Bringing Opiates Off the Streets and Undertaking Excess Scripts: A novel opiate reclamation and prescription reduction program.

BACKGROUND: Opioid diversion and misuse continue to present problems in modern medicine. The "opioid epidemic" has claimed more than 250,000 lives since 1999, with studies pointing to prescription opioids as the culprit for future opiate misuse. Currently, there are no well-described, data-driven processes to educate surgeons on reducing opiate prescribing, informed by personal practice patterns. We designed and implemented a novel opiate reclamation and prescription reduction program for surgeons to reclaim unused medications and decrease prescribing using individual provider data. METHODS: We performed a prospective collection of all unused opiate pain medications for general surgery postoperative patients from July 15, 2020 to January 15, 2021. Patients brought their unused opiates to their routine postoperative follow-up appointment, where they were counted and disposed of in a secure drug take-back bin. Reclaimed opiates were totaled, analyzed, and reported to the providers, who used their individual reclamation rates to refine prescribing habits. RESULTS: During the reclamation period, 168 operations were performed, with a total of 12,970 morphine milligram equivalents of opiate prescribed by 5 physicians. A total of 6,077.5 morphine milligram equivalents (46.9%) were reclaimed, which is the equivalent of 800 5-mg tablets of oxycodone. A review of these data led to a 30.9% decrease in opiate prescriptions by participating surgeons in addition to the reclamation of an additional 3,150 morphine milligram equivalents over the next 6 months. CONCLUSION: Continuous monitoring of the medications returned by patients now continues to inform our providers' prescribing practices, decreases the amount of opiates in the community, and improves patient safety.

Routine in-person post-operative follow-up for uncomplicated laparoscopic appendectomy does not change management.

INTRODUCTION: Eliminating points in the continuum of care that do not change management is a safe strategy for cost containment and workflow efficiency in health systems. As a process improvement initiative, we sought to identify whether routine, outpatient follow-up changes management in laparoscopic appendectomy in a military hospital. METHODS: We performed a retrospective chart review of adult patients undergoing laparoscopic appendectomy during a one-year period. The primary outcome was identification of a change in management during routine in person follow-up. Secondary outcomes included location of patient presentation with a post-operative event (clinic, emergency department, primary care provider), and if those visits changed management. Events were defined as any deviation from the typical post-operative course within 6 weeks of surgery, including abnormal specimen pathology. RESULTS: One-hundred and seventy-six appendectomies were performed over one year, and 148 patients met inclusion criteria (median age = 27, 66.9% male). Perforation was identified in 10.1% of patients. Seventeen-point-five percent of patients had a post-operative event, of which persistent pain was the most common. Only 2.0% of all patients saw a change in management at their routine in person follow-up appointment. Eighty percent of patients with any post-operative events sought care outside of their routine in person follow up appointments. No variable was independently associated with a change in management. CONCLUSION: Routine in-person clinical follow-up for laparoscopic appendectomy almost never changes management. Perforated appendicitis may be an indication for in-person follow-up. Considering a telemedicine model for post-operative follow-up of laparoscopic appendectomy patients will provide a safe and effective alternative to in-person clinic visits, while saving patients time and allowing providers the clinic freedom to prioritize more urgent and new patients.

Trends in Surgical Case Volume During Pacific Partnership Missions Onboard USNS Mercy.

INTRODUCTION: Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. MATERIALS AND METHODS: Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. RESULTS: A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician-gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. CONCLUSIONS: Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

Recovering Coronavirus Disease Patients in the Active Duty Military Population: A Review of Current Evidence and Special Considerations for Uniformed Providers.

Patients acutely infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coronavirus disease (COVID-19) may continue to have symptoms well beyond 2 weeks. The range of symptoms and physiological sequelae can impact medical readiness even in a relatively young and healthy cohort of service members. It is important to monitor, document, and investigate symptoms from all service members recovering from COVID-19. Military medicine must be prepared to support and manage cases of patients who are recovered from acute COVID-19 but are suffering from post-COVID-19 complications.

