Comparison of Urban Off-Road Vehicle and Motorcycle Injuries at a Level 1 Trauma Center

j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 0 ( 2 4 5 ) 3 7 3 e3 7 6

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Comparison of Urban Off-Road Vehicle and Motorcycle Injuries at a Level 1 Trauma Center Christopher A. Butts, PhD, DO,a,* Roberto Gonzalez, BS,b John P. Gaughan, MS, PhD, MBA,c Janika San Roman, MPH,b Steven Ross, MD,b John Porter, MD,b and Joshua P. Hazelton, DOd a

Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey b Division of Trauma, Surgical Critical Care, & Acute Care Surgery, Cooper University Hospital, Camden, New Jersey c Department of Internal Medicine, Cooper University Hospital, Department of Internal Medicine, Camden, New Jersey d Division of Trauma, Acute Care, and Critical Care Surgery, Department of Surgery, Penn State University College of Medicine, Hershey, Pennsylvania

article info

abstract

Article history:

Background: Recently, there has been an increase in the usage of dirt bikes and all-terrain

Received 1 March 2019

vehicles in urban environments. Previously, it has been shown that crashes involving

Received in revised form

these urban off-road vehicles (UORVs) resulted in different injury patterns from crashes

27 June 2019

that occurred in rural environments. The aim of this study was to compare injury patterns

Accepted 19 July 2019

of patients involved in crashes while riding UORVs versus motorcycles (MCs).

Available online xxx

Methods: A retrospective review (2005-2016) of patients who presented to our urban level I trauma center as a result of any MC or UORV crash was performed. Patients who presented

Keywords:

after 48 h from the time of accident were excluded. A P < 0.05 was considered significant.

Urban off-road vehicle

Results: We identified 1556 patients who were involved in an MC or UORV crash resulting in

Motorcycle crash

injury (MC: n ¼ 1324 [85%]; UORVs: n ¼ 232 [15%]). Patients in UORV crashes were younger

Dirt bike crash

(26.2 y versus 39.6 y), less likely to be helmeted (39.6% versus 90.2%), required fewer

Injury patterns

emergent trauma bay procedures (28.4% versus 36.7%), and needed fewer operative in-

Helmet usage

terventions (45.9% versus 54.2%) (all P < 0.05). Both groups had a similar Injury Severity

Traumatic injury

Score (12.2 versus 12.6; P ¼ 0.54) and Glasgow Coma Score (13.8 versus 13.5; P ¼ 0.46). UORV patients had a lower mortality (0.9% versus 4.7%; P < 0.05) compared to MC crash patients despite similar injury patterns. Conclusions: Our data demonstrate that patients sustaining UORV injuries were younger and less likely to be helmeted but have a lower mortality rate after a crash, despite sustaining similar injuries as motorcyclists. This study provides an overview of how crashes involving UORV usage is a unique phenomenon and not entirely comparable to MC crashes. ª 2019 Elsevier Inc. All rights reserved.

* Corresponding author. Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6300, New Brunswick, NJ 08901. Tel.: þ1 732 235 7766; fax: þ1 732 235 2964. E-mail address: [email protected] (C.A. Butts). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.07.069

