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Wheeled Vehicles and Injury Risk to Children

Wheeled Vehicles and Injury Risk to Children. Michael A. Gittelman, MD Associate Professor, Division of Emergency Medicine Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio. 2003 Emergency Department Case. 10 y/o female 15 mph on flat surface No helmet or seatbelt

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Wheeled Vehicles and Injury Risk to Children

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  1. Wheeled Vehicles and Injury Risk to Children Michael A. Gittelman, MD Associate Professor, Division of Emergency Medicine Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Injury Free Coalition for Kids

  2. 2003 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 Injury Free Coalition for Kids

  3. Objectives • 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 Injury Free Coalition for Kids

  4. The 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 Injury Free Coalition for Kids

  5. Pool fences, flotation devices Restraint systems, road design Smoke alarms, smoking cessation ??? ATV/Dirtbikes Injury Free Coalition for Kids

  6. Bicycle Injuries Rollerblade/Scooter/ Skateboard Injuries Injury Free Coalition for Kids

  7. Injury 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 Injury Free Coalition for Kids

  8. Motorized Recreational Vehicles • 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 Injury Free Coalition for Kids

  9. ATV 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 Injury Free Coalition for Kids

  10. ATV 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, Alcohol Deaths occur in: Collisions (56%) (more than half with fixed object) Overturns (35%) (backward more common than forward) Only 1% occur on ATV trails Injury Free Coalition for Kids

  11. ATV Injury Trends 46% increase, yet some decline 2007 & 2008 49% increase ED visits 1 Roughly 40,000 ED injuries to kids < 16 yrs of age http://www.atvsafety.gov/stats.html Injury Free Coalition for Kids

  12. ATV 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 Injury Free Coalition for Kids

  13. Dirtbike 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. Injury Free Coalition for Kids

  14. 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 Off –Road vs Street Cycle Risks Street Use Off-Road Injury Free Coalition for Kids

  15. Motorized Two-wheeled Injury Patterns Mean age = 12 years • 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 Injury Free Coalition for Kids

  16. Non-motorized Wheeled Vehicles • 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 Injury Free Coalition for Kids

  17. Small Wheeled Vehicle Risk 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 Injury Free Coalition for Kids

  18. Small Wheeled Vehicle Injury 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 Injury Free Coalition for Kids

  19. Bicycles • 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. Injury Free Coalition for Kids

  20. Bicycle Injury Risk Factors • Children 5-14 y.o. • Males • Riding environment • Traffic • Nighttime • Road Surface • Riding Experience • Equipment Injury Free Coalition for Kids

  21. Bicycle Injury Patterns • Head/CNS injuries-most common cause of fatal debilitating injury • Helmets are 88% effective in preventing TBI • Handlebar injuries • Most other injuries-minor and self-limited Injury Free Coalition for Kids

  22. ATVs vs. Bicycles,Cars, & Motorcycles • 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 Injury Free Coalition for Kids

  23. Public Health Approach to Prevention • Define the problem • Identify causes or risk factors • Develop or test interventions • Implement intervention and measure prevention effectiveness Injury Free Coalition for Kids

  24. Haddon 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 Healthcare training Road/trail accessibility Insurance, Health Care, Rehab Vehicle size, speed Trail design INITIAL CAMPAIGN AREAS Injury Free Coalition for Kids

  25. Summary • Pick high risk/catastrophic injuries • Target a particular at risk group • Intervention E’s • Education • Environment • Enforcement/Legislation • Engineering Injury Free Coalition for Kids

  26. Addendum Slides Injury Free Coalition for Kids

  27. ATV Injury Free Coalition for Kids

  28. ATV 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 roads 4-H Community Safety Program, Changing Behaviors, Saving Lives, 2004 Other programs—hospitals, research Injury Free Coalition for Kids

  29. Key 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? Injury Free Coalition for Kids

  30. ATV Enforcement/Legislation American Academy of Pediatrics Consumer Product Safety Commission Other Federal Agencies State level policies Injury Free Coalition for Kids

  31. Professional 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 Injury Free Coalition for Kids

  32. Federal 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 decree warning 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 Injury Free Coalition for Kids

  33. 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 Injury Free Coalition for Kids

  34. 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 Injury Free Coalition for Kids

  35. State-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 Injury Free Coalition for Kids

  36. Acceptability 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 Injury Free Coalition for Kids

  37. Enforcement 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 Injury Free Coalition for Kids

  38. Key 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? Injury Free Coalition for Kids

  39. ATV 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 Injury Free Coalition for Kids

  40. 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 Injury Free Coalition for Kids

  41. ATV testing Injury Free Coalition for Kids

  42. Results 301.4 lbs Injury Free Coalition for Kids

  43. Injury Free Coalition for Kids The Oregonian, May 18, 2007

  44. Key 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? Injury Free Coalition for Kids

  45. Small Wheeled Vehicle Interventions • Protective gear • Helmets • Wrist guards (except for scooters) • Knee and elbow pads • Proper equipment maintenance • Anticipatory guidance and education • No skateboards for kids < 10 y.o ; no scooters for kids < 8 y.o. Injury Free Coalition for Kids

  46. Bicycle-Related Interventions • Bicycle helmets • Education of parents and children • Proper bicycle size and maintenance • Environmental modifications Injury Free Coalition for Kids

  47. Bike Helmet Legislation vs Education • 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 Injury Free Coalition for Kids

  48. Non-legislative Efforts to Promote Helmet 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 Injury Free Coalition for Kids

  49. 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 Injury Free Coalition for Kids Collaborative effort Multidisciplinary A variety of settings

  50. Summary 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 SuccessfulATV injury prevention will require: Collaboration across all stakeholders Rigorous application of behavioral, public health, and engineering sciences New and creative approaches Long term perspective Injury Free Coalition for Kids

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