is fairly straightforward for motor vehicle accidents, deceleration injuries, or assaults to the lower abdomen. Here, we describe a case of bladder rupture not associated with pelvic fracture in a 58-year-old man. The “seat-belt sign” and gross hematuria were present. Emergency surgery was performed with excellent results and he was discharged in stable condition.

Blunt abdominal trauma in children

This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intra-abdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and emergency department disposition after diagnosis. The importance of the seat belt sign on physical examination and screening laboratory data remains controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma (FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed emergently. Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not require routine hospitalization after blunt abdominal trauma.

Does This Adult Patient Have a Blunt Intra-abdominal Injury?

Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma. To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma. We conducted a structured search of MEDLINE (1950-January 2012) and EMBASE (1980-January 2012) to identify English-language studies examining the identification of intra-abdominal injuries. A separate, structured search was conducted for studies evaluating bedside ultrasonography. We included studies of diagnostic accuracy for intra-abdominal injury that compared at least 1 finding with a reference standard of abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve studies on clinical findings and 22 studies on bedside ultrasonography met inclusion criteria for data extraction. Critical appraisal and data extraction were independently performed by 2 authors. The prevalence of intra-abdominal injury in adult emergency department patients with blunt abdominal trauma among all evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI, 2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of injuries. The presence of a seat belt sign (likelihood ratio [LR] range, 5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2; 95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding (LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of abdominal tenderness to palpation does not rule out an intra-abdominal injury (summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or organ injury on bedside ultrasound assessment is more accurate than any history and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46); conversely, a normal ultrasound result decreases the chance of injury detection (adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the likelihood of intra-abdominal injury include a base deficit less than -6 mEq/L (LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2), hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in combination, particularly in identification of patients who do not need further diagnostic workup. Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.

Seatbelt: A Double-Edged Sword

Intra-abdominal vascular injury due to blunt trauma is unusual in children. Due to its rarity, detailed reports dealing with its management are scarce in paediatric literature. Diagnosis of these injuries is challenging, and a high degree of awareness is necessary for rapid identification and treatment of these injuries. We report the case of a child with seatbelt sign and mesenteric vein injury due to blunt trauma to the abdomen during a motor vehicle accident where the seatbelt was incorrectly placed. She also sustained cervical vertebral injury. The pattern of injuries in children in these situations may differ from that found in adults. While seatbelts have undoubtedly saved many lives, awareness about correct placement of these restraints is extremely necessary.

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

Chance fractures in the pediatric population

The pediatric Chance fracture (PCF) is an uncommon injury, but it has been increasingly reported. Knowledge is limited to few case reports and short series. To understand the various aspects of this injury, the authors reviewed the current literature. A literature search was conducted using the PubMed and Ovid online databases and relevant key words. All articles that were in English and provided information regarding PCF as a sole or part of the objective were retrieved. Seventy-three articles were found to fulfill the inclusion criteria. Relevant information about PCF collected from these articles included: 1) mode of trauma, 2) associated injuries, 3) radiological classification, and 4) treatment. Chance fractures in children are potentially devastating injuries largely caused by motor vehicle collisions, and these fractures may be more common than previously thought. Concomitant intraabdominal injuries are common and should be suspected, particularly when a seat belt sign is observed. Blunt abdominal aortic injuries are rarely associated, but should be evaluated for and treated appropriately. Magnetic resonance imaging is best for defining ligamentous injury, which aids in defining the pattern of injury, facilitating appropriate treatment regimens.

Seatbelts and road traffic collision injuries

Modification of seatbelts and their legislation played an important role in reducing morbidity and mortality of occupants in road traffic collisions. We aimed to review seatbelt development, its mechanism of action and its effects. Seatbelts reduce injury by preventing the occupant from hitting the interior parts of the vehicle or being ejected from the car. We have made a linear regression correlation between the overall seatbelt compliance and road traffic death rates in 46 high income countries to study the relationship between seatbelt use and mortality. There was a very highly significant negative correlation between the seatbelt compliance and road traffic death rates (R = - 0.77, F = 65.5, p < 0.00001). Seatbelt-related injuries include spinal, abdominal or pelvic injuries. The presence of a seatbelt sign must raise the suspicion of an intra-abdominal injury. These injuries can be reduced if seatbelts were applied correctly. Although seatbelts were recognized as an important safety measure, it still remains underused in many countries. Enforcement of seatbelt usage by law is mandatory so as to reduce the toll of death of road traffic collisions.

