On equal footing: Trends in ankle/foot injuries for men vs. women

OBJECTIVES

The objective of the current study was to examine trends in ankle/foot (A/F) injuries during the period 2001-2014, in order to determine whether the incidence of these injuries has changed and whether a previously identified difference in risk by gender still existed. In addition, other driver and crash-related risk factors were examined separately for men and women.

METHODS

Passenger vehicle drivers aged 16+ were identified from NASS-CDS; weighted data were analyzed for model years 2001-2014. Model years (MY) were grouped as 2001-2004 (older) vs. 2005-2014 (newer), and drivers in frontal crashes were included. Ankle injuries included fractures and dislocations to the malleolus and distal tibia/fibula. Foot injuries included fractures and dislocations of the talus, calcaneus, and tarsal/metatarsal bones. Logistic regression models were constructed to identify risk factors, including MY, age, belt use, toepan/instrument panel intrusion, and body mass index (BMI) separately for each gender using odds ratios.

RESULTS

The incidence of A/F injuries declined significantly between older and newer MY, especially for women. Whereas before MY 2005, ankle and foot injury risk was significantly higher for women than men, risks for ankle injury are now virtually the same for both genders, and women are only 1.2 times more likely than men to sustain a foot injury in a frontal crash. From multivariable regression models, however, it is apparent that there are different risk factors for A/F injuries for men vs. women. Body weight was a significant factor for both groups, but for men it was a risk only for those extremely obese, whereas for women those who were categorized as overweight were also at increased risk. Age greater than 55 was also found to be a risk factor for foot injuries among women but not men. For men and women, toepan intrusion remained the most important factor for both foot and ankle injuries, with significantly higher odds ratios noted for men. Foot pedals were a more likely injury source for women, whereas the toepan was more likely for men. In addition, belt use was protective for ankle injuries in women but not men.

CONCLUSIONS

Significant declines in A/F injuries have been noted in recent years, especially for women, whose risks are now similar to those for men. However, significant risk factors remain for each gender, primarily related to body habitus (BMI) and toepan intrusion. Age was a risk factor for foot injuries among women, for whom the foot pedals were more likely to be an injury source. Toepan intrusion remains a major factor for both men and women, but, with the exception of 30+ cm of intrusion, odds ratios were primarily much higher for men in each category of intrusion.

S-100β does not predict outcome after mild traumatic brain injury

OBJECTIVE

To determine the usefulness of S-100β, a marker for central nervous system damage, in the prediction of long-term outcomes after mild traumatic brain injury (MTBI) Hypothesis: Mid- and long-term outcomes of MTBI (i.e. 3, 6 and 12 months post-injury and return-to-work or school (RTWS)) may be predicted based on pre-injury and injury factors as well as S-100β.

METHODS

MTBI subjects without abnormal brain computed tomography requiring intervention, focal neurological deficits, seizures, amnesia > 24 hours and severe or multiple injuries were recruited at a level I trauma centre. Admission S-100β measurements and baseline Concussion Symptom Checklist were obtained. Symptoms and RTWS were re-assessed at follow-up visits (3-10 days and 3, 6 and 12 months). Outcomes included number of symptoms and RTWS at follow-up. Chi-square tests, linear and logistic regression models were used and p < 0.05 was considered statistically significant.

RESULTS

One hundred and fifty of 180 study subjects had S-100β results. Eleven per cent were unable to RTWS at 12 months. S-100β levels were not associated with post-concussive symptomatology at follow-up. In addition, no association was found between S-100β levels and RTWS.

CONCLUSION

Amongst MTBI patients, S-100β levels are not associated with prolonged post-concussive syndrome or the inability to RTWS.

Aortic injuries in newer vehicles

The occurrence of AI was studied in relation to vehicle model year (MY) among front seat vehicular occupants, age≥16 in vehicles MY≥1994, entered in the National Automotive Sampling System Crashworthiness Data System between 1997 and 2010 to determine whether newer vehicles, due to their crashworthiness improvements, are linked to a lower risk of aortic injuries (AI). MY was categorized as 1994-1997, 1998-2004, or 2005-2010 reflecting the introduction of newer occupant protection technology. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals for the association between AI and MY independent of possible confounders. Analysis was repeated, stratified by frontal and near lateral impacts. AI occurred in 19,187 (0.06%) of the 31,221,007 (weighted) cases, and contributed to 11% of all deaths. AIs were associated with advanced age, male gender, high BMI, near-side impact, rollover, ejection, collision against a fixed object, high ΔV, vehicle mismatch, unrestrained status, and forward track position. Among frontal crashes, MY 98-04 and MY 05-10 showed increased adjusted odds of AI when compared to MY 94-97 [OR 1.84 (1.02-3.32) and 1.99 (0.93-4.26), respectively]. In contrast, among near-side impact crashes, MY 98-04 and MY 05-10 showed decreased adjusted odds of AI [OR 0.50 (0.25-0.99) and 0.27 (0.06-1.31), respectively]. While occupants of newer vehicles experience lower odds of AI in near side impact crashes, a higher AI risk is present in frontal crashes.

Declining statewide trends in motor vehicle crashes and injury-related hospital admissions

Numbers of crashes, rates of police-reported injury severity, and hospital admission rates were calculated for the ten year period between 2001 and 2010 in Maryland. Comparisons were made for two 5-year periods of 2001-2005 and 2006-2010. Crash characteristics remained similar for the two five-year periods, but there was a significant increase in occupant age. Declines in police-reported injury severity were noted for each of four age groups: 16-29, 30-54, 55-64, and 65+, with smaller declines among older occupants. In addition, there were significant declines in hospital admissions, comparing the two time periods. Although reductions in crashes may be attributable to various roadway, behavioral, and other safety improvement efforts, reductions in hospital admission rates most likely reflect major improvements in crashworthiness implemented during the past decade. For those admitted to hospitals, significant increases in injury severity were noted between the first and second time periods. There was an association between age and ISS, a measure of total bodily injury, with the highest ISS scores noted for the youngest and oldest groups (16-29 and 55+, respectively). In addition, there was a significant increase in the mean age over time, from 39 in 2001 to 43 in 2010, p<.001. In general, the incidence and severity of injuries increased for all body regions. There was also a significant increase in hospital mortality, although length of hospital stay remained the same. Given these trends, increased efforts need to focus on both injury prevention and treatment for the increasing population of older, sometimes frail, vehicle occupants.

Disparities in trauma center access of older injured motor vehicular crash occupants

BACKGROUND

To evaluate whether older injured motor vehicular crash (MVC) occupants' access to trauma centers (TC) reflects the lower threshold suggested in triaging recommendations.

METHODS

Adult front seat occupants of MVCs transported to a hospital from 1999 through 2006 included in the National Automotive Sampling System (NASS) were studied. Cases were classified by their age in years (≤60 years or >60 years). Younger and older injured MVC occupants were compared in relation to their likelihood of being transported to a TC. Multiple logistic regression models were built to adjust for confounders.

