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Wheeled Vehicles and Injury Risk to Wheeled Vehicles and Injury Risk to ChildrenChildren
Michael A. Gittelman, MDAssociate Professor, Division of Emergency Medicine
Cincinnati Children’s Hospital Medical CenterCincinnati, Ohio
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2003 Emergency Department Case2003 Emergency Department Case
10 y/o female 15 mph on flat surface No helmet or seatbelt Sharp turn & vehicle
flipped Suffered traumatic
brain injury Pt died in the ICU 3
days later
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ObjectivesObjectives
Understand the magnitude of childhood injuries Discuss properties of wheeled vehicles (eg.ATVs,
dirtbikes, bicycles) making them risks for injury Learn specific risk factors for these type of injuries Discuss the public health approach to prevention As a group discuss potential interventions
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The Injury ProblemThe Injury Problem
Leading cause of death from ages 1-44 years
Results in more deaths in children than all other diseases combined
#1 cause of years of potential life lost
Costs hundreds of billions of dollars annually in US
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Restraint systems, road design
Pool fences, flotation devices
Smoke alarms, smoking cessation
???ATV/Dirtbikes
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Bicycle Injuries
Rollerblade/Scooter/ Skateboard Injuries
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Injury DefinitionsInjury Definitions “Any intentional or unintentional damage
to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen.”
Force (Mass X Speed) = Magnitude of injury Catastrophic Injury = Injuries that result in
permanent, severe neurologic disability or death
-National Committee for Injury Prevention and Control, 1989
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Motorized Recreational Motorized Recreational VehiclesVehicles
All-terrain Vehicles (ATVs)—off-road use, no license, > 40,000 injuries/yr (roughly 200 deaths/yr) – age < 15
Powered off-road cycles—use on rough terrain; no license, > 23,000 injuries/yr – age < 19– Minibikes—small, bicycle frame, lawn mower engine– Minicycles—miniature motorcycles, more horsepower– Trail bikes—larger, more powerful than minicycles
Powered Street-use Cycles— 10,000 injuries/yr (roughly 350 deaths/yr) – ages < 21– Mopeds—bicycles with small motors, may not need license– Scooters—enclosed engine, small wheels, larger engine– Motorcycles—greater speeds, license required, 20 x > risk of
death than MVC Golf cart injuries roughly 5000 injuries/yr
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ATV CharacteristicsATV Characteristics
Gasoline powered Knobby tires High center of gravity Engine displacement
50-500 cm3
Speeds > 70 MPH Mainly designed for a
single rider and off-road use
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ATV Injury RisksATV Injury Risks Children under 16 years old 5x greater risk
– 14% of ATV drivers but ~35% of injuries and deaths Most children killed (95%) are operating vehicles
rated for adults Rural white males are typical victims (Male 2x > Female) Three-wheeled vehicles—50% more likely to be injured Inexperienced drivers, Recreational use, AlcoholDeaths occur in:
Collisions (56%) (more than half with fixed object)Overturns (35%) (backward more common than
forward)Only 1% occur on ATV trails
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ATV Injury TrendsATV Injury Trends
1 Roughly 40,000 ED injuries to kids < 16 yrs of agehttp://www.atvsafety.gov/stats.html
YearReported Deaths¹
Estimated Deaths
Estimated Number of Emergency-Room Treated
Injuries
20081 410 * 135,100
2007 699 816 150,900
2006 832 907 146,600
2005 804 932 136,700
2004 753 855 136,100
2003 653 762 125,500
2002 548 606 113,900
2001 517 593 110,100
2000 450 551 92,200
1999 397 534 82,000
1998 251 287 67,800
1997 241 291 52,800
46% increase, yet some decline 2007 &
2008
49% increase ED visits
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ATV Injury PatternsATV Injury Patterns Mean age = 11.1 years Body parts injured
– 32% face/head, 13% lower ext, spinal cord, abd injuries
Types of injuries sustained
– 31% fractures, 12% lacs, 11% organ,6% ICI
14% occurred on the street (60% of deaths)
70% home/other site 72% No protective gear or helmet
Gittelman, Pediatrics 2006
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Dirtbike CharacteristicsDirtbike Characteristics
Two-wheeled, motorized vehicles (minibikes, trailbikes, dirtbikes, mopeds, etc.) used for recreation and transportation.