Bharath Sriraman and Lyn English: Theories of mathematics education: seeking new frontiers. (Springer series: advances in mathematics education)

Many years ago, I had the good fortune to board an air-plane flight across the USA and find both Jim Greeno andDavid Clarke on the plane. The three of us quickly retiredto the back of the airplane, where we had a wide-rangingconversation for more than 5 h. We talked about our dif-ferent theoretical orientations to looking at classrooms.Clarke was involved in the study of student understanding;I was trying to model teaching; Greeno was focusing on theclassroom community. As we discussed each other’s work,we pursued points of commonality and difference, and thestrengths and limitations of the approaches we had taken.(None was adequate to explain everything; each explainedsomething that the others did not.) As always, a few peoplestood around the back of the plane, some stretching orotherwise occupied.At the end of the flight, the seat belt sign came on, andthe three of us shook hands and prepared to go on our way.At that point, one of the bystanders came up to us and said,‘‘Thank you so much. That was an absolutely wonderfulseminar. I learned a great deal from your exchanges.’’I had precisely that kind of feeling when I finishedreading Theories of Mathematics Education: Seeking NewFrontiers. This rather substantial volume is organized into19 parts, each of which, after the initial overview (‘‘Sur-veying theories and philosophies of mathematics educa-tion,’’ by the editors), typically contains a brief preface, asubstantial essay, and from one to three commentaries onthe essay. Thus, the book can be seen as a series of dialogsamong some of the top professionals in the field, to whichreaders have the privilege of ‘‘listening in.’’ This is anexcellent format, one that is extremely well suited fordiscussions of theory. When issues are ‘‘settled,’’ a set ofdefinitive, handbook-like chapters may be appropriate. Butwhen ideas are being sorted out, a set of dialogs helps toreveal more of the unsettled (as well as the settled) terrain.That is a good thing.To begin at the beginning, Jeremy Kilpatrick notes in hispreface to Part I (the survey by the editors mentionedabove) that Europeans have, in general, been more explicitand reflective about issues of theory than have those in theUSA. Thus, the international authorship of the book bringsvalue added to the American context. Kilpatrick mentions,among other things, the need for greater clarity about therelationship between theories and models, a point to whichI shall return: as a reviewer I cannot resist the temptation toenter into the dialogs begun by the authors.The volume itself offers a tapestry of theory-relatedissues in mathematics education: some closely related,some parallel, and some orthogonal. Although there are noformal section breaks in the book, there is a tacit organi-zation in the order of the chapters, with the more broadlytheoretical and metatheoretical chapters coming in Parts Ithrough V, and a broad range of issues-oriented theoreticalchapters in the sequel.The volume begins with various perspectives on the‘‘big picture.’’ Sriraman and English, citing Lincoln andGuba (1994), reference some of the themes mathematicseducation should address:1. What is reality? Or what is the nature of the worldaround us?…2. How do we about knowing the world around us?…3. How can we be certain in the ‘‘truth’’ of what weknow? (p. 7)

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

Purpose Abdominal wall bruising (AWB) is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC) and is highly suspicious but not indicative of intestinal injury. The aim of this study was to find objective clinical and radiologic predictors for the need of an abdominal exploration in these children. Materials and Methods A retrospective chart review of children admitted from 1998 and 2008 with AWB after MVC was conducted. Demographics, vital signs, physical examinations, radiologic investigations, associated injuries, management, and outcome were extracted. Univariate and multivariate statistical analyses were done. Results Fifty-three children with a median age of 9 years (range, 3-16 years) were included. Forty-four patients (83%) had abdominal pain on arrival, and 25 (47%) had free intraabdominal fluid on ultrasound/scan. Intraabdominal injuries were noted in 29 patients (55%), and the most common were mesenteric or bowel injuries (25%), splenic injuries (13%), and hepatic injuries (8%). Ten patients (19%) needed therapeutic laparotomy, and all were victims from collision involving 2 moving vehicles, had abdominal pain, free intraabdominal fluid, and tachycardia. Five patients (50%) operated on had lumbar fracture compared to only 4 patients (9%) in the nonoperative group. Pulse rate higher than 120 ( P = .048), lumbar fracture ( P = .008), and free intraabdominal fluid ( P ≤ .001) were significant predictors for intestinal perforation. Overall survival was 98% with 1 death because of head trauma. Conclusion Intraabdominal injuries in children with AWB after MVC are frequent. Associated lumbar fracture, the presence of free intraabdominal fluid, and pulse rate higher than 120 are significant predictors of intestinal injuries. An abdominal exploration should be considered in these patients.

Neck & neck. Seat belt sign on the neck is as serious a finding as on the abdomen.

Neck & neck. Seat belt sign on the neck is as serious a finding as on the abdomen.