The motorcycle accident patient: ED considerations + management / Pearls & Pitfalls

Author: Laryssa Patti, MD (Instructor, Department of Emergency Medicine, Rutgers Robert Wood Johnson Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician at SAUSHEC)

A 26-year-old male is brought to the emergency department after a being involved in a motorcycle collision. The patient was wearing a partial face helmet and was ejected approximately 30 feet. Upon presentation, the patient is awake, alert, and oriented, with abrasions over his exposed skin. What do you do next? 

Why do we care about motorcycle injuries?

In 2014, according to the National Highway Traffic Safety Administration, the number of deaths on motorcycles was over 27 times the numbers of cars. Over a decade’s worth retrospective data from Alberta, Canada, showed that motorcyclists are 3.5 times more likely to get injured or die in comparison to other drivers. According to 2014 from the U.S. Department of Transportation, the majority of motorcycle injuries and fatalities occur between the hours of 3pm and midnight, sometimes the busiest times in our emergency departments (“III: Motorcycle Crashes”, Aug 2016).

Why are motorcycles prone to crashing?

1. They drive differently than cars

Not all motorcycles have antilock brakes. Braking a motorcycle is different than braking a car in that there are separate brakes for each wheel, and braking hard can lock the brakes, causing the motorcycle to roll over. Additionally, there rarely are airbags on motorcycles. The first motorcycle with airbags became available only in 2006 (“III: Motorcycle Crashes”, Aug 2016).

2. Motorcycle passengers are at a higher risk

In a retrospective study from a trauma center in Singapore, passengers of motorcycles were more likely to have fatal injuries than the drivers after a crash (Leong et al., 2009). Fitzharris et al. (2009) found that pillion riders (i.e., those riding behind the motorcycle driver) were more likely to sustain lower extremity crush injuries.

3. Motorcycles don’t have to drive on the road

A 2010 Australian study showed that even as on-road motorcycle accidents were decreasing, the overall number of motorcycle crash fatalities were increasing, likely due to off road accidents (Mikokca-Walus et al., 2010). Some of these off road accidents may occur because riders are frequently younger and unlicensed and are driving off-road because they are not legally permitted to operate motorcycles on roads (Pym et al., 2013).

4. Riders aren’t restrained by the vehicle

It goes without saying that motorcycles don’t have seatbelts (and this is probably for the best), but the vehicle does also not contain a motorcycle driver after a collision, allowing for ejection of the driver. In a Chinese study, injury severity correlated with ejection velocity of motorcycle drivers (Chen et al., 2010). This compounds the number of injuries that a motorcycle driver can possibly sustain – for example, blunt trauma from a high fall if the rider is ejected; blunt trauma from a collision with a stationary object; and skidding across the ground.

5. Motorcycles are missed by other vehicles

Motorcyclists are often taught to “slice and dice” (moving to leftmost lane of a multi-lane road in order to minimize hazards on their left side) and “split” lanes of traffic (moving between cars to avoid hazards), these practices can decrease visibility for drivers in cars (“How to ride in heavy traffic”). Additionally, motorcyclists may travel in groups, and slower riders can get separated, allowing them to be missed (“Group riding: safety in numbers”).

Motorcycle personal protective equipment (PPE) is not the same as in cars

1. PPE is not required, but serious bikers will use it

The U.S. Armed Forces require motorcycle drivers to wear helmets, eye protection, above the ankle footwear, long sleeved shirts or jackets, pants that meet the top of the riding boot, full fingered riding gloves made from abrasion-resistant material, ideally in reflective or high visibility colors and materials (“Motorcycle PPE”). If a driver is not required to wear this gear by the military, there are very few requirements on PPE.

Many motorcycle interest groups and insurance forums recommend that motorcyclists wear protective gear, including specialized foam padded gear called “armor.” These jackets, pants, and gloves are covered in shred resident fabric to protect the rider should they skid on the ground. Additionally, specialized waterproof gear is recommended for inclement conditions, as motorcyclists are continually exposed to the elements. These garments are often thick and may be difficult to remove. Additionally, during short trips or hot weather, some cyclists often forgo this protective equipment, leading to increased rates of injury (“The 5 pieces of gear”, “Motorcycle safety gear”, “Personal protective gear”, de Rome et al., 2006).