RESULTS

A total of 35,830 cases representing 7,894,940 cases after weighting were analyzed. Older occupants were less likely to be transported to a TC than younger ones (47% vs. 55%, p < 0.0001). Older individuals were more likely to be restrained, passengers, and seated on the impacted side of lateral crashes. Injury severity was higher among the older group (mean Injury Severity Score, 4.1 vs. 3.1; p < 0.0001) and so was the resulting mortality (1.7% vs. 0.6%, p < 0.0001). Multiple logistic regression models after adjusting for confounders (i.e., other triage criteria) revealed a lower likelihood of TC transport (odds ratio, 0.75 [0.57-0.98]) for the older group.

CONCLUSION

In contrast to the American College of Surgeons triaging recommendations, injured MVC occupants older than 60 years are less likely to be transported to a TC than their younger counterparts. Further studies should establish whether the lower access to TC experienced by the older population is a function of geographical factors, emergency medical services unconscious bias, or other factors.

Frailty and injury causation

PURPOSE

: The current study will attempt to elucidate whether frailty has a role in motor vehicle crash injury causation.

METHODS

: The association between frailty and injury was studied among Crash Injury Research Engineering Network (CIREN) cases. The baseline "physical functioning" (PF) score of the SF-36 was used as a marker of frailty (i.e., PF score <75). Frailty associations with ISS and occupant, vehicular and crash factors were explored. Frailty association with delta V was analyzed among injured (i.e., brain, rib, or femur) belted occupants in frontal crashes to establish whether frailty confers a different risk of each particular injury.

RESULTS

: Frailty occurred in 13.7 % of the cohort (n=1,747). Median (q1-q3) ISS was 14.0 (10-22) among the frail and 17.0 (10-24) among the non frail (p=0.40). Frailty was significantly associated with advanced age, male gender, the presence of co-morbidities, extreme BMIs, frontal and near-side crashes and delta V < 45 km/h. Seat belt use and ISS<16 were not associated with frailty. Multiple linear regressions, adjusting for age, gender and BMI revealed a negative association between frailty and log delta V (coefficient -0.188, p=0.04) among those with rib fractures but not among those with brain injuries or femur fractures.

CONCLUSION

: PF score, a marker of frailty, is associated with similar ISS and lower delta V and is independently linked to lower delta V thresholds for some injuries (i.e. rib fractures) but not for others (i.e. brain injuries and femur fractures). These associations suggest a potential role of frailty in injury causation.

Degree of urbanization and mortality from motor vehicular crashes

PURPOSE

: The purpose of this study is to establish whether motor vehicular crash (MVC) case fatality varies across different urbanization levels in the USA using a representative sample of crashes.

METHODS

: Odds ratios (ORs) and 95% confidence intervals (CIs) for the association between urbanization level [i.e., central city (CC), suburban (SU) and others (OT)] and mortality were estimated in the 1997 - 2010 National Automotive Sampling System Crashworthiness Data System. Multiple logistic regression was used to adjust for confounders. Analysis was repeated for the occurrence of pre-hospital and hospital deaths.

RESULTS

: 49,040,520 weighted occupants were included in the study. The distribution of occupants by urbanization categories was: SU 45%, OT 42%, and CC 13%. Case fatality was higher among OT occupants (0.81%) than among SU (0.51%) and CC (0.37%) occupants. Similar findings were present for pre-hospital deaths (OT 0.52%, SU 0.30%, and CC 0.21%) and hospital deaths (OT 0.29%, SU 0.21%, and CC 0.16%). Multivariate analysis revealed that adjusted odds of death were higher for OT cases [OR=1.55 (1.05-2.30)] than the CC. Adjusted odds of death for SU (OR=1.05 (0.81-1.37) were not different than CCs. Similar but accentuated findings were found for pre-hospital deaths. In contrast, adjusted odds of hospital death were not different among the 3 groups.

CONCLUSION

: Occupants of vehicles crashing in OT (i.e., rural areas and small cities) experience a higher likelihood of dying after MVCs than those in CC and SU. Pre-hospital deaths, not hospital deaths, are responsible for this disparity.

Impulsive or depressive personality traits do not impede behavioral change after brief alcohol interventions

The authors investigated whether impulsivity and depression affect the success of interventions to reduce alcohol use. Unadjusted and adjusted regression models were constructed to analyze the effect of impulsivity and depression on 12-month outcomes of participants of a trauma center based randomized trial of brief personalized motivational interventions versus information and advice. Of 497 problem drinkers enrolled in the program, 248 completed the 12-month follow-up. Impulsivity, male gender, being older than 35, and intentional mechanism of injury had a direct association with drinking. After interventions, a decrease in drinking was found that was unaffected by the presence of impulsivity or depression indicators.

Crash-related mortality and model year: are newer vehicles safer?

OBJECTIVE

The objective of this study was to determine whether occupants of newer vehicles experience a lower risk of crash-related mortality.

METHODS

The occurrence of death was studied in relation to vehicle model year (MY) among front seat vehicular occupants, age ≥ 16 captured in the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) between 2000 and 2008. The associations between death and other occupant, vehicular and crash characteristics were also explored. Multiple logistic regression models for the prediction of death were built with model year as the independent variable and other characteristics linked to death as covariates. Imputation was used for missing data; weighted data was used.

RESULTS

A total of 70,314 cases representing 30,514,372 weighted cases were available for analysis. Death occurred in 0.6% of the weighted population. Death was linked to age>60, male gender, higher BMI, near lateral direction of impact, high delta v, rollover, ejection and vehicle mismatch, and negatively associated with seatbelt use and rear and far lateral direction of impact. Mortality decreased with later model year groups (MY<94 0.78%, MY 94-97 0.53%, MY 98-04 0.51% and MY 05-08 0.38%, p=<0.0001). After adjustment for confounders, MY 94-97, MY 98-04 and MY 05-08 showed decreased odds of death [OR 0.80 (0.69-0.94), 0.82 (0.70-0.97), and 0.67 (0.47-0.96), respectively] when compared to MY <94.

CONCLUSION

Newer vehicles are associated with lower crash-related mortality. Their introduction into the vehicle fleet may explain, at least in part, the decrease in mortality rates in the past two decades.

Improving trauma triage using basic crash scene data

OBJECTIVE

to analyze the occurrence of severe injuries and deaths among crash victims transported to hospitals in relation to occupant and scene characteristics, including on-scene patient mobility, and their potential use in triaging patients to the appropriate level of care.

METHODS

the occurrence of death and ISS>15 were studied in relation to occupant, crash and mobility data readily available to EMS at the scene, using weighted NASS-CDS data. Data set was randomly split in two for model development and evaluation. Characteristics were combined to develop new triage schemes. Overtriage and undertriage rates were calculated for the NASS-CDS case trauma center allocation and for the newly developed triage schemes.

RESULTS

Compared to the NASS-CDS distribution, a scheme using patient mobility alone showed lower overtriage of those with ISS≤15 (38.8% vs. 55.5%) and lower undertriage of victims who died from their crash-related injuries (2.34% vs. 21.47%). Undertriage of injuries with ISS> 15 was similar (16.0 vs. 16.9). A scheme based on the presence of one of many scene risk factors (age>55, GCS<14, intrusion ≥18", near lateral impact, far lateral impact with intrusion ≥12", rollover or lack of restraint use) resulted in an undertriage of 0.86% (death) and 10.5% (ISS>15) and an overtriage of 63.4%. The combination of at least one of the scene risk factors and mobility status greatly decreased overtriage of those with ISS<15 (24.4%) with an increase in death undertriage (3.19%). Further combination of mobility and scene factors allowed for maintenance of a low undertriage (0.86%) as well as an acceptable overtriage (48%).

