Robert Berger, MD, FACS Assistant Medical Director Trauma ...

Robert Berger, MD, FACS
Assistant Medical Director
Trauma Services ‐ FMC
October 27, 2009

• Are there really risks?
• What increases the risks
• Cases
• Extremes of Age
• Protective Factors
• Recommendations
Goals

Examples of Risks
www.youtube.com

WEST VIRGINIA –ATV ACCIDENT
CAPITAL
• 8x natl average for death rate per‐capita
• 2004‐2006: 112 fatal ATV crashes
• 95% were drivers, 15% with helmets
• 65% were head injuries after traffic collision
• 55% were thorax/abd compression injuries after
rollovers
• ETOH in 50%, of those 88% avg 0.17
• 21% positive test for other drugs
Kaplan, et al., Fatal ATV crashes. Am J Prev Med. 2009 Apr;36(4);311‐6.

NEW ZEALAND ATV INJURIES
• 2000‐2006, 218 cases
• Mechanisms: Fall (48%), collision (31%), rolling (14%)
• Mean age 9.9 yrs
• Child was driver (53%), passenger (28%)
• Mean ISS 7.9, LOS 2 days, Helmet use (14%)
• OR (51%), ICU (7.8%), Disability (2.8%)
• Deaths – 16 children
• NZ Comparison – avg. age is less and shorter LOS
Jones, et al., ATV injuries in New Zealand. N Z Med J. 2009 Sep 11;122(1302):11‐
28.

FMC DATA
• 1/2008 to 9/2009
• 134 pts, Avg age 31
• 60 = 10 (7%)
• 20% intoxicated
• Direct to OR 25 (19%)
• Direct to ICU 17 (13%)
• Avg LOS 4.12 days
• Deaths ‐ 2

FMC DATA
• Types of Injuries
• 40% Extremity Trauma
• 23% Chest
• 15% Head
• 8% Abdominal
• 4% Pelvis
• 4% Back
• 3% Neck

PEDIATRIC ATV INJURIES
• 1993‐1998 vs. 1998‐2003 (St. Louis Children’s Hosp.)
• 89% increase in sales in last 5 years
• 184 pts, 90% required admission
• 8.7 vs 24.5 pts / yr treated
• 4 of 44 (9%) vs 24 of 140 (17%) immediate OR
• 12 of 44 (27%) vs 51 of 140 (36%) ICU or death
• 68% with multiple injuries
• 35% wore helmets
• Avg age 11.5 +/‐ 3.9 yrs
Foglia, et., Unsafe at any speed‐kids riding ATVs, J Pediatr Surg. 2005
Jun;40(6):929‐34.

ATV & BICYCLE INJURIES
•

PEDIATRIC ATV INJURIES
• Types and severity (Univ. of Tennessee)
• 96 pts, 30 month period, 2:1 male:female
• Avg age 11.0 yrs,
• 61 pts (64%) hospitalized, 54 (56%) required surgery
• Orthopedic injuries 58 (60%)
• Femoral fx in younger pts, pelvic fx in older (>13yrs)
• Head injuries 34 (35%)
• Intra‐abd/thoracic injury 23 (24%)
• Multi‐system involvement 19 (20%)
Sawyer, et al., Age‐related patterns of injury in children in ATV
accidents. J Pediatr Orthop. 2008 Dec;28(8):854‐8

PEDIATRIC ATV INJURIES
• 512 consecutive children at tertiary care peds hospital
• Little Rock Arkansas
• 244 (48%) Head injuries (5 of 6 deaths)
• 104 skull fx ‐brain, subdural and epidural
• Associated with long term disability
• 227 fx in 172 children (Femur most common)
• 9 partial foot amputation
• 97 torso injuries (multiple organ injuries)
Greenberg, et al., Imaging findings in 512 children after ATV accidents. Pediatr
Radiol. 2009 Jul;39(7):677‐84.

Cost?
• How much did all of these injuries cost? Researchers
estimate that hospital charges for ATV‐related
injuries in children and teens cost more than $74
million, most of which was paid by private insurance
companies.

ORTHOPEDIC TRAUMA
• 6 yr review in Kentucky, 1998‐2003
• Male (85.4%), white (98%), ETOH (25%), Helmet (15%)
• Rollover (63.3%) – primary mechanism
• 707 total injuries
• fx/dislocation of spine(26%), ribs (24.1%), clavicle (6%),
radius‐ulna(5.3%), tib‐fib (4.7%)
• LOS 8.1 days, 28% to ICU for avg 8.4 days, 18.6% directly
to OR
• 78.2% home, 12.8% to rehab, 4.8% death, 3.2% to another
hospital
Barber, et al., Orthopedic trauma from ATV use in Kentucky. J
Trauma. 2007May;62(5):1163‐70.