Mitigation of radiation exposure during surgical hepatectomy after yttrium-90 radioembolization.

Yttrium-90 (Y-90) radioembolization for the treatment of hepatocellular carcinoma can present safety challenges when transplanting recently treated Y-90 patients. To reduce surgeons' contact with radioactive tissue and remain within occupational dose limits, current guidelines recommend delaying transplants at least 14 days, if possible. We wanted to determine the level of radiation exposure to the transplant surgeon when explanting an irradiated liver before the recommended decay period. Anex-vivoradiation exposure analysis was conducted on the explanted liver of a patient who received Y-90 therapy 46 h prior to orthotopic liver transplant. To estimate exposure to the surgeon's hands, radiation dosimeter rings were placed inside three different surgical glove configurations and exposed to the explanted liver. Estimated radiation doses corrected for Y-90 decay were calculated. Radiation safety gloves performed best, with an average radiation exposure rate of 5.36 mSV h-1in the static hand position, an 83% reduction in exposure over controls with no glove (31.31 mSv h-1). Interestingly, non-radiation safety gloves also demonstrated reduced exposure rates, well below occupational regulation limits. Handling of Y-90 radiated organs within the immediate post-treatment period can be done safely and does not exceed federal occupational dose limits if appropriate gloves and necessary precautions are exercised.

Perforated Appendicitis: An Unintended Consequence During the Coronavirus-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had major clinical impact across the globe. Delayed presentation for medical emergencies has been noted by the medical community. There has been limited reporting on the impact for the care for emergent surgical conditions. We sought to describe the effect of the global pandemic on the presentation and outcomes for the most common urgent general surgery disease process, acute appendicitis. METHODS: We performed a retrospective review of patients admitted to the United States Naval Hospital Okinawa during the COVID-19 pandemic, from January 2020 to May 2020 (COVID cohort), and compared them to a historical cohort (pre-COVID cohort) over the prior 2 years. Demographics, clinical presentation data, and interventions were collected. RESULTS: Of the 80 patients with appendicitis, 20% presented perforated. Most patients were male (71%), presented with 1 day of symptoms and had a length of stay of 1 to 2 days. Comparing groups, 13% of the pre-COVID group vs. 31% of the COVID cohort presented perforated (P = .04), with a symptom duration of 1.6 vs. 2.7 days before presentation (P = .075), respectively. CONCLUSIONS: The COVID-19 pandemic and the global systematic response has impacted unrelated medical and surgical conditions. At our overseas military hospital with minimal disease burden, we observed a delay in presentation for acute appendicitis with a higher incidence of perforation. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself.

The rate of deep vein thrombosis doubles in trauma patients with hypercoagulable thromboelastography.

BACKGROUND: Venous thromboembolism (VTE) in trauma can occur in patients at low risk. Conventional coagulation tests do not predict VTE. Studies investigating thromboelastography (TEG) for VTE risk are conflicting and have not included routine surveillance to detect deep vein thrombosis (DVT). We undertook a prospective study of TEG to evaluate its utility in predicting VTE. METHODS: We conducted a prospective cohort study on all adult trauma patients admitted to our Level I trauma center from 2013 to 2015. TEG was performed immediately on arrival to the trauma bay. Hypercoagulable TEG was defined as reaction time (R) below, angle (α) above, or maximum amplitude (MA) above reference ranges. All patients received mechanical and/or pharmacologic prophylaxis and were followed up for DVT with our ultrasound surveillance protocol. The primary outcome was lower-extremity DVT. After bivariate analysis of variables related to DVT, those with p values of 0.100 or less were included for multivariate logistic regression. RESULTS: A total of 983 patients were evaluated with TEG on admission; of these, 684 (69.6%) received at least one surveillance ultrasound during the index admission. Lower-extremity DVT was diagnosed in 99 (14.5%) patients. Hypercoagulability based on admission TEG occurred in 582 (85.1%) patients. The lower-extremity DVT rate was higher in patients with hypercoagulable TEG than in those without hypercoagulable TEG (15.6% vs. 8%; p = 0.039). Multivariate analysis showed hypercoagulable TEG remained associated with DVT after adjustment for relevant covariates available at admission, with an odds ratio of 2.41 (95% confidence interval, 1.11-5.24; p = 0.026). CONCLUSION: Most trauma patients were hypercoagulable at admission and remained at risk of developing DVT. The rate of DVT doubled in patients with hypercoagulable TEG indices despite prophylaxis. Beyond its current clinical roles, TEG is useful for assessing DVT risk, particularly in patients otherwise perceived to be at low risk. LEVEL OF EVIDENCE: Prognostic study, level II.