CONCLUSION

Patient mobility data easily obtained at the scene of a crash allows triaging of injured patients to the appropriate facility with a high sensitivity and specificity. The addition of crash scene data to scene mobility allows further reductions on undertriaging or overtriaging.

Vehicle model year and crash outcomes: a CIREN study

OBJECTIVE

To quantify the effect of model year (MY) on the occurrence of severe injuries and death after involvement in motor vehicle crashes.

METHODS

Cases involving adult front seat occupants of vehicles MY > or = 1994 equipped with frontal airbags were selected from the Crash Injury Research and Engineering Network (CIREN) database. Cases were grouped by MY: 1994-1997, 1998-2004, and 2005-2007 (MY groups [MYG] 1, 2, and 3, respectively. MYGs were compared in relation to mortality, Injury Severity Score (ISS), and the occurrence of Abbreviated Injury Severity score (AIS) 3+ and AIS4+ injuries to each body region using Mantel Haenszel chi-square, Kruskal-Wallis, and Bonferroni corrected t test. To adjust for confounders, multiple logistic regression models were built to explore the association of MYG with death. Covariates included age, BMI, delta v, principal direction of force (PDOF), restraint use, and vehicle type.

RESULTS

A total of 1888 cases was distributed within MYG1 (34%), MYG2 (62%), and MYG (34%). Age, gender, BMI, and PDOF distribution did not differ among MYGs. Though ISS distribution was not different, a decrease in the occurrence of AIS4+ of the thorax and spine regions was noted over time. Mortality also decreased over time (18, 9, and 4% MYG 1, 2, and 3, respectively). Multivariate analysis revealed a protective effect of MYG2 and MGY3 (odds ratio [OR], 0.57 [0.44-0.75] and 0.22 [0.07-0.50], respectively) in relation to death.

CONCLUSIONS

Front seat occupants of later MY vehicles injured during crashes experience a decreased likelihood of very severe thoracic injuries, spinal injuries, and death.

PTSD after severe vehicular crashes

PURPOSE

To describe predictors of PTSD after motor vehicle crashes (MVC).

METHODS

MVC patients were interviewed during their hospitalization and at 6 and 12 months post-injury. Interviews included information about behavioral factors, circumstances around the crash, recovery and PTSD screening. PTSD was defined as the development of 3 or more of 7 PTSD symptoms. Association of risk factors with PTSD development at 6 and 12 months was analyzed using contingency tables. Multiple regression models were built for the prediction of PTSD.

RESULTS

367 and 317 patients completed the 6 and 12 month interviews respectively. PTSD developed in 27.5 % (n=101) and 24.3 % (n=77) of the population at 6 and 12 months respectively. PTSD occurred more frequently among females, those with a previous history of depression, violent injury, or other traumatic events, and those whose crashes involved a fatality. Those who were culpable for the crash, age<30, and sustained brain injuries were less likely to develop PTSD at 6 months. Occupant position, education, marital status, alcohol problems, injury severity, heart rate, and blood alcohol + status did not show any significant association with PTSD. In the multiple logistic regression, female gender, history of depression, culpability, prior violent injury, and a fatality in the crash were associated with PTSD at 6 months. Only prior violent injury, and a death in same crash were predictors at one year.

CONCLUSION

PTSD occurs frequently after MVCs. Female gender, prior violent injury, death of another occupant and history of depression are associated with PTSD development.

Sociodemographic characteristics associated with substance use status in a trauma inpatient population

Substance use is significantly associated with physical injury, yet relatively little is known about the prevalence of specific substance use disorders among trauma patients, or their associated sociodemographic characteristics. We evaluated these issues in an unselected sample of 1,118 adult inpatients at the University of Maryland Shock Trauma Center, Baltimore, MD, who were interviewed with the psychoactive substance use disorder section of the Structured Clinical Interview for DSM-III-R. Among trauma inpatients, lifetime alcohol users (71.8% of subjects) were more likely male; users of illegal drugs (45.3%) were also more likely to be younger, unmarried, and poor. Patients with current drug abuse/dependence (18.8%) were more likely to be non-white, less educated, and poor; those with current alcohol abuse/dependence (32.1%) were also more likely male, unmarried, and older. These findings highlight the need for screening for substance use disorders in trauma settings and referral of patients to substance abuse treatment programs.

A controlled trial of brief intervention versus brief advice for at-risk drinking trauma center patients

BACKGROUND

Numerous reports document that preinjury alcohol use is associated with all modes of injury requiring treatment in a trauma center, with 25% to 50% or more of patients testing positive for alcohol at the time of admission. There is evidence that in trauma patients unaddressed alcohol use problems result in recurrent injury requiring readmission to a trauma center and/or death.

METHODS

A randomized clinical trial was conducted to assess the effectiveness of two types of brief interventions to reduce drinking and the consequences of drinking. Trauma patients defined as at-risk alcohol users (n=497) were randomized into two treatment options: a brief personalized motivational intervention (PMI), or brief information and advice (BIA). After a brief assessment, PMI subjects received a motivational session, feedback letter, and two postdischarge telephone contacts, whereas the BIA group received a brochure and one postdischarge telephone contact. Both groups were reassessed at 6 and 12 months postinjury.

RESULTS

Both the PMI and BIA groups had statistically significant reductions in drinking, binge episodes, and consequences related to drinking that persisted from the 6- to the 12-month follow-up. However, although not statistically significant, for those classified as lower-level drinkers (<or=1 drink per day), there was a consistent pattern of maintaining reductions for the PMI group at 12 months compared with the BIA group.

CONCLUSION

Our results suggest that brief interventions (PMI and BIA) that link alcohol consumption with trauma injury and consequences of drinking can be effective in reducing drinking and consequences related to drinking in a significant portion of at-risk nondependent drinkers.

Risk of psychoactive substance dependence among substance users in a trauma inpatient population

One measure of a substance's addictive risk is the proportion of users who become dependent. This study evaluates the lifetime and current risk of substance dependence among lifetime substance users' among trauma inpatients and provides a relative ranking of addictive risk among the substances. Data on use of 8 substance groups (alcohol, opiates, marijuana, cocaine, other stimulants, sedative-hypnotics, hallucinogens, other drugs) were obtained by interview (Structured Clinical Interview for the DSM-III-R) from 1,118 adult trauma inpatients. Prevalence of lifetime dependence among lifetime users ranged from 80.7% for opiates and 70.9% for cocaine to 33.3% for hallucinogens and 26.6% for sedative-hypnotics. The rank order of addictive risk was similar to that found in the general population. Trauma inpatients had a higher absolute addictive risk than the general population, comparable to the risk found in patients in treatment for substance use disorders, suggesting the importance of screening trauma inpatients for substance dependence.

