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Playing in the back seat
  1. Mark G Jenkins1,
  2. M Rao2
  1. 1Specialist Registrar in Accident and Emergency
  2. 2Senior House Officer in Surgery, Altnagelvin Hospital, Londonderry, Northern Ireland BT47 6SB

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    Editor,—We read with interest the letter of fatal intra-abdominal injury associated with incorrect use of a seat belt and would like to present another aspect of seat belt misuse.1 A pair of 7 year old identical twins presented to the accident and emergency (A&E) department after being involved in a head-on road traffic accident. Both had been restrained in four point child seats in the back of the car.

    In the department, one was complaining of abdominal pain, the other none. On examination of the twins, both were haemodynamically stable. Twin 1 had bruising to her abdomen, the other none. This bruising was linear in nature across her abdomen, “the seat belt sign”. She had no focal tenderness.

    In view of the seat belt sign, twin 1 was admitted and an abdominal ultrasound was performed at this stage. The ultrasound showed a small amount of fluid in the pouch of Douglas, but no other free fluid or lacerations of visceral organs.

    Overnight she remained painful, but haemodynamically normal. A further ultrasound was performed the next day which showed free fluid within her abdomen.

    A laparoscopy was performed that confirmed turbid fluid and this was converted to a laparotomy. Three lesions were found in her jejunum, one full thickness and two partial. A 15 cm resection of her jejunum was performed with anastomosis. She made an uneventful recovery.

    On detailed questioning while in the A&E department, she stated that she had been playing a game with her twin sister and had wriggled out of her shoulder straps. This had converted her four point child seat into a lap belt. Twin 2 had remained properly restrained in her child seat.

    Lap belt use has been recognised as a mechanism of blunt injury to the small bowel. The seat belt sign is associated with an increased likelihood of intestinal injury.2 This lap belt injury in children usually occurs when children are to large for their safety seats and too small for adult seat belts.3

    This case highlights the importance of the seat belt sign, but more importantly that children within their own safety seats need to be restrained properly within them. Incorrect usage results in injury similar to adult lap belts.

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