Many are illegally operated at excessive speeds, by minors, on public roads.
US Consumer Product Safety Commission estimated 40,000 ED visits nationwide due to two-wheeled off-road vehicles (26% to children < 15 years old)– Mean age of pediatric moped
injuries is < 13 years.
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Off –Road vs Street Cycle RisksOff –Road vs Street Cycle Risks
Illegal use on roadways Poor design
– Small tires– Short wheelbase– Slow acceleration– Inadequate brakes
No helmet Young age,
inexperienced driver Males Alcohol
> 1 rider Design issues
– Lack of stability and protection in a crash
– Insufficient acceleration, smaller engines
No helmet < 20 y.o/Inexperienced
driver High traffic roads Males Alcohol
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Motorized Two-wheeled Motorized Two-wheeled Injury PatternsInjury Patterns
Body parts injured– 37% lower ext, 28% face/head– 3x risk of serious head injuries in
non-helmet wearers; cause most deaths
Types of injuries sustained– 54% fractures, 14% lacs, 6% ICI
40% occurred on the street 93% for recreational purposes > ½ of deaths are instantaneous Protective gear
– 59% no helmet, 97% no protective gear
Pomerantz, Pediatrics 2005
0
5
10
15
20
25
30
35
40
45
0-4years
5-8years
9-12years
13-16years
> 16years
Mean age = 12 years
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Non-motorized Wheeled Non-motorized Wheeled VehiclesVehicles
Bicycles – 275,000 injuries/yr (roughly 140 deaths/yr)
Scooters - 40,000 injuries/yr Rollerblades/skates – 38,000 injuries/yr Skateboarding - 61,000 injuries/yr Annual injuries by product
– 70% Bikes
– 14% Rollerblades/Skates
– 16% Skateboards
Estimates of nonfatal injuries for children < 14 yrs of age
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Small Wheeled Vehicle Small Wheeled Vehicle Risk FactorsRisk Factors
Males > Females– Scooters, rollerblades and skateboards
– Females for roller skates Children < 15 y.o. Speed, risk-taking behaviors and loss of balance Usually occur first 2 weeks of obtaining product Obstacles and hard impact surfaces Lack of protective gear
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Small Wheeled Vehicle Small Wheeled Vehicle Injury PatternsInjury Patterns
Body part injured– Wrist is most common– Lower extremity (knee, ankle) injuries– 5% head injuries
Types of injuries– 30%-40% fractures for scooters, in-line and
roller skates, 21% for skateboards– Traumatic brain injury
<2% require hospitalization
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BicyclesBicycles Responsible for more childhood injuries than any other consumer
product except the automobile. More than 70% of all children ages 5-14 years ride bikes. Head injury is the leading cause of death in bicycle crashes
– Non-helmeted riders are 14 times more likely to be involved in a fatal crash
– 98% of the bicyclists killed reportedly do not wear helmets.
Bicycle helmets reduce the risk of head injury by 88% – National estimates report that bicycle helmet use among child
bicyclists ranges from 15 percent to 25 percent. – Universal use of bicycle helmets could annually prevent
135 - 155 deaths 39,000 - 45,000 head injuries Lifetime medical cost totalling between $134 and $174
million.