"Delay to operating room" fails to identify adverse outcomes at a Level I trauma center.

BACKGROUND: The American College of Surgeons Committee on Trauma devised process audit filters to identify opportunities for improvement (OFI), prevent adverse outcomes, and improve quality. Delay to the operating room for primary trauma laparotomy is a process audit filter that has not been definitively associated with improved outcomes. We sought to evaluate the effectiveness of delay to the operating room of greater than 2 hours (DOR) to independently identify an adverse outcome or an OFI at our Level I trauma center. METHODS: Trauma patients who underwent primary exploratory laparotomy from July 2006 to March 2015 were reviewed. Those with DOR were identified and compared with those without DOR. To analyze the ability of DOR to independently identify an adverse outcome or an OFI, DOR patients were further divided into those with isolated DOR and those with DOR in conjunction with one or more other process audit filter. Primary outcome was the presence of a complication. Secondary outcome was an identified OFI. Medical records of patients with either outcome were reviewed to determine if the outcome resulted directly from DOR. RESULTS: Of 472 patients, 109 (23%) had DOR and 363 (77%) did not. There were no significant differences in age, sex, or injury severity between the two groups. The rates of complications among DOR patients and those without DOR were not significantly different (35% vs. 38%, p = 0.59). The DOR was the only process audit filter flagged in 31(28%) patients in the DOR group. This subgroup had no identified complications but incurred two OFIs; neither OFI was associated with an adverse outcome. CONCLUSION: In trauma patients undergoing primary exploratory laparotomy, DOR fails to independently identify adverse outcomes. These findings suggest that DOR, as a routinely collected process audit filter, is not an effective indicator of suboptimal care or adverse outcomes at a Level I trauma center. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.

Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation guidelines provide indications for neurosurgical intervention in traumatic brain injury (TBI) with moderate or severe intracranial hemorrhage (ICH). In TBI patients with less severe ICH, the utility of neurosurgical consultation remains unclear. We sought to determine if routine neurosurgical consultation is necessary for mild blunt TBI patients with ICH. METHODS: A retrospective cohort study was conducted on 500 consecutive blunt TBI patients aged 15 years or older with Glasgow Coma Scale score of ≥13 and ICH on initial head computed tomography admitted to a Level I trauma center over 28 months. Outcomes were neurosurgical intervention (craniotomy, craniectomy, ventriculostomy, or intracranial pressure monitor placement) and in-hospital mortality. Statistical significance was assessed at a p < 0.05. RESULTS: Of 500 patients, 49 (9.8%) underwent neurosurgical intervention. Neurosurgical intervention was more frequent in male patients (75.5% vs. 61.2%, p = 0.049), patients with higher head Abbreviated Injury Scale score (4.7 vs. 3.8, p < 0.0001), patients with an abnormal initial neurological examination (30.6% vs. 12.6%, p = 0.001), or patients with skull fracture (28.6% vs. 16.0%, p = 0.026) and was associated with higher mortality (8.2% vs. 2.0%, p = 0.010). Neurosurgical intervention was not associated with intoxication, preinjury antiplatelet/anticoagulation agents, or progression of ICH on second head computed tomography. Neurosurgical consultation was documented in 466 patients (93.2%). For patients without neurosurgical intervention, consultation did not change management. CONCLUSION: Routine neurosurgical consultation for blunt TBI with ICH seems unnecessary, regardless of intoxication or preinjury antiplatelet or anticoagulation therapy. A more selective approach is warranted to decrease hospital charges and optimize use of neurosurgical consultation. LEVEL OF EVIDENCE: Care management study, level IV.