2. A comment on helmets in particular

In the 1960s and 1970s, mandatory helmet laws were required in order for states to receive federal highway and transportation funding, but by 1976, this requirement was repealed. Now, only19 states and the District of Columbia have universal helmet laws, requiring a motorcyclist to use a helmet at all times, and three states (Iowa, Illinois, and New Hampshire) have no helmet requirement (“Motorcycle helmet use”).

In 1997, after Arkansas repealed its mandatory motorcycle helmet law, epidemiologic studies showed an increase in fatalities in unhelmeted motorcycle accidents, longer ICU stays, and increased hospital financial burden (Bledsoe et al. 2002) and an increase in the number of alcohol related unhelmeted motorcycle fatalities (Bledsoe and Li, 2005).

A similar epidemiological study found that states with universal helmet laws, in comparison to those with laws only requiring helmets for riders under age 21, had decreased rates of traumatic brain injuries (TBI), less TBI associated disability, and lower rates of in-hospital death (Weiss et al., 2010). Several retrospective studies have shown that unhelmeted motorcycle drivers are more likely to sustain facial injuries (Crompton et al. 2012 and Christian et al. 2014). Motorcyclists wearing open face helmets were twice as likely to sustain injuries requiring operative intervention in comparison to those wearing full-face helmets in a retrospective Brazilian study (Cini et al., 2014). In a 2008 Cochrane review of 61 observational studies, motorcycle helmet use was associated with a reduction of risk of death by 42% and head injury by 69% in motorcycle accidents (Liu BC et al., 2008).

Where do motorcyclists get injured?

For motorcyclists in Maryland, the most common cause of accidents was a collision with another vehicle or fixed object (e.g., parked car, curb, guardrail, tree) (Dischinger et al., 2006).  Head and neck trauma is most common cause of fatal injury, followed by thoracic cage trauma (Ankarath et al., 2002), however, injuries to the extremities are more common (Doyle et al., 1995).

What’s road rash?

Road rash is a medical colloquialism for the wounds that result when a rider’s unprotected skin scrapes along a surface, usually asphalt, cement, or the ground. These wounds can manifest as abrasions, avulsions, or lacerations and are classified, like burns, by the depth of skin involvement. Although superficial injuries may only require good wound care including topical antibiotic ointment and pain control, deeper wounds may require excision and/or grafting, especially if abrasions cross joints. Additionally, asphalt particles may embed within the dermis and become re-epithelialized, causing skin tattooing (Fantus and Rivera, 2015).

What about high-risk groups?

Older riders present a particular risk during an accident. In 2014, riders over 40 accounted for over half of motorcyclist fatalities.  Older riders had a higher rate of upper trunk injuries and fractures, as well as internal organ injuries and brain injuries. This may be secondary to changes in bone strength, fat distribution, and chest wall elasticity with age, as well as a higher rate of co-morbid conditions (Jackson and Mello, 2013).  Motorcyclists operating large engine motorcycles (greater than 1L) were more likely to roll over, and had increased risk of head injury. Younger drivers (under age 40) were less likely to wear helmets and more likely to have head injuries. Riders over 40 were found to have significantly higher incidence of thoracic injuries and more likely to have multiple rib fractures (Dischinger et al., 2006).  Additionally, obese riders are also at risk for different injuries. In a four year review of the Trauma Registry System, riders with a body mass index (BMI) over 30 had an increased risk of humeral, pelvic, and rib fractures, and lower rates of maxillary and clavicle fractures (Liu et al., 2016).

Multiple studies have shown that intoxicated drivers have an increased risk of injury. In a retrospective study in Taiwan, where motorcycles are not allowed on highways, and most accidents occur in urban areas, intoxicated motorcyclists were more likely to not be wearing helmets but tended to have less severe injuries than sober motorcyclists. Authors attributed this difference to inattention being the most common cause of accident in intoxicated motorcyclists in comparison to sober motorcyclists.  However, unhelmeted intoxicated motorcyclists had a higher rate of severe head injury (e.g., cranial fracture, intracranial hemorrhage, cerebral contusion) (Liu et al., 2015). A review of the National Trauma Database found that alcohol and tobacco use were associated with decrease in helmet use (Lastfogel et al., 2016).

What else should I know about motorcyclists?

1. Outlaw motorcycle gangs (OMGs) are a real thing in the U.S.

These criminally involved gangs take the name “one-percenter” motorcycle clubs, after a representative from the American Motorcycle Association stated that “there are 1% who are not [law-abiding]” after a motorcycle rally in Hollister, California, turned violent in 1947. There are multiple different types of these clubs, ranging from large clubs like Hells Angels and the Pagans, to less criminally active support clubs, like the Gray Ghosts. Gangs can be involved in alliances and feuds with other gangs in the area.