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Introduction All-terrain vehicles (ATV) and dirt bikes (DBs) are popular modes of recreational transportation in rural environments. Previous studies have examined the injury patterns of both ATVs and DBs but that data are limited to primarily rural locations.1,2 Recently, there has been an increase in the usage of ATVs and DBs in urban metropolitan environments.3-5 Our group previously examined urban off-road vehicle (UORV) injury patterns compared to more traditional rural off-road vehicle (RORV) usage.5 In that study, UORV patients were found to be less likely to wear helmets, sustained a higher percentage of traumatic brain injuries (TBIs), have a higher percentage of extremity injury, have a lower presenting Glasgow Coma Score (GCS), and have a higher mean Injury Severity Score (ISS). They were also more likely to undergo an emergent procedure in the trauma bay when compared to RORV usage.5 Although this study looked at the difference in injury patterns between urban and rural usage, to our knowledge, no comparison has yet been made to similar modes of transportation within the urban environment. Motorcycles (MCs) are a common mode of transportation, but unlike enclosed automobiles, they leave the operator exposed. The motorcyclist must rely on helmets and specialized clothing for protection in the event of a crash. According to the National Highway Traffic Safety Administration’s (NHTSA) 2015 report on MC accidents, 4967 people die annually in motorcycle crashes (MCCs) and more than 88,000 are injured.6 This population has been heavily studied in regard to injury patterns, helmet usage, and injury prevention initiatives.7-10 A recent 2010 evidence-based review of helmet usage conducted by the Eastern Association for the Surgery of Trauma (EAST) showed that greater than 50% of MCC-related fatalities were a result of head injuries. As many as 90% of some patient cohorts presented with additional injuries.11 To our knowledge, no comparison between UORV and MC injury patterns and hospital outcomes has been previously reported. We hypothesized that UORV riders would sustain similar injuries and have similar outcomes to patients involved in MCCs.

Materials and methods An IRB-approved retrospective review (2005-2016) of all patients who presented to our level-I trauma center as a result of a UORV or MC injury was performed. A waiver of consent was obtained for this study. The date range was chosen to provide an equal distribution of years for both the paper chart and electronic medical records to account for any documentation inconsistencies. MC was defined as per the New Jersey Motor Vehicle Code as vehicle (including motor bikes, bicycles, or and tricycles) with an attached motor.12 UORV was defined as per our previous study as any ATV or DB accident that occurred on a paved inner city, suburban, or major roadway.5 Inclusion criteria included patients of any age who presented to our institution as either a UORV or MC accident. Exclusion criteria included (1) any MCC that occurred on a formal racetrack, of which there is one in our catchment area; (2) any

crash that did not occur on a paved inner city, suburban, or major roadway; (3) patients who presented to our institution more than 48 h after the time of initial injury; (4) any patient who died before arrival at the hospital; and (5) incidents where there was significant details missing from the medical record. Patient demographics, location of injury, GCS, ISS, and procedural interventions were all recorded. The type of injury sustained was divided by anatomic location. Head injury was defined as any type of TBI (subdural, epidural, subarachnoid, intraparenchymal, etc.), skull fracture, or concussion. Spinal injury was defined as any injury to the cervical, thoracic, or lumbar spine or spinal cord injury. Facial injury was defined as any facial fracture. Thoracic injury was defined as any injury occurring from the first rib down to the level of the diaphragm, within the thoracic cavity. Abdominal injury was defined as any injury occurring below the diaphragm down to the pelvis including any bladder injury. Pelvic injury was defined as any injury to the pelvic bones or sacrum. Extremity injury was defined as any injury to either the upper extremity (from the humeral head moving distal) or the lower extremity (from the femoral head moving distal). We further examined the need for blood product administration, operative intervention, interventional radiology intervention, and emergent procedures performed during trauma resuscitation. Emergent procedures were defined as central venous access, tube thoracostomy, needle compression, intubation, cricothyrotomy, or diagnostic peritoneal lavage during the initial trauma resuscitation.5 Comparisons of continuous variables were carried out using Wilcoxon rank-sum test. Comparisons of categorical variables (group frequencies) were carried out using chisquare analysis. Multivariate analysis for outcomes adjusted for age was carried out using multiple logistic regression. A two-tailed P-value of <0.05 was considered statistically significant. Statistical analyses were carried out using SAS v9.4 (SAS Institute, Cary, NC).

Results A total of 1556 patients over the 12-year study period met our inclusion criteria (MC n ¼ 1324 [85%]; UORV n ¼ 232 [15%]). Table 1 shows all patient demographics. In both groups, the patients were predominately male (MC 91.8% versus UORV

Table 1 e Patient demographics. MC (n ¼ 1324)

UORV (n ¼ 232)

Age

39.6

26.2

Male

91.8%

91.4%

Female

8.2%

8.6%

GCS

13.5

13.8

ISS

12.7

12.2

Helmet use

90.2%

39.6%

P <0.05 0.84 0.84 0.46 0.54 <0.05

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butts et al  urban off-road vehicle injury patterns