Sarcopenia as a predictor of mortality in elderly blunt trauma patients: Comparing the masseter to the psoas using computed tomography.

BACKGROUND: Sarcopenia, or age-related loss of muscle mass, is measurable by computed tomography (CT). In elderly trauma patients, increased mortality is associated with decreased psoas muscle cross-sectional area (P-Area) on abdominal CT. Fall is the leading cause of injury in the elderly, and head CT is more often obtained. Masseter muscle cross-sectional area (M-Area) is readily measured on head CT. Hypothesizing that M-Area is a satisfactory surrogate for P-Area, we compared the two as markers of sarcopenia and increased mortality in elderly trauma patients. METHODS: All blunt-injured patients aged 65 years or older admitted to our trauma center during 2010 were included. Two-year postdischarge mortality was identified by matching records to county, state, and national death indices. Bilateral M-Area was measured on admission head CT at 2 cm below the zygomatic arch. Bilateral P-Area was measured on abdominal CT at the fourth vertebral body. Average M-Area and P-Area values were calculated for each patient. Cox proportional hazards models evaluated the relationship of M-Area and P-Area with mortality. Model predictive performance was calculated using concordance statistics. RESULTS: Among 487 patients, 357 with M-Area and 226 with P-Area were identified. Females had smaller M-Area (3.43 cm vs 4.18 cm; p < 0.050) and P-Area (6.50 cm vs 10.9 cm; p < 0.050) than males. Masseter muscle cross-sectional area correlated with P-Area (rho, 0.38; p < 0.001). Adjusted Cox regression models revealed decreased survival associated with declining M-Area (hazard ratio, 0.76; 95% confidence interval, 0.60-0.96) and P-Area (hazard ratio, 0.68; 95% confidence interval, 0.46-1.00). Masseter muscle cross-sectional area and P-Area discriminated equally well in best-fit models. CONCLUSIONS: In elderly trauma patients, M-Area is an equally valid and more readily available marker of sarcopenia and 2-year mortality than P-Area. Future study should validate M-Area as a metric to identify at-risk patients who may benefit from early intervention. LEVEL OF EVIDENCE: Prognostic study, level III.

Frailty in trauma: A systematic review of the surgical literature for clinical assessment tools.

BACKGROUND: Elderly trauma patients have outcomes worse than those of similarly injured younger patients. Although patient age and comorbidities explain some of the difference, the contribution of frailty to outcomes is largely unknown because of the lack of assessment tools developed specifically to assess frailty in the trauma population. This systematic review of the surgical literature identifies currently available frailty clinical assessment tools and evaluates the potential of each instrument to assess frailty in elderly patients with trauma. METHODS: This review was registered with PROSPERO (the international prospective register of systematic reviews, registration number CRD42014015350). Publications in English from January 1995 to October 2014 were identified by a comprehensive search strategy in MEDLINE, EMBASE, and CINAHL, supplemented by manual screening of article bibliographies and subjected to three tiers of review. Forty-two studies reporting on frailty assessment tools were selected for analysis. Criteria for objectivity, feasibility in the trauma setting, and utility to predict trauma outcomes were formulated and used to evaluate the tools, including their subscales and individual items. RESULTS: Thirty-two unique frailty assessment tools were identified. Of those, 4 tools as a whole, 2 subscales, and 29 individual items qualified as objective, feasible, and useful in the clinical assessment of trauma patients. The single existing tool developed specifically to assess frailty in trauma did not meet evaluation criteria. CONCLUSION: Few frailty assessment tools in the surgical literature qualify as objective, feasible, and useful measures of frailty in the trauma population. However, a number of individual tool items and subscales could be combined to assess frailty in the trauma setting. Research to determine the accuracy of these measures and the magnitude of the contribution of frailty to trauma outcomes is needed. LEVEL OF EVIDENCE: Systematic review, level III.

Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: A prospective observational study of two centers.

BACKGROUND: Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in trauma. Controversy exists regarding the use of lower extremity duplex ultrasound screening and surveillance (LEDUS). Advocates cite earlier diagnosis and treatment of deep venous thrombosis (DVT) to prevent clot propagation and pulmonary embolism (PE). Opponents argue that LEDUS identifies more DVT (surveillance bias) but does not reduce the incidence of PE. We sought to determine the magnitude of surveillance bias associated with LEDUS and test the hypothesis that LEDUS does not decrease the incidence of PE after injury. METHODS: We compared data from two Level 1 trauma centers: Scripps Mercy Hospital, which used serial LEDUS, and Christiana Care Health System, which used LEDUS only for symptomatic patients. Beginning in 2013, both centers prospectively collected data on demographics, injury severity, and VTE risk for patients admitted for more than 48 hours. Both centers used mechanical and pharmacologic prophylaxis based on VTE risk assessment. RESULTS: Scripps Mercy treated 772 patients and Christiana Care treated 454 patients with similar injury severity and VTE risk. The incidence of PE was 0.4% at both centers. The odds of a DVT diagnosis were 5.3 times higher (odds ratio, 5.3; 95% confidence interval, 2.5-12.9; p < 0.0001) for patients admitted to Scripps Mercy than for patients admitted to Christiana Care. Of the 80 patients who developed DVT, PE, or both, 99% received prophylaxis before the event. Among those who received pharmacologic prophylaxis, the VTE rates between the two centers were not statistically significantly different (Scripps Mercy, 11% vs. Christiana Care, 3%; p = 0.06). CONCLUSION: The odds of a diagnosis of DVT are increased significantly when a program of LEDUS is used in trauma patients. Neither pharmacologic prophylaxis nor mechanical prophylaxis is completely effective in preventing VTE in trauma patients. VTE should not be considered a "never event" in this cohort. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level III.

Aspirin as added prophylaxis for deep vein thrombosis in trauma: A retrospective case-control study.

BACKGROUND: Current prophylaxis does not completely prevent deep vein thrombosis (DVT) in trauma patients. Recent data suggest that platelets may be a major contributor to hypercoagulability after trauma, indicating a potential role for antiplatelet medications in prophylaxis for DVT. We sought to determine if preinjury aspirin use was associated with a reduced incidence of lower extremity DVT in trauma patients. METHODS: Using a retrospective case-control design, we matched 110 cases of posttrauma lower extremity DVT one-to-one with controls using seven covariates: age, admission date, probability of death, number of DVT risk factors, sex, mechanism of injury, and presence of head injury. Data collected included 26 risk factors for DVT, prehospital medications, and in-hospital prophylaxis. Logistic regression models were created to examine the relationship between prehospital aspirin use and posttrauma DVT. RESULTS: Preinjury aspirin was used by 7.3% of cases (patients diagnosed with in-hospital DVT) compared with 13.6% of controls (p = 0.1). Aspirin was associated with a significant protective effect in multivariate analysis, with an odds ratio of 0.17 (95% confidence interval, 0.04-0.68; p = 0.012) in the most complete model. When stratified by other antithrombotic use, aspirin showed a significant effect only when used in combination with heparinoid prophylaxis (odds ratio, 0.35; 95% confidence interval, 0.13-0.93; p = 0.036). CONCLUSION: Preinjury aspirin use seems to significantly lower DVT rate following injury. This association is strongest when heparinoid prophylaxis is prescribed after patients on preinjury aspirin therapy are admitted. Aspirin as added prophylaxis for DVT in trauma patients needs to be further evaluated. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Attenuation of cardiovascular stress with sympatholytics does not improve survival in patients with severe isolated traumatic brain injury.

