Motor-Vehicle Injury Patterns in Emergency-Department Patients in a South-European Urban Setting.

Abstract

The objectives are to identify the main injury patterns in the various types of user (of cars, motorcycles/mopeds, bicycles and pedestrians) injured in traffic crashes and treated in hospital emergency services, along with their main demographic characteristics.

One-year cumulative survey all of patients attended to emergency departments in Barcelona, Spain, over a 12-month period (1998) for injuries due to motor vehicle crashes. Bivariate descriptive analyses were conducted to identify the different profiles of motor-vehicle injury patients by age, sex, user type, injured body region and type of injuries. ISS scoring was used to determine injury severity.

Of the nearly 17,000 injured traffic victims during 1998, 62% were men. Young people between 15 and 39 (71.6%) were most affected. 42% were users of two-wheeled motor vehicles, followed by car occupants (32%) and pedestrians (24%). Neck sprain (33 %) was the most common injury among car occupants, multiple contusion and contusion of lower limbs among two-wheeled motor vehicles (23.5% and 14% respectively) and pedestrians (17.3% and 14.4% respectively) and upper limb fractures (20%) among cyclists.

Motorcycle and moped users, mainly young males, have the highest probability of suffering injuries, with lower limbs being the most affected anatomical region. Elderly pedestrians sustaining injuries to the lower limbs and the head contribute substantially to the overall injury situation.

The impact of traffic injuries as one of the main causes of death, morbidity and disablement in the developed countries is well known (Murray et al., 1996). Traffic injuries represent an important health problem in Spain (Seguí-Gómez, 2000) being one of the leading European Union countries in terms of numbers of injured cases and deaths due to this cause (Laumont, 1998). In spite of the fact that at the beginning of the nineties morbidity/mortality rates due to traffic accidents declined (Ministerio Sanidad, 1999; Redondo et al, 2000), in recent years they have risen again (Plasència, in press).

In Barcelona (1,700,000 inhabitants), the second largest city in Spain, significant efforts have been made to determine mortality (Pañella et al., 1991), morbidity (Plasència et al., 1995) and disablement (Ferrando et al., 1998a) related with traffic injuries. Studies have also been carried out to assess the impact of legislative measures implemented in the city aimed at reducing traffic injury mortality (Plasència et al, 1998; Ferrando et al., 1998b) as well as the utilization of hospital emergency services (Seguí-Gómez et al., 1996, Cirera et al., 1998) as a valid and reliable source of information for monitoring characteristics of traffic injury cases.

The objectives of the present study are to identify the main injury patterns in the various types of user (of cars, motorcycles/mopeds, bicycles and pedestrians) injured in traffic crashes and treated in hospital emergency services, along with their main demographic characteristics.

Methods

Subjects: subjects were those individuals attended to by the emergency department of seven Barcelona public hospitals for injuries due to a MV crash during 1998.

Source of information

Data analyzed were transmitted from 7 emergency departments participating in the DUHAT (Dades d’Urgències Hospitalàries per Accidents de Trànsit) project (Institut Universitari de Salut Pública de Catalunya, 1995), coordinated by the Municipal Institute of Health, and cover 90% of cases attended to by the Barcelona Public Hospitals Network. This project, begun in 1994, systematically collects information on MV crash victims seen in emergency departments of the Barcelona Public Hospitals Network, including demographic and diagnostic data, as well as user type information. The remaining 10% of injury cases for which information is not available comprises cases attended to by private sources of care, which also tend to be lower overall severity.

Methods

For the period under study, the data base comprised 16976 cases. The variables transmitted from the participating centers and which are used in this study include: sex, age, type of user (car, motorcycle/moped, bicycle, pedestrian) and injury diagnoses. The coding of these diagnoses, according to ICD-9-CM criteria (WHO, 1988), was carried out either by coders within each hospital, or by coders of the Municipal Institute of Health.

Severity of injuries was determined using the ICDMAP program (The Johns Hopkins Health Research and Development Center and the Maryland Institute of Emergency Medical Services System, 1988) which automatically converts diagnoses in terms of ICD-9-CM codes into AIS and ISS codes. In 16.3 % of the cases it was not possible to do this conversion due to unspecific or missing diagnosis.