Social, behavioral and driving characteristics of injured pedestrians: a comparison with other unintentional trauma patients

Pedestrian injuries represent 11% of all motor vehicle related injuries in the USA. This study attempts to define the epidemiology of the pedestrian victim. Patients admitted to a regional adult trauma center were interviewed and evaluated for substance abuse. Pedestrians were compared with the remaining unintentional trauma patients with regard to demographics, socioeconomics, possession of a driver's license, injury prone behaviors, risk taking dispositions, and BAC levels using the Student's t-test and Pearson's chi2 statistic (alpha=0.05). Multivariate logistic regression models were built with pedestrian mechanism as the outcome. When compared to the remaining unintentional trauma population (N=661), pedestrians (N=113) were significantly more likely to be black, not married, unemployed, binge drinkers, alcohol dependent, drug dependent, BAC+, to have a low income, low educational achievement, younger age, and to not have a driver license. Black race, unemployment of 1 year or more, never licensed, lapsed license, revoked license and BAC>200 mg/dl showed statistical significance in the multiple logistic regression. Pedestrians represent a sub-population with a low socioeconomic status and high incidence of substance abuse. Unemployment, not having a driver's license, black race, and a BAC>200 mg/dl were strongly linked to being an injured pedestrian.

The association between age, injury, and survival to hospital among a cohort of injured motorcyclists

Despite the significant increase in mortality among older motorcyclists during the past decade, few studies have addressed specific injuries or mortality rates among all those injured. The purpose of this study is to describe the crash and injury characteristics among a cohort of motorcyclists injured in Maryland, and to determine the influence of age and crash type on mortality, injury patterns, and place of death (scene vs. hospital). Possible biases introduced by studying only those hospitalized are described. Based on the findings, specific injury prevention strategies for older vs. younger riders are proposed.

Risk Factors Associated with Pelvic Fractures Sustained in Motor Vehicle Collisions Involving Newer Vehicles

BACKGROUND

Despite advances in automotive safety, pelvic fractures caused by motor vehicle collisions remain a significant cause of mortality, morbidity, and functional disability. This study was designed to evaluate epidemiologic and biomechanic risk factors associated with pelvic fractures resulting from motor vehicle collisions. We utilized the Crash Injury Research Engineering Network (CIREN) database to identify these risk factors in newer vehicles.

METHODS

Data were prospectively collected at the ten CIREN centers from 1996 to 2005. Specific data were then abstracted on all patients, biomechanic crash characteristics, and injuries sustained. Patients involved in a frontal or near-side lateral impact with pelvic fractures were compared with those without. Univariate analysis was performed using a chi2 analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations.

RESULTS

Of the 1,851 patients studied, 511 (27.6%) had a pelvic fracture. The overall mortality was 17%. Injury specific factors associated with pelvic fracture were higher Injury Severity Score (ISS) and fatality of the patient. Biomechanic factors associated with the risk of pelvic fracture included; no airbag deployment (p < 0.001), smaller vehicle (p = 0.05), and lateral deformation location (p < 0.001). When stratified by vehicle deformation location, logistic regression models revealed statically significant variables in a frontal impact which included; higher body mass index, higher ISS, large patient vehicle, no seatbelt use, and higher deltaV. For near-side lateral impacts, multivariate analysis revealed statistically significant variables of lower body mass index, higher ISS, female sex, small vehicle size, and higher deltaV.

CONCLUSIONS

Even in newer vehicles with federally mandated safety features, pelvic fractures remain a common injury. Pelvic fractures may serve as a marker of crash severity and specific crash characteristics are associated with pelvic fractures. Lateral crashes are significantly more likely to result in a pelvic fracture and, therefore, prevention of pelvic fractures should focus on improving occupant safety in near-side lateral impacts. Recognition of other associations should lead researchers to further investigate causative factors that will ultimately result in improved vehicle design.

Risk perception and impulsivity: association with risky behaviors and substance abuse disorders

Low risk perception and high impulsivity, in conjunction with substance abuse disorders, are associated with the occurrence of injury in the general population. The study described in this article investigated the association of risk perception and impulsivity with risky behaviors (infrequent seat belt use, drinking and driving, riding with a drunk driver, binge drinking, and speeding for the thrill) among adults with unintentional blunt trauma. Patients (N = 756) were assessed for substance abuse disorders and participation in risky behaviors. Risk perception and impulsivity were measured by questionnaire. Pearson's chi-square statistic was used to investigate risk perception, impulsivity, substance abuse, and possible confounders relative to risky behaviors. Odds ratios were calculated using logistic regression methodology. Univariate results indicated that low risk perception and high impulsivity were significant risk factors for risky behaviors. After adjustment for confounding factors, low risk perception and high impulsivity remained significantly associated with risky behaviors in the trauma patient population.

Crash culpability and the role of driver blood alcohol levels

Twenty years ago the American Medical Association reported the relationship between blood alcohol concentration (BAC) and crash causation. This study addresses culpability, age, gender and BAC in a population of drivers injured in motor vehicle crashes. Five years of hospital and crash data were linked, using probabilistic techniques. Trends in culpability were analyzed by BAC category. Given BAC level, the youngest and oldest drivers were more likely to have caused their crash. Women drivers had significantly higher odds of culpability at the highest BAC levels. Seatbelt use was also associated with culpability, perhaps as a marker for risk-taking among drinkers.

Injury patterns and severity among hospitalized motorcyclists: a comparison of younger and older riders

In recent years there has been a significant increase in mortality among motorcyclists, especially older riders (40+ years). However, few studies have compared the nature and severity of injuries sustained by older vs. younger cyclists. The purpose of this analysis was to determine differences, if any, in injury patterns to older vs. younger motorcyclists and to explore rider, vehicle, and environmental factors associated with these differences. Older riders were found to have a significantly higher incidence of thoracic injury, especially multiple thoracic injuries, and specifically multiple rib fractures. Older motorcyclists were also more likely to ride larger motorcycles, and were more involved in collisions involving overturning or striking highway structures. Large engine sizes were associated with increased risk of head and thoracic injuries, but not abdominal injuries. The magnitude of increased risks related to 1000+ cc engine size was higher among older motorcyclists than younger motorcyclists.

Population-based study of police-reported sexual assault in Baltimore, Maryland

OBJECTIVE

To document the population-based incidence of sexual assault in Baltimore, Md, victims' alcohol/drug use, and pre-event circumstances.

METHODS

Between 1997 and 1999, the city's sexual assault treatment center treated 1,038 victims (age>or=13 years). Data were extracted from forensic narratives. Analysis was restricted to frequency tables and bar graphs. Incidence was calculated based on 1998 population figures.

RESULTS

The incidence of sexual assault among females aged 13 years or older was 117 per 100,000. Seventy percent of patients were less than 30 years old. Fifty-three percent tested positive for alcohol/drugs. Two thirds sustained physical or genital injury; 30% sustained both. The most common pre-event circumstances were walking/being followed (27%) and visiting a friend's home (24%).

CONCLUSION

This study revealed a high prevalence of physical/genital injury, supporting the call for an injury severity scale for sexual assault and for increased substance abuse counseling and educational/health resources to mitigate sexual assault and offer meaningful response when such crimes occur.

Life-altering outcomes after lower extremity injury sustained in motor vehicle crashes

BACKGROUND

Lower extremity injuries (LEIs) sustained in vehicular crashes result in physical problems and unexpected psychosocial consequences. Their significance is diminished by low Abbreviated Injury Scale scores.

METHODS

Drivers who sustained LEIs were identified as part of the Crash Injury Research and Engineering Network (CIREN) and interviewed during hospitalization, at 6 months, and at 1 year. All were occupants of newer vehicles with seatbelts and airbags.