BACKGROUND: Studies have shown improved survival after traumatic brain injury (TBI) with the administration of sympatholytics, including ß-blockers and clonidine, which is thought to attenuate the cardiovascular stress response. However, the use of sympatholytics has not been studied in patients with isolated severe TBI (ISTBI). We hypothesized that ISTBI patients receiving sympatholytics who demonstrated a reduction in cardiovascular stress would have improved outcomes compared with similarly injured patients without these cardiovascular changes. METHODS: We reviewed the medical records of 338 ISTBI patients (head Abbreviated Injury Scale [AIS] score > 3 and associated injury AIS score < 1) admitted to a Level I trauma center from 2010 through 2014. All patients were managed according to Brain Trauma Foundation guidelines. Demographic, clinical, and survival probability data were gathered. The primary outcome was inpatient mortality. Cardiovascular stress was assessed using the rate-pressure product (RPP = systolic blood pressure × heart rate / 100) calculated both before and after sympatholytic administration. Associations between independent variables and mortality were adjusted for total hospital length of stay. RESULTS: Among ISTBI patients, observed mortality was 6% (n = 20), while predicted mortality by Trauma and Injury Severity Score (TRISS) was 11% (n = 38). Administration of sympatholytics was associated with reduction in RPP in univariate analysis (p = 0.035). After adjusting for length of stay, neither receipt of ß-blockers nor reduction in RPP was associated with survival. Mean reduction in RPP among survivors was not different from that among nonsurvivors (-4.0% vs. -11.9%, p = 0.148). In addition, RPP reduction among patients who received sympatholytics occurred at the same rate in survivors as nonsurvivors (67% vs. 68%, p = 0.894). Severity of head injury, intraventricular hemorrhage, and any intracranial operative intervention were significantly associated with mortality. CONCLUSION: Although sympatholytic administration is associated with a significant decrease in RPP, the survival benefit seen in patients with multiple injuries with TBI is not observed among ISTBI patients. Further research on the role of sympatholysis in the management of ISTBI is warranted. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Experimental injury study of children seated behind collapsing front seats in rear impacts.

In the mid 1990's the U.S. Department of Transportation made recommendations to place children and infants into the rear seating areas of motor vehicles to avoid front seat airbag induced injuries and fatalities. In most rear-impacts, however, the adult occupied front seats will collapse into the rear occupant area and pose another potentially serious injury hazard to the rear-seated children. Since rear-impacts involve a wide range of speeds, impact severity, and various sizes of adults in collapsing front seats, a multi-variable experimental method was employed in conjunction with a multi-level "factorial analysis" technique to study injury potential of rear-seated children. Various sizes of Hybrid III adult surrogates, seated in a "typical" average strength collapsing type of front seat, and a three-year-old Hybrid III child surrogate, seated on a built-in booster seat located directly behind the front adult occupant, were tested at various impact severity levels in a popular "minivan" sled-buck test set up. A total of five test configurations were utilized in this study. Three levels of velocity changes ranging from 22.5 to 42.5 kph were used. The average of peak accelerations on the sled-buck tests ranged from approximately 8.2 G's up to about 11.1 G's, with absolute peak values of just over 14 G's at the higher velocity change. The parameters of the test configuration enabled the experimental data to be combined into a polynomial "injury" function of the two primary independent variables (i.e. front seat adult occupant weight and velocity change) so that the "likelihood" of rear child "injury potential" could be determined over a wide range of the key parameters. The experimentally derived head injury data was used to obtain a preliminary HIC (Head Injury Criteria) polynomial fit at the 900 level for the rear-seated child. Several actual accident cases were compared with the preliminary polynomial fit. This study provides a test efficient, multi-variable, method to compare the injury biomechanical data with actual accident cases.