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Bicycle Injury Risk FactorsBicycle Injury Risk Factors
Children 5-14 y.o.MalesRiding environment
– Traffic– Nighttime– Road Surface
Riding ExperienceEquipment
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Bicycle Injury PatternsBicycle Injury PatternsHead/CNS injuries-most common cause of
fatal debilitating injury– Helmets are 88% effective in preventing TBI
Handlebar injuriesMost other injuries-minor and self-limited
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ATVs vs. Bicycles,Cars, & ATVs vs. Bicycles,Cars, & MotorcyclesMotorcycles
ATV injury severity significantly higher than bicycle injury for children
ATV injury severity scores comparable to MVC
More frequent head trauma (50%) among patients who sustained ATV rather than motorcycle injuries (30%)
Brown, J Pediatric Surgery 2001
Acosta and Rodriguez, J of EM 2007
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Public Health Approach to Public Health Approach to PreventionPrevention
Define the problem Identify causes or
risk factors Develop or test
interventions Implement
intervention and measure prevention effectiveness
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Haddon Matrix for ATV InjuryHaddon Matrix for ATV Injury
Host/Human
Agent Physical Environment
Socio-economic
Environment
Pre-event
Driver experience, size, maturity
Vehicle size, HP, safety features, stability
Weather,Site of use, obstacles
Training, Legislation (helmets, etc)
Event Helmet use, other protective gear
EMS systems
Post-event
Healthcaretraining
Road/trail accessibility
Insurance,Health Care,Rehab
Trail designVehicle size, speed
INITIAL CAMPAIGN AREAS
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SummarySummary
Pick high risk/catastrophic injuriesTarget a particular at risk groupIntervention E’s
– Education– Environment– Enforcement/Legislation– Engineering
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Addendum SlidesAddendum Slides
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ATVATV
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ATV EducationATV Education Industry-sponsored programs
(SVIA)– <10% of new purchasers comply– Large secondary market with limited
access– No formal evaluation published
National 4H program– Consultant evaluation demonstrated
increased helmet use and safety gear– Less effective with use on or along
roads4-H Community Safety Program, Changing Behaviors, Saving Lives, 2004
Other programs—hospitals, research
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Key questions: EducationKey questions: Education What is the message—no ATV use or safer ATV use? What is the most important target audience—parents,
adolescents? Dose of exposure needed to cause change in behavior? Does training really work? Can objective markers of physical readiness and/or maturity
predict ATV risk? How effective is secondary prevention—can brief
interventions work to motivate parents/youth after an ATV crash?
Should we adopt a Graduated Driver’s Licensing approach to ATV safety?
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ATV Enforcement/LegislationATV Enforcement/Legislation
American Academy of PediatricsConsumer Product Safety CommissionOther Federal AgenciesState level policies
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Professional Society PolicyProfessional Society Policy American Academy of Pediatrics:
– Education: motorcycle helmets; eye protection; and protective reflective clothing
– Engineering: seat belts; roll bars; headlights; and speed governors
– Legislation: helmet use; banning 3 wheelers;requirements for licensing/certification;
minimum driver age 16 years; prohibition of alcohol, passengers, and ATV use at night
Pediatrics, 105: 1352-54, June 2000
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Federal ATV PolicyFederal ATV Policy 1983-86: 300% increase in ATV-related ED visits 1988-98: Consumer Product Safety Commission
– Banned three-wheeled ATV’s
– 10 year consent decreewarning labels, minimum age recommendations increased voluntary safety standards, nationwide training
program 2002-04: Petition to CPSC to ban ATV sales to youth under
16 years 2006: Senate hearings on new rules for manufacturing
standards and youth ATVs
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Changing Rules at CPSC? Changing Rules at CPSC?
Previous standards:– 50 cc: ages 12 and under– 90 cc: ages 12-16– > 90 cc: ages 16 and older
Proposed new standards:– Speed rather than size determines vehicles
considered “youth models”– More rigid manufacturing standards– Restricts some offshore imports
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Do laws work for ATVs?Do laws work for ATVs?
Study compared states with – No laws
– Laws governing equipment only
– Laws governing driver behavior States with no laws had injury rates twice as high as
those with laws
Several studies indicating a trend toward increased helmet use in jurisdictions with helmet laws
Source: Helmkamp, AJPH, 2001
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State-level LegislationState-level Legislation
44 states have at least minimal ATV legislation‐ Typical legislation includes parental
supervision for young children, licensing/registration requirements, and bans on riding ATVs on public roads
‐ States without these laws have significantly higher death rates
AJPH, 91: 1792-1795, November 2001
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Acceptability of LegislationAcceptability of Legislation Recent wave of laws nationally indicates support
Recent survey of Ohio voters:– 90% supported legislation in general terms
– 78% supported helmet requirement Among ATV riders, helmet use would double if law passed
– 81% of voters supported passenger restriction and restriction for children <16
– 77% supported training requirements
Source: Center for Injury Research and Policy, Columbus, OH, 2007
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EnforcementEnforcement
Poor enforcement of existing policies is a major downfall
Even in areas with motivated enforcement, laws may not apply on private property
Substantial local variability in support for legislation, including ATV use on paved surfaces
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Key questions: EnactmentKey questions: Enactment
Do existing policies work to decrease injuries? What combination of policies is required to achieve
effective prevention? How can we improve enforcement? Are other avenues for policy (insurance, liability)
potentially more effective than legislation?