ATV INJURY TRENDS
• 10 years of data from East Tennessee
• Divided at 5 years, 300 crashes
• 78% increase in injuries in last 3 years
• Similar ISS / types
• Pediatric admits decreased, age trended up
• Drug use 40%, No helmet 96%
• 9 deaths in last 6 years (3.6%)
• Discharge – 86% home, 7% to rehab
Testerman, GM., 300 ATV crashes., Tenn Med. 2009 Aug;102(8):45‐7.

GERIATRIC ATV TRAUMA
• Natl Trauma Data Bank 1989 to 2003
• 6308 ATV‐related traumas
• Commonly HTN (138 vs 131 mmHg)
• Longer LOS (8.3 vs 4.8 days)
• ICU days (3.1 vs 1.3 days)
• > 60 yrs increased risk of mortality (OR 6.96)
• Independent predictor of mortality
Hawkins, et al, ATV trauma in the elderly: analysis of natl database. Am Surg.
2008 Aug;74(8):767‐9.

GERIATRIC ATV INJURIES
• 250 ATV admits 2001 – 2007 (3 yr comparison)
• Injuries increased 78%
• Pediatrics decreased, Over age 50 increased
• 4 deaths < 16, 3 deaths > age 50
• > 50 yrs with sever thoracic injuries and used more
hospital resources
Testerman, GM., Increased ATV crashs in older riders. South Med J. 2009
May;102(5):461‐4.

SPINAL INJURIES
• Database on spine or spinal cord injuries
• ATV related vs general consult population
• 36 pts
• Male:female 11:1
• Avg age 13.7 yrs younger
• Axial or burst fx significantly higher
• 50% vs 12%
Vaccaro, et al., ATV and assoc. spinal injuries. Spine. 2008 Aug 15;33(18):1982‐5.

Protective Factors
• Protective Gear
• Helmets
• Training Courses
• Right Age, Right Size
• No Drug/Alcohol Use
• Follow Guidelines (Single or Dual Machine)
• Legislation

• Pediatricians should advocate for the passage of the AAP's
model bill 19 that:
• prohibits the use of ATVs, on‐ or off‐road, by children and
adolescents younger than 16 years;
• requires an automobile drivers' license, and preferably
some additional certification in ATV use;
• prohibits the use of ATVs on public streets and highways;
• prohibits passengers from riding on ATVs;
• prohibits operating an ATV under the influence of alcohol;
and
• prohibits the use of ATVs between sundown and sunrise.

Perceptual, Motor, and Maturity Factors: Children up to age 16
are at risk when operating ATVs because they:
• Perceive distances to be greater than what they actually
are.
• Have a shorter attention span than adults.
• React more slowly than adults.
• Tend to believe that products purchased by their parents
are safe.
• Take more risks‐particularly males‐and perceive less
danger in those risks than adults.
• Get into trouble trying to imitate friends who show off
new skills or stunts.
• Often believe a little experience makes them expert riders
who know everything there is to know about ATVs.
Parents must make the correct judgments when their
children ignore obvious limitations, dangers, and risks.

Age and Engine Size
• For your child's safety and comfort, you must match
your child with an ATV engine size that is appropriate
for his or her age group.
• Ages 6‐11: Under 70cc
• Ages 12‐15: 70 to 90cc
• Ages 16 and older: Over 90cc
• www.offroad‐ed.com/wi/course/youth_operators.htm

INJURY PREVENTION
• Injury recidivism may be related to high risk
behaviors
• “Trauma is a chronic disease”
• 280 surveys
• Minor Injury – 21%, Major Injury 9%
• Injured patients less likely to use helmet
• (78% vs 74% ‐ Minor)
• (77% vs 56% ‐ Major)
• Pattern of persistent high risk behavior despite injury
Gomez, et al, Current helmet and protective equip usage among previously
injured ATV and Motorcycle riders. Injury Prevention. 2004;10:56‐58.

INJURIES AFTER GOVT MANDATES
• 1985‐1999 vs 2000‐2005
• ATV injuries admitted to Trauma Center (UCSD)
• 164 vs 269
• 53.6% vs 27.5% Closed‐Head Injury
• 11.6% vs 5.2% Spinal Cord Injury
• 62.8% vs 45.3% Soft‐tissue injury
• 18.9% vs 33.0% Long‐bone fractures
• Increased #s but injury prevention such as helmet
laws may be having a positive impact
Coimbra et al, Am J Surg. 2008 Jun;195(6):789‐92.

All You Can Do Is All You Can Do