RESULTS

Sixty-five patients were followed for 1 year. Injuries included mild brain injury (43%), ankle/foot fractures (55%), and bilateral injuries (37%). One year post-injury, 46% reported limitations in walking and 22% with ankle/foot fractures were unable to return to work. Depression (39%), cognitive problems (32%), and post-traumatic stress disorder (18%) were significant in the mild brain injury group.

CONCLUSIONS

Long-lasting physical and psychological burdens may impede recovery and alter the lifestyle of patients with LEI. These issues need to be addressed by trauma center personnel.

Crash culpability relative to age and sex for injured drivers using alcohol, marijuana or cocaine

While there is a great deal of data documenting the etiologic role alcohol use plays in crash culpability, there is a dearth of data for other drugs. The purpose of this study was to assess crash culpability for single drug use among injured drivers admitted to a regional trauma center. This study is the largest of its kind involving trauma center patients. Clinical toxicology results obtained for patient care were linked to police crash reports containing a field attributing crash culpability. Drugs studied were alcohol, cocaine, and marijuana. As expected crash culpability was strongly associated with pre-crash alcohol use. In contrast, for both men and women, this study did not find an association between crash culpability and marijuana use. The data documents a significant association between cocaine use and crash culpability for both sexes and for drivers 21 to 40 years of age. This is the first large study to assess for crash culpability among injured drivers relative to cocaine use. Each year approximately 42 to 43,000 people die annually as the result of vehicular crashes. (NHTSA, 2005) For the decade 1994 through 2003, alcohol was a factor in 40-43% fatal injury crashes - the fatally injured person being either a vehicular occupant or pedestrian. Specifically 25 to 29% of drivers of cars and light trucks involved in those crashes were alcohol positive. Further, it is estimated that 80% or more of those drivers had blood alcohol concentrations (BAC) of 80 mg/dl or greater. (NHTSA, 2005).

Consequences and costs of lower extremity injuries

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Pedestrian injuries and vehicle type in Maryland, 1995-1999

Pedestrian deaths constitute the second largest category of motor vehicle deaths in the US. The present study examined how pedestrian injury is associated with vehicle type, while controlling for vehicle weight and speed.Police, trauma registry, and autopsy data were linked for injured pedestrians. Logistic regression analyses were performed to control for vehicle weight and speed. Outcomes included pedestrian mortality, injury severity score, and injuries to specific body regions. Compared to conventional cars, pedestrians hit by sport utility vehicles and pick-up trucks were more likely to have higher injury severity scores (odds ratio=1.48; 95% confidence interval: 1.18-1.87) and to die (odds ratio=1.72; 95% confidence interval: 1.31-2.28). These relationships diminished when vehicle weight and speed were controlled for. At lower speeds, pedestrians struck by sport utility vehicles, pick-up trucks, and vans were approximately two times as likely to have traumatic brain, thoracic, and abdominal injuries; at higher speeds, there was no such association. The overall increased danger sport utility vehicles and pick-up trucks present to pedestrians may be explained by larger vehicle masses and faster speeds. At slower speeds being hit by sport utility vehicles, and pick-up trucks, and vans resulted in specific injuries, indicating that vehicle design may contribute to different injury patterns.

Psychosocial and physical factors associated with lower extremity injury

With the increasing availability of modern occupant restraints, more drivers and passengers are surviving high-energy crashes. However, a large number, especially those involved in frontal and offset frontal crashes, incur disabling lower extremity injuries. In the past, not much attention was paid to these injuries, as they were usually not life threatening. Despite the low AIS scores associated with injuries to the lower extremities, they pose a major physical and psychological burden on patients' and their ability to return to pre-crash functioning. Associated injuries, such as mild brain injuries, and psychosocial factors such as depression, also influence the long-term outcome.

Autopsy study of motorcyclist fatalities: the effect of the 1992 Maryland motorcycle helmet use law

OBJECTIVES

This study sought to determine the impact of Maryland's all-rider motorcycle helmet law (enacted on October 1, 1992) on preventing deaths and traumatic brain injuries among motorcyclists.

METHODS

Statewide motorcyclist fatalities occurring during seasonally comparable 33-month periods immediately preceding and following enactment of the law were compared.

RESULTS

The motorcyclist fatality rate dropped from 10.3 per 10 000 registered motorcycles prelaw to 4.5 postlaw despite almost identical numbers of registered motorcycles. Motorcyclists wearing helmets had a lower risk of traumatic brain injury than those not wearing helmets (odds ratio = 0.31, 95% confidence interval = 0.14, 0.68).

CONCLUSIONS

Maryland's controversial motorcycle helmet law appears to be an effective public health policy and may be responsible for saving many lives.

Characteristics of traffic crashes in Maryland (1996-1998): differences among the youngest drivers

Motor vehicle crashes (MVCs) are the leading cause of death among teenagers in the US. The present study examines how crash rates and crash characteristics differed among drivers aged 16-21 in the state of Maryland from 1996 to 1998. The results show that, based on police reports. the youngest drivers have the highest rate of MVCs per licensed driver and per annual miles driven. Furthermore, crash characteristics suggest that inexperience rather than risky driving may account for the differing rates. Drivers closer to the age of 16 had their crashes under the safest conditions: during the day in clear weather while drinking less.

Alcohol/drug abuse, driving convictions, and risk-taking dispositions among trauma center patients

The objective of this study was to evaluate the relationship between alcohol/drug abuse diagnoses, driving convictions (speeding, reckless driving, impaired driving, license violations), and risk-taking dispositions among a series of injured drivers admitted to a trauma center. The driving records of 778 patients were linked to diagnoses of psychoactive substance use disorders (PSUDs), admission blood alcohol concentration (BAC), mode of injury, and results of a risk-taking disposition survey. Twenty-nine percent of patients had one or more convictions in the 3 years before injury. Types of violation were not related to mode of injury. Although there was a positive association between prior impaired-driving convictions, current alcohol dependence, and a BAC + status, a consistent pattern relative to other violations, PSUDs, and BAC status was not apparent. Risk-taking disposition scale scores indicated that patients without PSUDs and without convictions tended toward less risk-taking behavior than patients with PSUDs and with convictions. The complex inter-relationships between PSUDs, risk-taking dispositions, and being convicted of driving dangerously require additional study so that intervention programs and injury prevention initiatives can be targeted effectively.

Factors influencing the patterns of injuries and outcomes in car versus car crashes compared to sport utility, van, or pick-up truck versus car crashes: Crash Injury Research Engineering Network Study

BACKGROUND

Data using crash dummies suggest that motor vehicle crashes (MVCs) involving passenger sedans (S) vs sport utility, vans, or light trucks (SUVTs) produce more severe injuries than those involving two sedans (SvS). However, no detailed data regarding pattern of injuries or force mechanisms involved have been presented in real patients.

METHODS

The relationship of injury patterns and severities with MVC reconstruction data were obtained in 412 MVC patients, drivers or front seat passengers. Crashes were examined with regard to impact direction, frontal (F) or lateral (L) crashes, vehicle mass ratio, ISS, DELTA V, seat belt use, and airbag deployment (AB).