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ATV EngineeringATV Engineering
Little is known (outside the ATV manufacturing industry) about the real-life performance characteristics of ATVs
Less is known about vehicle performance with children on board
Little is known about the performance characteristics of protective gear – Helmet effectiveness—reduction of 42% for mortality; 62%
reduction in any head injury - Rodgers, Accident Anal Prev,1990
– Yet no significant difference in mean ISS between helmeted and non-helmeted riders. Helmet usage was not associated with a reduction in head/facial injuries. –Gittelman, Pediatrics, 2006
Engineering research from objective sources is lacking
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ATV Stability Project ATV Stability Project
45% of ATV crashes result from the machine tipping over– 43% lateral (side to side)
– 57% longitudinal (front to back) Objective: Determine if tipping increases with
– engine size
– weight of person
– number of passengers
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ATV testingATV testing
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ResultsResultsFront to Rear Comparison
0
100
200
300
400
500
600
0 10 20 30 40 50 60 70
Rotational Degree of Platform
We
igh
t/L
ift
UTV 4
UTV 3
ATV 2
ATV 1
UTV 5
301.4 lbs
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The Oregonian, May 18, 2007
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Key questions: EngineeringKey questions: Engineering Can vehicles be modified to make them safe(r) for
children? – If so, how: Speed regulators, stability control, roll
bar/seat belts? Which is more important in safety: speed control or
size of vehicle?– Will such vehicles be produced?– If produced, will they appeal to consumers?
Can helmets be improved (more appealing, lighter, cooler) and retain effectiveness?
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Small Wheeled Vehicle Small Wheeled Vehicle InterventionsInterventions
Protective gear– Helmets– Wrist guards (except for scooters)– Knee and elbow pads
Proper equipment maintenanceAnticipatory guidance and educationNo skateboards for kids < 10 y.o ; no
scooters for kids < 8 y.o.
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Bicycle-Related Bicycle-Related InterventionsInterventions
Bicycle helmetsEducation of parents and childrenProper bicycle size and
maintenanceEnvironmental modifications
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Bike Helmet Legislation vs Bike Helmet Legislation vs EducationEducation
Dannenberg, Gielen – 1993 Am J Public H– 8 to 13% and 7 to 11% where education
involved only– 11-37% with education and law
Cochrane database 2008– 2 studies significant reduction in head injury
after legislation
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Non-legislative Efforts to Promote Non-legislative Efforts to Promote Helmet UseHelmet Use
Royal – Inj Prev 2007– Best effect with community based programs
and those providing free helmets compared to in school or subsidized helmets
– Education did not increase ownership of helmets
Increase bike helmet use when parent uses helmet
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Injury Control Strategies Injury Control Strategies Human
– Education/Empowerment Industry-sponsored programs 4 H Program Hospital, schools, etc.
Agent– Engineering/Technology
Tipping, seatbelts, rollbars, engine size
Environmental modifications– Enforcement/Legislation
AAP Policy, CPSC, State Govt
– Safe places to ride
Collaborative effort
Multidisciplinary
A variety of settings
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SummarySummary
Significant injuries occur to children as a result of ATVs and Dirtbikes
ATV/Dirtbike injury prevention challenges many accepted paradigms of injury control– May be some successes as deaths have declined
Many questions exist about effective prevention strategies Successful ATV injury prevention will require:
– Collaboration across all stakeholders– Rigorous application of behavioral, public health, and
engineering sciences – New and creative approaches– Long term perspective
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Questions?Questions?