Patches and tattoos can give indication as to a gang member’s history. Jackets, referred to as “colors” made of leather or denim, will frequently have patches that show their wearer’s gang, chapter, and affiliates. Bikers have reacted hostilely when colors are damaged or treated without respect. Frequently, bikers have weapons on them; these may not be limited to guns and knives. For example, Hells Angels are known to carry hammers.

In addition, many of these gangs may be prone to respond aggressively to interpersonal violence between different OMGs. Although patients may be unwilling to go into detail about how injuries were sustained, it is important to ascertain whether the OMG member was injured in an altercation, involved in a motor vehicle collision with another member of an OMG, or involved in single person motor vehicle collision, in order to prevent violence with the emergency department (Bosmia et al., 2014 and Quinn and Forsyth, 2011).

2. But most motorcyclists aren’t in gangs

According to a Media Audit survey, the majority of motorcycle owners are married, an average age of 41 years, and make higher than the average annual income (“Motorcycle Culture”).

Takeaways

1. Motorcyclists are at high risk of injury because riding a motorcycle is inherently riskier than a car.
2. Helmets decrease injuries.
3. Older riders are more likely to have more severe thoracic injury.
4. Be aware of the OMGs in your area, but don’t think that every motorcyclist is in one.

In the words of Hunter S. Thompson (which is likely applicable to most EM physicians):

“Life should not be a journey to the grave with the intention of arriving safely in a pretty and well preserved body, but rather to skid in broadside, in a cloud of smoke, thoroughly used up, totally worn out, and loudly proclaiming, ‘Wow! What a Ride!’”

References / Further Reading

1. Bledsoe GH and Li G. Trends in Arkansas motorcycle trauma after helmet law repeal. Southern Medical Journal 2005; 98(4):436-440.
2. Bledsoe GH, Schexnayder SM, Carey MJ, et al. The negative impact of the repeal of the Arkansas motorcycle helmet law. J Trauma. 2002 Dec;53(6):1078-86
3. Bosmia AN, Quinn JF, Peterson TB, et al. Outlaw Motorcycle Gang: Aspects of the One-Percenter Culture for Emergency Department Personnel to Consider. Western J Emerg Med. 2014;15(4):523-528.
4. Chen H-B, Hang J-J, Zhang B, et al. Establishment of the model of motorcyclist ejection injury. Chinese Journal of Traumatology 2010; 13(2):67-71
5. Christian JM, Thomas RF, and Scarbecz M. The incidence and pattern of maxillofacial injuries in helmeted versus non helmeted motorcycle accident patients. J Oral Maxillofac Surg 2014, 72:2503-2506.
6. Cini MA, Prado BG, et al. Influence of type of helmet on facial trauma in motorcycle accidents. British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792.
7. Crompton JG, Oyetunji TA, Pollack KM et al. Association between helmets and facial injury after a motorcycle collision. Arch Surg. 2012;147(7):674-676.
8. de Rome L Brandon T. (2007), A Survey of Motorcyclists in NSW, 2006: A report to the Motorcycle Council of NSW,Produced by LdeR Consulting for the Motorcycle Council of NSW, Inc., 15 Huddleston Street, Colyton
9. Doyle D, Muir M, Chinn B. Motorcycle accidents in Strathclyde region, Scotland during 1992: a study of the injuries sustained. Health Bull. (Edinburgh), 53 (6) (1995), pp. 386–394.
10. Fantus RJ and Rivera EA. Hit the road, jacked – road rash injures. Bulletin of the American College of Surgeons, 2015 June, 100(6):49-50
11. Dischinger PC, Ryb GE, Ho SM, Braver ER. Injury Patterns and Severity Among Hospitalized Motorcyclists: A Comparison of Younger and Older Riders. Annual Proceedings: Association for the Advancement of Automotive Medicine (2006); 50:237-249.
12. Fitzharris M, Dandona R, Kumar GA, Dandona L. Crash characteristics and patterns of injury among hospitalized motorised two-wheeled vehicle users in urban India. BMC Public Health 2009;9:11.
13. “Group Riding: Safety in Numbers.” Motorcycle Safety. DMV.org. Web. “How to ride in heavy traffic.” Motorcycle Safety. DMV.org. Web. http://www.dmv.org/how-to-guides/motorcycle-traffic.php 22 Aug 2016.
14. “How to ride in heavy traffic.” Motorcycle Safety. DMV.org. Web. http://www.dmv.org/how-to-guides/motorcycle-traffic.php 22 Aug 2016.
15. Jackson TL and Mello MJ. Injury patterns and severity among motorcyclists treated in US emergency departments, 2001-2008: a comparison of younger and older riders. Inj Prev 2013;19:297-302 doi:10.1136/injuryprev-2012-040619
16. Lastfogel J, Soleimani T, et al. Helmet Use and Injury Patters in Motorcycle-Related Trauma. JAMA Surg. 2016;151(1):88-90. doi:10.1097/SLA.
17. Leong QM, Shyen KGT, et al. Young adults and riding position: factors that affect mortality among inpatient adult motorcycle casualties: a major trauma center experience. World J Surg (2009); 33:870-873
18. Liu BC, Ivers R, Norton R, Boufous S, Blows S, Lo SK. Helmets for preventing injury in motorcycle riders. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004333. DOI: 10.1002/14651858.CD004333.pub3.
19. Liu H-T, Liang C-C, Rau C-S, et al. Alcohol-related hospitalizations of adult motorcycle riders. World Journal of Emergency Surgery 2015, 10(2): 1-8.
20. Liu H-T, Rau C-S, Wu S-C, et al. Obese motorcycle riders have a different injury pattern and longer hospital length of stay than the normal-weight patients. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine 2016, 24(50):1-9.
21. Mikocka-Walus A, Gabbe B, Cameron P. Motorcycle-related major trauma: On-road versus off-road incidence and profile of cases. Emergency Medicine Australasia (2010); 22:470-476.
22. “Military motorcycle PPE comparison chart.” org, Nov 2011. Web. http://www.motorcycleppe.com/ 22 Aug 2016.
23. Monk JP, Buckley R, Dyer D. Motorcycle-related trauma in Alberta: A sad and expensive story. Can J Surg. 2009;52(6):235-240.
24. “Motorcycle Crashes.” III. Insurance Information Institute, Aug. 2016. Web. http://www.iihs.org/iihs/topics/t/motorcycles/fatalityfacts/motorcycles. 19 Aug. 2016.