RESULTS

In 309 F-MVC, AB reduced overall ISS (24.3 to 17.9) with a reduction in the mean severity of traumatic brain injury (TBI) GCS < or = 12, from 48% to only 28%. This AB protection from TBI was preserved as DELTA V increased to > 30 mph even though non-AB protected body areas (thorax, lung, liver, and lower extremity injuries) all increased. When vehicles of incompatible size and mass (SUVT) had F-MVC with sedans the incidence of severe TBI rose as did face lacerations despite AB or belt use. In L-MVC between SUVT and sedans compared with SvS MVC, there was a cephalad shift in body injuries with increased thorax, but decreased lower extremity injuries. The incidence of TBI increased. Analysis of injury contact sites (hits) showed more hits and a wider distribution of contract sites in SUVT vs sedan MVC. These appeared due to the greater mass excess and larger mass ratio, hood height, and width in the F-SUVT vs S crashes. All of these factors plus the increased bumper height above the body frame side-door sill were injury causal factors in the L-SUVT vs S MVCs.

CONCLUSION

Both F and L crashes between sedans and SUVT with a high mass ratio shift the pattern of injury cephalad with increased thorax and intrathoracic organ injuries, and more severe TBI. These data suggest that improved head and thorax side-impact buffering and design features which transmit MVC forces from the higher front end of the larger mass SUVT to the frame of the sedan may better protect sedan occupants from side-impacts.

A longitudinal study of former trauma center patients: the association between toxicology status and subsequent injury mortality

BACKGROUND

Despite the current emphasis on injury prevention, little has been done to incorporate alcohol intervention programs into the care of the injured patient. The purpose of this study was to determine whether patients admitted to a trauma center with positive toxicology findings (TOX+) have a higher subsequent injury mortality than those without such findings (TOX-).

METHODS

We followed a cohort of 27,399 trauma patients discharged alive between 1983 and 1995 to determine subsequent mortality. Death certificates were obtained to identify the cause of death.

RESULTS

TOX+ patients had an injury mortality rate approximately twice that of the TOX- group (1.9% vs. 1.0%, p < 0.001). Overall, 22.7% of the deaths were due to injury; the TOX+ rate was 34.7% versus 15.4% for the TOX-.

CONCLUSION

These data add strength to the premise that untreated substance abuse-related injury remains an untapped injury prevention opportunity.

Epidemic increases in cocaine and opiate use by trauma center patients: documentation with a large clinical toxicology database

BACKGROUND

Although reports have documented alcohol and other drug use by trauma patients, no studies of long-term trends have been published. We assessed substance use trends in a large cohort of patients admitted to a regional Level I adult trauma center between July 1984 and June 2000.

METHODS

Positive toxicology results, collected via retrospective database review, were analyzed for patients admitted directly to the center. Data were abstracted from a clinical toxicology database for 53,338 patients. Results were analyzed for alcohol, cocaine, and opiates relative to sex, age (< 40/> or = 40 years), and injury type (nonviolence/violence). Positive toxicology test result trends were assessed for the 3 years at the beginning and end of the period (chi2). Testing biases were assessed for sex, race, and injury type.

RESULTS

The patient profile was as follows: men, 72%; age < 40 years, 69%; nonviolence victims, 77%. Alcohol-positive results decreased 37%, but cocaine-positive and opiate-positive results increased 212% and 543%, respectively (all p < 0.001). Cocaine-positive/opiate-positive results increased 152%/640% for nonviolence and 226%/258% for violence victims, respectively (all p < 0.001). In fiscal year 2000, cocaine-positive and opiate-positive results were highest among violence victims (27.4% for both drugs). Cocaine-positive and opiate-positive results among nonviolence victims were 9.4% and 17.6%, respectively. Patients who were minorities or victims of violence were not tested more frequently than other patients.

CONCLUSION

Epidemic increases in cocaine and opiate use were documented in all groups of trauma patients, with the greatest increases being in violence victims. Alcohol use decreased for all groups.

Medical conditions and car crashes

Most previous studies of medical conditions associated with driver safety have focused on specific diseases. This analysis is based on a linkage of police report and hospital discharge data, and correlates various medical diagnostic categories and specific conditions with police determinations of driver culpability for all drivers admitted to Maryland hospitals during a 3-year period. Using odds ratios, various conditions have been identified which are associated with an increased risk of crash culpability. Further research is needed to confirm these findings, and to determine the role of the conditions vs. the possible influence of medications prescribed to treat these conditions.

Use of blood alcohol concentration and laboratory tests to detect current alcohol dependence in trauma center patients

OBJECTIVE

To assess the utility of laboratory markers of severe alcoholism in a cross-sectional population of male trauma center patients, who have a high rate of current alcohol dependence (CAD).

METHODS

A total of 684 men were assessed for CAD by using standard criteria, all of whom had complete laboratory data. The ability of tests to predict CAD was ascertained by using Student's t test, sensitivity, specificity, and area under the curve (AUC) of receiver operating characteristic curves.

RESULTS

Mean values of five tests were individually associated with a CAD diagnosis. Gamma-glutamyltransferase, aspartate aminotransferase, and mean corpuscular volume had sensitivities less than or equal to 0.51 and AUC less than or equal to 0.67. Blood alcohol concentration (BAC) and serum osmolality had sensitivities of 0.64 and 0.74 and AUC of 0.74 and 0.76, respectively. Each marker, when combined with BAC, showed little improvement in AUC over BAC alone.

CONCLUSIONS

Laboratory tests are not highly predictive of CAD in male trauma patients. A combination of BAC tests and interview screens is suggested for use in this patient population.

Effect of change in velocity on the development of medical complications in patients with multisystem trauma sustained in vehicular crashes

Medical complications such as sepsis or multiple organ system failure increase the morbidity and mortality associated with injuries sustained in car crashes. This study addresses the question of the association, if any, between one crash characteristic, i.e. change in velocity (delta v), and subsequent medical complications. Data on seventy-six severely injured patients were obtained as part of an in-depth, trauma-center-based study of the biomechanics of vehicular trauma. Factors found to be predictive of the development of complications included patient age > or = 36 years, delta v > or = 30 mph, and injury severity score > or = 25. Vehicle occupants involved in crashes with a delta v > or = 30 mph had a risk of complications more than five times greater than for those in the lower delta v group. Better knowledge of the dynamics and severity of the crash could help clinical staff anticipate the development of complications and initiate timely prevention strategies.

Screening trauma patients for alcoholism according to NIAAA guidelines with alcohol use disorders identification test questions

Drinking pattern criteria (drinking frequency and number of drinks per occasion) issued by the National Institute on Alcohol and Abuse and Alcoholism (NIAAA) to screen primary practice patients for alcohol problems were evaluated in 1216 injured patients treated in a regional trauma center. Vehicular crash victims predominated (50.2%, of whom 64.5% were drivers), followed by victims of violence (31.2%) and nonviolent-injury victims (18.5%). Alcohol Use Disorders Identification Test (AUDIT) questions #1 (drinking frequency) and #2 (drinks/day) were used to assess the patients for current alcohol dependence (CAD). AUDIT responses roughly approximating NIAAA guidelines (high threshold: drinks > or = 4 times/week, > or = 5 drinks/day) and those indicating less drinking (low threshold: drinks > or = 2-3 times/ week, > or = 3 drinks/day) were chosen. Comparisons were made relative to sensitivity and specificity of responses in detecting CAD. When low threshold responses were used for either question, sensitivity to detect CAD increased overall (#1 from 0.53 to 0.80, #2 from 0.62 to 0.88) as well as among the subgroups of patients, whereas specificity remained high or at acceptable levels overall (#1 from 0.95 to 0.82, #2 from 0.92 to 0.71) and among the subgroups of patients. Study findings suggest that, among injured drivers and other groups of trauma center patients, lesser amounts of drinking should be used as screening criteria for CAD than are used for the general population.