Bivariate descriptive analyses were performed to identify the various injury patterns (by anatomical region and type of injury) among the different types of injured users, as well as their main demographic characteristics (by age and sex). All statistical analyses were carried out using the SPSS statistical package (Norusis, 1993)

Results

During the year 1998, nearly 17,000 injured traffic victims were treated in the emergency departments of the seven main hospitals of the city (table 1); of these, more than half were men (62%). In terms of age the groups most affected were young people between 15 and 39 (71.6%), in particular those in their twenties (40%).

Table 1.

Description of the principal characteristics of the traffic injury cases in Barcelona, 1998.

	Injured persons (N)	Percent (%)
Gender
Males	10563	62.2
Females	6413	37.8
Age
1-9	290	1.7
10-14	244	1.4
15-19	2407	14.2
20-29	6756	39.9
30-39	2966	17.5
40-49	1508	8.9
50-59	1087	6.4
60-69	771	4.5
70-79	595	3.5
>80	325	1.9
Type of User
Car	2758	31.8
Motorcycle/moped	3601	41.6
Pedestrian	2097	24.2
Bicycle	30	0.7
Other (public transport)	208	1.7
Anatomical Region
Head	1687	11.8
Neck	2664	18.7
Face	1065	7.5
Thorax	1603	11.2
Abdomen	131	0.9
Upper limbs	2763	19.4
Lower limbs	4312	30.3
ISS	Mean: 2.1;
	Standard deviation: 2.1

Almost half the injured were users of two-wheeled motor vehicles (42%), followed by car occupants (32%) and pedestrians (24%). Injured bicycle users represented 0.7% of the total number of injured cases. The anatomical region with the greatest number of injuries was lower limbs (30 %), followed by upper limbs (19.4 %) and neck (18.7 %). Severity (ISS) for all injuries taken together was 2.1. Only 10% of the injury cases treated by emergency services were subsequently admitted to hospital.

In all groups of users, the presence of men is notable (table 2) with the exception of pedestrians where there are slightly more women (51%). The numbers of young injured cases is also notable, except among pedestrians where 37% are over 50 years of age. The neck was the anatomical region sustaining most injuries (39%) among car users, lower limbs among two-wheeled motor vehicles (45%) and pedestrians (40.5%) and upper limbs among cyclists (48%). Cyclists presented injuries of greater severity (ISS=3) followed by pedestrians (ISS=2.7).

Table 2.

Description of the principal characteristics of traffic injury cases by user type. Barcelona 1998

	Car users		Motorcycle / moped users		Pedestrian		Bicycle users
	Users (N)	%	N	%	N	%	N	%
Gender *
Males	1519	55.2	2595	72	1024	49	27	90
Females	1234	44.8	1009	28	1067	51	3	10
Age *
1-9	60	2.2	2	0.1	84	4.1	0	0
10-14	37	1.3	14	0.4	81	3.9	1	3.3
15-19	148	5.4	735	20.4	155	7.4	6	20
20-29	997	36.2	1901	52.7	336	16.1	12	40
30-39	566	20.6	628	17.4	263	12.6	7	23.3
40-49	382	13.9	196	5.4	200	9.6	2	6.7
50-59	291	10.6	92	2.5	238	11.4	1	3.3
60-69	166	6	20	0.5	257	12.3	1	3.3
70-79	80	2.9	14	0.4	281	13.4	0	0
>80	26	0.9	2	0.1	194	9.3	0	0
Anatomical region *	Injuries (N)	%	N	%	N	%	N	%
Head	270	10.9	207	7.3	342	18.9	1	4
Neck	972	39.1	150	5.2	66	3.6	0	0
Face	299	12	133	4.6	154	8.5	2	8
Thorax	347	13.9	254	9	181	10	1	4
Abdomen	20	0.8	33	1.1	22	1.2	0	0
Upper limbs	276	11.1	775	27.3	308	17	12	48
Lower limbs	296	11.9	1288	45.3	733	40.5	9	36
ISS *	Mean : 1.9		Mean: 2.19		Mean: 2.7		Mean: 3
	Standard deviation: 1.9		Standard deviation: 2.2		Standard deviation: 2.7		Standard deviation: 3.1

^*p < 0.01

Neck sprain (33 %) was the most common injury among car occupants (figure 1), multiple contusion and contusion of lower limbs among two-wheeled motor vehicles (23.5% and 14% respectively) and pedestrians (17.3% and 14.4% respectively) and upper limb fractures (20%) among cyclists.