25. “Motorcycle Culture.” BScene Magazine. Sept 2012. Web. http://www.bscenemag.com/b-culture/motorcycle-culture. 22 Aug 2016.
26. “Motorcycle helmet use.” Insurance Institute for Highway Safety: Highway Loss Data Institute. Insurance Information Institute, Aug. 2016. Web. http://www.iihs.org/iihs/topics/laws/helmetuse/mapmotorcyclehelmets. 22 Aug. 2016.

27. “Motorcycle Safety Gear: Safety Trumps Style.” Allstate Insurance, Web. https://www.allstate.com/tools-and-resources/motorcycle-insurance/tips-for-buying-motorcycle-safety-gear.aspx. 22 Aug 2016.
28. National Highway Traffic Safety Administration. 2016. Traffic safety facts, 2014: motorcycles. Report no. DOT HS-812-292. Washington, DC: US Department of Transportation.
29. “Personal Protective Gear for the Motorcyclist.” Cycle Safety Information. Motorcycle Safety Foundation, https://msf-usa.org/downloads/Protective_gear_REV.pdf. 22 Aug 2016.
30. Pym AJ, Wallis BA, Franklin RC, Kimble RM. Unregulated and unsafe: the impact of motorcycle trauma on Queensland children. Journal of Paediatrics and Child Health (2013); 49:493–497.
31. Quinn JF and Forsyth FJ. The Tools, Tactics, and Mentality of Outlaw Biker Wars. American Journal of Criminal Justice 2011; 36(3):216-230.
32. “The 5 pieces of gear that you need to ride a motorcycle.” Best beginner motorcycles, March 2015. Web. http://www.bestbeginnermotorcycles.com/5-pieces-gear-you-need-ride-motorcycle 22 Aug 2016.
33. Weiss H, Agimi Y, and Steiner C. Youth motorcycle-related brain injury by state helmet law type: United States 2005-2007. Pediatrics 2010 Dec;126(6):1149-55. doi: 10.1542/peds.2010-0902. Epub 2010 Nov 15.