Lower limb response and injury in frontal crashes

This article examines two observational and two experimental data sets that emphasize lower limb injuries in passenger car crashes. Statistics show that 60% of moderate-to-severe below-knee injuries sustained by front seat occupants in head-on crashes occur with > 3 cm of footwell intrusion. Moreover, crash tests and computer simulations of car-to-car frontal offset collisions show no causal relationship between the magnitude of footwell intrusion and the axial load measured in the dummy leg. This article correlates below-knee injuries with several factors that influence their frequency and severity, such as the vehicle change in velocity, the magnitude of footwell intrusion, the rate and timing of the intrusion and the size of the vehicle. The vehicle change in velocity and the intrusion rate and timing had the greatest influence on the risk of lower limb injury, while the other factors had much less of an effect.

The accuracy of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test in screening trauma center patients for alcoholism

OBJECTIVE

To evaluate the accuracy of questionnaire screening instruments to identify lifetime alcohol dependence among trauma center patients.

METHODS

The study was conducted at a Level I trauma center between September 1994 and November 1996. Patients meeting eligibility requirements (> or = 18 years old, admission from injury scene, > or = 2 days of hospitalization, intact cognition) were evaluated for alcohol abuse and dependence. Screening instruments consisted of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test. Screening results were compared with lifetime alcohol dependence diagnoses made using the in-depth Psychoactive Substance Use Disorders section of the Structured Clinical Interview. Accuracy was quantified as sensitivity, specificity, positive/negative predictive values, and receiver operating characteristic curves (used to calculate area under the curve).

RESULTS

Of the 1,118 patients studied, lifetime alcohol dependence was diagnosed by Structured Clinical Interview in 397 (35.5%), and abuse was diagnosed in 90 (8.1%) others. The CAGE was the best predictor of lifetime alcohol dependence, i.e., had the largest area under the curve (93%) and the highest sensitivity (84%), specificity (90%), positive predictive value (82%), and negative predictive value (91%). Among patients testing positive for alcohol, 63% had a lifetime alcohol dependence diagnosis.

CONCLUSION

The CAGE is an efficient screening test to detect alcohol dependence in trauma center populations. It should be used in combination with alcohol testing to identify patients at risk of alcohol use problems.

Alcoholism at the time of injury among trauma center patients: vehicular crash victims compared with other patients

A structured in-depth interview employing standardized criteria was used to determine the prevalence of lifetime and current alcohol dependence (alcoholism) in unselected consecutive patients admitted to a regional Level I trauma center. Of 629 patients, 157 (25.0%) were current alcoholics at the time of injury. An additional 87 (13.8%) were diagnosed as lifetime non-current alcoholics. There was no significant difference in the rates of current alcohol dependence among patients injured in vehicular crashes (23.5%), other unintentional trauma victims (29.3%), and those injured as a result of violence (24.6%). Of BAC+ (blood alcohol concentration positive) patients, 54.5% were current alcoholics. However, 14.4% of alcohol-negative patients were also diagnosed as alcohol dependent.

Psychoactive substance use disorders among seriously injured trauma center patients

OBJECTIVE

To assess the prevalence of psychoactive substance use disorders (PSUDs) among a large, unselected group of seriously injured trauma center patients, using a standardized diagnostic interview and criteria.

DESIGN

Prevalence study.

SETTING

A level I regional trauma center.

PATIENTS

Trauma center patients fulfilling the following criteria were eligible subjects: aged 18 years or older, admission from injury scene, length of stay of 2 days or longer, and intact cognition.

OUTCOME MEASURES

The PSUDs were diagnosed using the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) and were categorized as abuse or dependence and past or current (within past 6 months). The SCID results were analyzed with respect to demographic factors, injury type, and blood alcohol concentration and urine toxicology results, using chi2 and logistic regression techniques.

RESULTS

Of the 1220 patients approached for study, 1118 (91.6%) consented. More than half (54.2%) had a diagnosis of a PSUD in their lifetime. Approximately 90% of alcohol and other drug use diagnoses were for dependence and more than 62% were current. Overall, 24.1% of patients were currently alcohol dependent (men, 27.7%; women, 14.7%; P<.001), and 17.7% were currently dependent on other drugs (men, 20.2%; women, 11.2%; P<.001). Current alcohol dependence rates were not associated with race; rates of dependence on other drugs were higher among nonwhites and victims classified with intentional injuries. While 54.3% of blood alcohol-positive patients were currently alcohol dependent and 38.7% of patients with positive urine screening test results for drugs other than alcohol and nicotine were currently drug dependent, 11.7% of blood alcohol-negative and 3.9% of drug-negative patients, respectively, had current diagnoses of dependence on psychoactive substances.

CONCLUSIONS

A high percentage of seriously injured trauma center patients are at risk of having current PSUDs. Patients with positive toxicology screening test results and/or positive screening questionnaire responses should be referred for formal evaluation and treatment.

Predictive model to identify trauma patients with blood alcohol concentrations > or = 50 mg/dl

OBJECTIVE

To develop a simple model for identification of trauma patients who are likely to have a blood alcohol concentration > or = 50 mg/dL (BAC + 50).

METHODS

Demographic, clinical, and BAC data were collected from the clinical trauma registry and toxicology data base at a Level I trauma center. Logistic regression was used to analyze data from 11,206 patients to develop a predictive model, which was validated using a subsequent cohort of 3,523 patients.

RESULTS

In the model development cohort, alcohol was detected in the blood of 3,180 BAC-tested patients (28.7%), of whom 91.2% had a BAC + 50 status. Preliminary analysis revealed associations between a BAC + 50 status and sex, age, race, injury type (intentional vs. unintentional), and time of injury (night vs. day and weekend vs. weekday). A predictive model using four attributes (sex and injury type) identified patients at low, medium, and high risk for being BAC + 50. The model was validated using the second group of patients.

CONCLUSION

Injured patients with a high probability of being alcohol positive can be identified using a simple scoring system based on readily available demographic and clinical information.

Airbag protection versus compartment intrusion effect determines the pattern of injuries in multiple trauma motor vehicle crashes

OBJECTIVE

A prospective study of the interaction between airbag (AB) and seat-belt (Bt) protection versus vehicular compartment (VC) intrusion effects on injury patterns in motor vehicle crash (MVC) trauma patients.

METHODS

Two hundred MVC patients, nonejected drivers or front seat passengers with multiple trauma or severe lower extremity (LE) trauma admitted to two Level I trauma centers.