91.4%; P ¼ 0.84). UORV riders were younger (MC 36.9 y versus UORV 26.2 y; P < 0.05) and less likely to be helmeted than MC riders (MC 90.2% versus UORV 39.6%; P < 0.05). Table 2 shows all patient outcomes with respect to need for interventions, length of stay, mortality, and patient disposition. Although the presenting GCS (MC 13.5 versus UORV 13.8; P ¼ 0.46) and overall ISS (MC 12.7 versus UORV 12.2; P ¼ 0.54) were similar among both groups, MC had longer hospital length of stay (MC 9.55 d versus UORV 6.96 d; P < 0.05), greater need for rehabilitation or skilled nursing facility placement after discharge (MC 13.4% versus UORV 8.2%; P < 0.05), and a higher 30-day readmission rate (MC 7.2% versus UORV 3%; P < 0.05). MC patients were more likely have blood products administered (MC 21.8% versus UORV 12.5%; P < 0.05), need emergent operative intervention (MC 54.2% versus UORV 45.9%; P < 0.05), emergent interventional radiology intervention (MC 9.6% versus UORV 4.3%; P < 0.05), or emergent trauma bay procedures (MC 36.7% versus UORV 28.5%; P < 0.05). We also examined injury patterns grouped by body region (Table 3). Both cohorts had similar injury patterns with the exception that MC had a greater percentage of thoracic injuries (MC 44.9% versus UORV 34.9%; P < 0.05). The multivariate analysis comparing outcomes of riders with or without a helmet, adjusted for age, showed that MC riders had a significantly increased risk of TBI when a helmet was not worn (OR 4.54; P < 0.001). MC and UORV riders had a significantly increased risk of facial injury when a helmet was not worn (ORs 2.611, 2.684; P < 0.001). Overall, patients involved in MC crashes had a higher mortality (MC 4.7% versus UORV 0.9%; P < 0.05).

Discussion The use of traditional off-road vehicles, such as dirt bikes and ATVs, is increasing in the urban environment. As these modes of transportation begin to be used more commonly in an urban environment, understanding of injury patterns can better help emergency medical providers and trauma

Table 2 e Patient outcomes.

OR

MC (n ¼ 1324)

UORV (n ¼ 232)

P

54.2%

45.9%

<0.05

9.6%

4.3%

<0.05

Emergent procedures

36.7%

28.5%

<0.05

Blood products

21.8%

12.5%

<0.05

ICU length of stay (d)

2.08

1.68

0.78

Hospital length of stay (d)

9.55

6.96

<0.05

Interventional radiology

30-day readmission

7.2%

3.0%

<0.05

Mortality

4.7%

0.9%

<0.05

Home

78.5%

81.0%

<0.05

Rehab/skilled nursing

Disposition

13.4%

8.2%

<0.05

Transfer

0.4%

1.3%

<0.05

AMA

0.5%

2.2%

<0.05

OR ¼ operating room; AMA ¼ against medical advice.

Table 3 e Comparison of injury patterns for MC and UORV accidents. Injury region

MC (n ¼ 1324); n (%)

UORV (n ¼ 232); n (%)

P

Head (TBI)

430 (32.4)

83 (35.8)

0.32

Spinal

284 (21.5)

42 (18.1)

0.25

Facial

117 (13.4)

42 (18.1)

0.06

Thoracic

595 (44.9)

81 (34.9)

<0.05

Abdomen

224 (16.9)

33 (14.2)

0.31

Pelvis

133 (10)

18 (7.8)

0.28

Extremity

285 (21.5)

124 (53.5)

