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A recognised clinical scenario in children is traumatic asphyxia with associated visceral injuries resulting from low-velocity compression of the torso.^11,12 Typically, a motor vehicle reverses over a toddler or older pre-school child in a driveway or car park.^7,13 In these cases, the pliability of a child's skeleton and soft tissues, together with the ability of the applied force to be distributed over the short time of the impact, often allows a good outcome.^7,12,13 This clinical scenario has been variously termed the driveway, back over, crush, non-traffic or low-velocity motor vehicle injury in the United States, but has not been well described in Australia.^4,6,13-18

We examined the experience of the New Children's Hospital, Westmead, (NCH) with driveway injuries, together with a review of cases reported to the New South Wales Paediatric Trauma Death (NPTD) Registry. Our objectives were to ascertain the extent of this problem, the nature of injuries, and the outcomes, in order to determine the optimal intervention strategy.

The ethics committee of the NCH approved the study.

Admissions to NCH: Data were collected from November 1995 (when the NCH opened) to February 2000. Patients were identified prospectively from the paediatric trauma database compiled by the trauma research nurse. In addition, a retrospective search was made of the case notes of all children admitted to NCH as a result of a pedestrian motor vehicle injury to ensure no cases had been missed.

Patients were either admitted directly to NCH from its catchment area of Sydney's western suburbs or transferred via the New South Wales Newborn and Paediatric Emergency Transport Service from peripheral centres.

NPTD Registry: The NPTD Registry records all deaths resulting from trauma of children under 16 years of age in NSW that are reported to the coroner. Data were available from inception of the database in January 1988 to December 1999. The police statement and coroner's report, together with the postmortem findings, were reviewed for children who had died following a driveway injury.

Admissions to NCH: There were 42 children admitted with injuries sustained as a result of a driveway motor vehicle injury, representing 12% of the 354 children admitted to NCH with pedestrian motor vehicle injuries. Thirteen patients had been transferred from another hospital. One of the children died. Twenty-six (63%) of the children who survived were under three years of age. Boys accounted for 74% of the children admitted.

NPTD Registry: There were 14 deaths from driveway injuries, including one of the 42 children admitted to NCH, reported over the 12-year period. These deaths represented 8% of the 174 pedestrian motor vehicle deaths reported to the registry over the same interval. Children who died were generally younger than patients admitted to NCH. Boys were again over-represented (78%).

A relative of the child or a family friend was the driver in 39 cases, including 12 of the 14 injuries leading to death.

A four-wheel-drive (4WD) or light commercial vehicle (LCV) was involved in 34% of injuries in which the child survived, compared with 64% of those with a fatal outcome. Overall, these vehicles accounted for 42% of all injuries. They were associated with a 2.5-times greater risk of fatality compared with other motor vehicles. In 42 cases, the vehicle reversed over the child; 4WDs and LCVs accounted for 19 of these cases.

Documentation of access limitation to the driveway was available in only three cases; in two this involved a front door only, and in one a fence gate, all of which had been left open.

One child without a head injury died in transit as a result of hypovolaemic shock from a near-complete transection of the right lobe of the liver.

In the children who survived, there was a lower incidence and severity of head and neck injuries and a greater incidence of limb trauma compared with children who died. In the surviving children, head injury was usually a consequence of a fall to the ground or cerebral oedema from traumatic asphyxia secondary to compression of the torso.

Final outcome was recorded as satisfactory or good for 34 of the 41 survivors, with a full return to normal activities and no significant physical or psychological sequelae. Active clinical and social problems were identified in seven patients (Box 4).

Of great concern was the number of fatalities associated with this injury mechanism: 8% of the total number of paediatric pedestrian motor vehicle deaths. Published figures range from 10.7% in New Zealand to 20% in the US, suggesting that our figure is representative.^7,18 Male predominance is a feature of most traumatic injuries,^{4,8,13,14,16,19} and was particularly noticeable in our series, even below the age of five years. Our data suggest a marked difference between boys and girls in their exploratory behaviour that occurs from an early age.²⁰

A family member or person known to the child was the driver in 86% of fatalities reported to the NPTD Registry; this high incidence is a feature of other series.^7,14,17,18 Clearly, the psychological consequences must be devastating to the family, friends and neighbours.¹⁸

Our results suggested a link between fatal outcome, age of the child and the size and weight of the vehicle involved.¹⁴ Both 4WDs and LCVs accounted for a much higher number of the fatalities in our study than would be expected from their prevalence on the roads. They account for less than 30.4% of registered motor vehicles in NSW (Australian Bureau of Statistics, Motor Vehicle Census 1998, personal communication), but were involved in just under two-thirds of the deaths and were associated with a 2.5-times greater risk of fatality compared with other motor vehicles.

Motoring and child safety organisations and health visitors should alert parents and relatives of young children to these findings to encourage greater awareness of the risks these vehicles pose to both toddlers and preschool children. Road safety organisations need to emphasise that the risk of injury appears to be particularly great when reversing in a driveway with this type of vehicle -- the increased ride height potentially reduces visibility and makes identification of a young child much more difficult, even with the use of convex mirrors or a wide-angle lens.^15,16

In some prestige vehicles, a proximity-warning device, consisting of ultrasonic transceivers located in the bumpers, at an extra cost to the customer of between $900 and $1600, allows detection of objects within 50 cm to 70 cm of the bumper and above a height of 30 cm. Although the effectiveness of such devices has not been proven in this situation, their wider introduction in high-risk vehicles may help reduce the frequency of this injury.^4,16

As nearly all the deaths involved massive head injuries not amenable to medical intervention, prevention represents the only effective approach to reducing fatalities.^14-16,18 We suggest that an effective form of injury prevention is urgently required, particularly in view of evidence that this injury is often associated with shared driveways.²¹ The frequent subdivision of redeveloped residential blocks in urban areas might be expected to lead to an increase in these injuries.²²

The optimal prevention would appear to be clear separation of the driveway and garage from the children's play area by a physical barrier such as a fence, wall or self-locking gate.^16,21 There are risks to the inquisitive child not only from moving vehicles but also automatic garage doors and unattended vehicles.^4,23 Although the construction of circular driveways might decrease the incidence of these injuries, such an approach would be impractical in most urban situations.⁴ The use of reversing alarms in passenger vehicles appears unlikely to be effective given that the group most at risk of injury, toddlers and preschool children, are too young to appreciate the significance of the alarm and act with appropriate speed.^4,17

We recommend that the same degree of vigilance taken with regard to swimming pool safety should be applied to the driveway, and that legislation should be introduced to limit access to this area either by design or the use of temporary fencing.^18,21 As an interim measure, we advocate extreme caution be exercised by parents, relatives and neighbours of young families when reversing out of driveways, particularly in vehicles with restricted rear view vision and at greater risk of causing fatal injury, such as four-wheel-drives, vans and trucks.

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18. Partrick DA, Bensard DD, Moore EE, et al. Driveway crush injuries in young children: a highly lethal, devastating and potentially preventable event. J Pediatr Surg 1998; 33: 1712-1715.
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22. Australian Bureau of Statistics. Building approvals, New South Wales and Australian Capital Territory -- December 1999. Canberra: ABS, 2000. (Catalogue no. 8731.1.)
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Reprints: Mr Andrew J A Holland, Department of Surgical Research, The New Children's Hospital, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, NSW 2124.
AndrewH3ATnch.edu.au

©MJA 2000
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