RESULTS

In frontal crashes, airbags (AB) more than Bt reduced Glasgow Coma Scale severity in brain injury, face fracture, shock, and the need for MVC extrication (all p < 0.05). Frontal AB also had a protective effect on LE fractures (41% vs. 66%, p < 0.01), but had no significant protective effect on pelvic fractures. When AB protection was present, it prevented brain and face fracture injuries caused by impact contacts and reduced the incidence of these injuries resulting from VC intrusions (p < 0.05). Thoracoabdominal injuries resulting from steering wheel intrusion showed AB protection against intrusions of twice the magnitude of those seen in non-AB vehicles (p < 0.05). In frontal MVCs, AB reduced LE fracture contact injuries but did not prevent LE fractures resulting from intrusions of instrument panel, toepan, or floor pedal structures. In lateral MVCs, Bt did not protect against brain, face, thorax, or pelvic injuries.

CONCLUSIONS

Safety measures beyond frontal airbags must address frontal crash LE injuries induced by steering wheel, instrument panel, and toepan passenger compartment structure intrusions. Lateral crash injuries may profit from side AB supplemental restraint protection.

A comparative analysis of alcohol in fatal and nonfatal bicycling injuries

Bicycling is the leading cause of recreational injury, resulting in more than half a million emergency department visits and about 900 deaths each year in the United States. Previous research on bicycling injury was conducted predominantly in children and focused on the effectiveness of safety helmets. Few studies have examined the role of alcohol in bicycling injuries. This study examined the magnitude of and factors related to alcohol involvement in fatal and nonfatal bicycling injuries, and tested the hypothesis that alcohol intoxication is associated with significantly increased likelihood of fatality given a serious bicycling injury. Medical examiner data on all fatally injured bicyclists aged 10 years or older from 1987 to 1994 in Maryland (fatal cases, n = 63) were compared with trauma registry data on all injured bicyclists who were treated at a regional trauma center during the same time period (nonfatal cases, n = 253) on variables related to blood alcohol concentrations (BACs), demographic characteristics, and injury circumstances. The fatal cases were more likely than the nonfatal cases to have positive BACs (30% vs. 16%, p < 0.01) and to be legally intoxicated (i.e., BACs > or = 0.10%) (22% vs. 13%, p < 0.01). For both fatal and nonfatal cases, intoxication was more prevalent among victims who were male, aged 20 to 39 years, or who were injured at nighttime (7:00 PM to 6:59 AM). Bicyclists who died at the scene were four times as likely as those who died at hospitals to be legally intoxicated (35% vs. 9%, p < 0.02). Given a serious bicycling injury, intoxication was associated with significantly increased likelihood of fatality, with an adjusted odds ratio of 2.8 (95% confidence interval, 1.3 to 6.3). This increased likelihood of fatality was probably due in part to the fact that the rate of helmet use at the time of injury among the intoxicated was much lower than among the sober (6% vs. 31%, p < 0.05). Results indicate that alcohol plays an important role in fatal and serious bicycling injuries. Preventing intoxicated biking should be incorporated into helmet campaigns and other bicycle safety programs.

Alcohol use among injured sets of drivers and passengers

Crash report and blood alcohol concentration (BAC) data were linked for 109 injured driver/passenger pairs admitted to a Level I trauma center. Among those occupants, 47 drivers (43%) (mean BAC, 147 mg/dl) and 45 passengers (41%) (mean BAC, 127 mg/dl) were BAC+. No occupant was BAC+ in 57 crashes (52%); both were BAC+ in 40 (37%); and only one was BAC+ in 12 (11%). When both occupants were BAC+, the driver had the higher BAC in 68% of cases, and when one was BAC+, it was the driver 58% of the time. In 6 additional alcohol-related crashes with one driver and two passengers, the "wrong" occupant was driving on 5 occasions. Hence, in the 58 crashes involving BAC+ occupants, the least appropriate occupant was driving 67% of the time.

Lower extremity fractures in motor vehicle collisions: the role of driver gender and height

In a previous study it was noted that there was a higher incidence of lower-extremity fractures among women drivers. Analyses were based on a linkage between trauma registry and police crash report data. The present study addresses the issue of whether the differences noted are attributed to driver gender or are merely a reflection of differences in driver height. An inverse association was noted between driver height and the incidence of lower-extremity fractures. Those shorter than average (5'7") for this population had a 64% increase in lower-extremity fracture, which can be mainly attributed to ankle/tarsal injuries. Thus, the incidence of these injuries appears to be a function of driver height, with an increase among shorter drivers, most of whom are women.

Lower extremity injuries in drivers of airbag-equipped automobiles: clinical and crash reconstruction correlations

OBJECTIVE AND DESIGN

To determine the relationship between airbags and lower extremity injuries, 10 drivers admitted to a level-I trauma center with substantial lower extremity trauma incurred in crashes involving airbag-equipped vehicles were studied in depth with regard to their injuries, the circumstances of the crashes, and the medical charges for the acute management of those injuries.

MATERIALS AND METHODS

During the clinical investigation portion of this study, we photographed lower extremity injuries, both soft tissue and radiographs, and performed a detailed surgical exploration during the debridement of open wounds or fracture fixation to treat them appropriately and to define the mechanism of injury, the fracture pattern, the pattern of soft-tissue insult, and the extent of periosteal stripping. We recorded the hospital and professional charges associated with the acute management not only of these injuries, but of the other injuries as well. The analysis performed for each case included a detailed crash reconstruction, including force, contact point, and vehicle intrusion data. Particular attention was paid to the dashboard and toe pan areas to determine deformation and intrusion and their association with thigh, leg, and foot injuries. Pertinent deformation and trajectory information was entered into the Calspan Reconstruction of Accident Speeds on the Highway (CRASH) computer program to generate a delta V or change in velocity measurement used as a measure of collision severity. When field data were incompatible with the limitations of the CRASH program, manual calculations such as "slide to stop" and conservation of momentum formulas were used.

RESULTS

The seven male and three female drivers had a mean age of 39.4 years. Only four used seatbelt restraints. The mean delta V was 28.3 mph and the mean maximum crush was 32.4 inches. The mean Injury Severity Score of 13.2. Musculoskeletal injuries included 11 foot/ankle fractures, 6 tibial fractures, 2 patellar fractures, 6 femoral fractures, and two acetabular/pelvic fractures. Other trauma included abdominal, thoracic, head and upper torso injuries, it seems that these safety devices do not prevent injuries to the lower extremity.

Marijuana and other drug use among automobile and motorcycle drivers treated at a trauma center

Serum from injured automobile and motorcycle drivers treated at a trauma center was tested for delta-9-tetrahydrocannabinol activity to determine precrash marijuana use. From June 1990 to March 1991, samples from approximately 20 automobile drivers per month and all motorcycle drivers were available for testing. Also, toxicology screens were performed for ethyl alcohol, cocaine, and phencyclidine (PCP) among the driver groups. Six (2.7%) of the 225 automobile (AUT) drivers and 34 (32.0%) of the 106 motorcycle (MTC) drivers were THC+ (p < .001). Compared with a prior study, the THC+ rate decreased significantly from 31.8% among AUT drivers (p < .001) but had not changed significantly from the 38.6% rate among MTC drivers. Positive toxicology rates were higher among the 261 MTC drivers compared to the 1,077 AUT drivers tested for ETOH, CO, and PCP, being 47.1% vs 35.2% (p < .001), 5.0% vs 8.0% (p < .08), and 1.5% vs 3.1% (NS), respectively.