0.38

surgeons care for these individuals. We previously compared urban and rural injury patterns as a result of crashes sustained while operating these vehicles. Our present study compares injury patterns between the use of road designed MCs and UORVs. We have demonstrated that these similar modes of transportation result in similar injury patterns. In comparison to the MC cohort, where data exist regarding the effects of helmet usage, and of helmet laws, there are little safety data regarding this new population of urban riders. In our study, we have found that UORV riders are younger and less likely helmeted yet despite this they had similar rates of TBI when compared to the MC cohort. Our MC cohort had similar demographic data and mortality to previous studies.13,14 When we examined helmet compliance, the MC population was 90.2% compliant consistent with previous studies in states with helmet laws.15,16 The high compliance rate is likely a result of New Jersey’s law requiring all motorcyclists to be helmeted.17 Interestingly, the UORV population was less likely to be helmeted (MC: 90.2% versus UORV: 39.6%; P < 0.05) despite mandatory helmet laws. Consistent with other studies, these riders are also less likely to be helmeted than when riding in a rural environment.5 The lack of helmet compliance is likely related to the fact that UORVs are used in environments where it is illegal to use these modes of transportation. No current data exist on the overall enforcement of such laws or how readily the states helmet law is enforced within our area. Despite this lack of safety equipment, they had a similar rate of TBI and presenting GCS when compared to MC. When multivariable analysis was performed comparing the relationship between riders and head injury, MC riders were at significantly increased risks of TBI when a helmet was not worn (OR 4.54; P < 0.001). We did not identify a similar relationship with UORV riders regarding helmet use and TBI. The only region of injury differing between the two cohorts was thoracic injury. MC had a higher percentage of thoracic injuries when compared to the UORV cohorts (MC: 44.9% versus 34.9 %; P < 0.05). The difference could be attributed to the older age of MC riders and the likelihood that MCs are more frequently used at higher speeds on highways. UORV riders had a higher rate of facial injuries likely stemming from the lower rate of helmet usage; however, the difference only approached statistical significance when compared to MC riders. Based on multivariable analysis, both modes of transportation showed a higher risk for facial injury when riders were with or without helmet, with UORV riders having a 2.68

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odds ratio of facial injury when P < 0.001. Similarly, MC riders had a 2.61 odds ratio of facial injury (P < 0.05). The remaining similarities in overall injury pattern likely result from the similar exposure and position of the operator and use in the same environment, which is different from our previously published data that demonstrated different injury patterns in crashes involving urban and rural use of ATVs or DBs.5 Victims of MC crashes required a higher intensity of emergent care as demonstrated by their increased need for blood product administration, operative intervention, interventional radiologic procedures, or emergent trauma bay procedures, despite having similar ISS to UORV riders. Although we cannot definitively determine why these patients required more initial resources and had a higher mortality, their older age as well as the possibility of higher rates of speed at the time of the crash may be contributing factors. Our study is not without limitations. This is a single-center, retrospective review which relies on the documentation in the medical record to provide the details regarding type and location of the injury. Exact details in some of the crashes were limited, and therefore, these patients were excluded from final analysis. During our 10 y study, protective gear, in vehicle mechanics and safety, and may have changed significantly. As with any study over a length period of time, trauma center personnel, prehospital care, resuscitation strategies, practice patterns, and inpatient management may have changed over the time. Another limitation of our study is exclusion of patients who died before arrival. The potential exists for there to be a selection bias as these patients could have been sicker than those in our study. This population was excluded as medical command often pronounces in the field and these individuals would have received no evaluation by the trauma team.

Conclusions To our knowledge, this is the first study to comprehensively look at interventions required for both MC and UORV users across the full spectrum of injury patterns. UORV riders tend to be younger and less likely to be helmeted but have a lower mortality rate after a crash, despite having similar injury patterns to MC. Although our data suggest a lower mortality in this patient population, the lack of helmet use in this young group is still concerning. Having a better understanding of the nature of crashes involving UORV can assist the emergency medical providers as well as the trauma center in caring for this unique patient population. Furthermore, this study may help highlight the seriousness of off-road vehicle usage in the urban environment and guide strategies to decreasing this dangerous practice.

Acknowledgment Authors’ contributions: C.B. and J.P.H. designed this study. C.B., R.G., and J.S. collected the data. C.B., J.G., and J.P.H. analyzed the data. All other authors participated in the data interpretation, manuscript preparation, and critical revisions of the manuscript.

Disclosure Dr Hazelton is the Chief Medical Officer for Z-Medica. This relationship is not in conflict with this manuscript.

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