Background Motor vehicle collisions (MVCs) are a common cause of injury and death throughout the world. Following an MVC some patients will remain in their vehicles due to injury, the potential for injury or physical obstruction. Extrication is the process of removing injured or potentially injured patients from vehicles following a motor-vehicle collision. Current extrication practices are based on the principles of 'movement minimisation' with the purpose of minimising the incidence of avoidable secondary spinal injury. Movement minimisation adds time to the process of extrication and may result in an excess morbidity and mortality for patients with time dependent injuries. The current extrication approach has evolved without the application of evidence-based medicine (EBM) principles. The principles of EBM; consideration of the relevant scientific evidence, patient values and preferences and expert clinical judgement are used as a framework for this thesis. Aims and Objectives To develop evidence-based guidance for the extrication of patients trapped in motor vehicles by applying EBM principles to this area of practice. This will be achieved through: - Describing the injury patterns, morbidity and mortality of patients involved in MVCs (trapped and not trapped). - To analyse the movement associated with and the time taken to deliver across a variety of extrication methods. - Determining the perceptions of patients who have undergone vehicle extrication and describe their experiences of extrication. - Developing consensus-based guidelines for extrication.

OBJECTIVES: To compare morbidity and mortality between pediatric victims of motor vehicle collisions (MVC) who were unrestrained to those restrained and to describe compliance with child restraint usage in our population. MATERIALS AND METHODS: A retrospective consecutive chart review study was performed on MVC victims 14 years old and younger who presented to our academic, level 1 trauma emergency department in 2003. Each patient's emergency department and hospital course was reviewed and data were collected. Odds ratios (ORs) were calculated for unrestrained children with respect to restrained children for fractures; intraabdominal injuries, intrathoracic injuries, intracranial injuries, admission, surgery, blood transfusion, intubation; and deaths. Hospital charges and length of hospital stay were compared between those unrestrained and restrained. Percentage of children unrestrained was determined. RESULTS: Of 336 patients, 81 (24%) were unrestrained. Mean hospital stay for unrestrained children was longer, 1.94 days (95% confidence interval [CI] 0.75-3.12) versus 0.098 days (95% CI 0.02-0.21). Unrestrained victims had higher mean charges, $14,754 (95% CI $7676-$21,831) versus $1996 (95% CI $1207-$2786). Admissions (OR = 14.48, 95% CI 5.91-38.63), fractures (OR = 5.85, 95% CI 2.13-16.89), intraabdominal injuries (OR = 20.16, 95% CI 2.36-930.68), and intrathoracic injuries (OR = 13.09, 95% CI 1.26-647.05) were all more likely in unrestrained patients. No restrained child had intracranial injury, whereas 9/81 (11.11%) of unrestrained did. Odds were higher in unrestrained for surgery [OR = 13.09, 95% CI 3.30-74.33] and transfusion [OR = 27.61, 95% CI 3.56-229.85]. Ten out of 81 (12.35%) of unrestrained children required intubation versus none for restrained. The only 2 mortalities were unrestrained patients. CONCLUSION: Critical injuries and cost of care are higher in unrestrained than restrained children. Improved compliance with child safety restraint in southern Arizona should decrease childhood morbidity and mortality from MVCs.