Figure 1.

Description of the principal lesions by injured traffic users. Barcelona 1998

Discussion

In this study, as in others previously carried out in Barcelona (Plasència et al., 1995), the important contribution of motorcycle and moped users to the total number of injured traffic victims in the city continues to manifest itself. The male, usually young, users of these vehicles are the group with the highest probability of presenting traffic accident injuries. Another subgroup with an important probability of presenting injuries is that of elderly pedestrians.

This is the first study in Barcelona that has looked at injury patterns presented by the different types of users involved in traffic injuries and treated in hospital emergency services. The study shows how the different types of injured users present with a variety of injury types and anatomical areas affected.

Thus, car occupants most frequently suffer neck injuries, followed by thorax, and limbs, mainly lower limbs, neck sprain and chest bruising being the most common injuries. These results agree with those found in other studies (Norin et al., 1997) in which traffic injury and disability among car occupants were investigated, and it was seen that the anatomical areas most frequently sustaining injury among patients with low levels of disability, as was the case in our study, were the neck and limbs, while among occupants presenting higher levels of disability, the head was the area most commonly affected. In other studies (Bring et al. 1996; Gargan et al., 1997) the neck also appears as one of the anatomical areas most commonly involved in injuries to car occupants.

It has been found (Chandler et al., 1997; McConnell et al., 1997; Gupta et al., 1998) that chest injuries in car collisions are associated with the use of seatbelts. As in our study information was not available about use of safety measures, we cannot assess whether injuries of the chest observed in our study is associated or not with seatbelt use. Limbs also appear in other studies (Crandall et al., 1998; Fildes et al., 1997) as anatomical regions with a high frequency of injuries among car occupants.

Motorcycle and moped users presented greater injuries of lower limbs, in agreement with results found in other research (Peek Asa et al., 1996). This is the first time that traffic injuries to bicycle users have been studied in Barcelona. Despite the low numbers of victims detected, they stand out as the victims sustaining injuries with the highest levels of severity. Limb fractures and multiple bruising were the injuries most often found In other studies (Puranik et al., 1998; Kennedy, 1996) the head was found to be the most affected region among seriously injured bicycle users. It is important to note that bicycle use is an emerging phenomenon in the city traffic flow, and thus it is expected the next few years will see a rise in the number of bicycle accident victims.

With regard to pedestrians, our results agree with those of other studies (Calhoun et al., 1998; Kong et al., 1996; Eastridge et al., 1997; Durkin et a., 1999) which point to the higher frequency of lower limb and head injuries, mainly bruising and lower limb fractures, and intracranial injuries without fracture of the cranium

The present study was carried out with traffic victims treated in hospital emergency services who presented injuries of low severity, the majority of whom did not require admission to hospital. In the DUHAT project, only 10% of MV crash victims attended by emergency services require hospital admission (Seguí, Plasència, Ferrando et al., 1995). These are a small subgroup of victims that generally involves more severe cases than those not admitted. In our information system for these victims we do not have the information related to the injury diagnoses that are presented in the hospital discharges, we have only the first injury evaluation carried out in the emergency services which in general provide an injury diagnoses less precise than that provided by the hospital discharge. For these reasons, patterns of injuries related to more severe MV crash victims could be underrepresented in our study.

Despite the limitation of identifying only patients with lower severity levels, several studies (Burt et al., 1998; Van Camp et al., 1998; Bring et al., 1996) point out the utility of working with these sources of information, as well as the importance of low severity traffic accident injuries in both health care terms and social terms (McClure et al., 1996).

Another limitation of this study appears as a consequence of the non-availability of information regarding the circumstances involved in producing the traffic accidents. Thus, we have not been able to relate such circumstances with the production of injuries, as has been done in several studies (McLellan et al., 1996; Peek Assa et al., 1996; Dolinis, 1997; Crandall et al., 1998; Fildes et al., 1997). Nor has it been possible to relate, as other studies have done (Norin et al., 1997; Chandler et al., 1997; Niemcryk et al., 1997; McConnell et al., 1997; Gupta et al., 1998; Van Camp et al., 1998; Sasso et al., 1997; Porter et al, 1998; Hollands et al., 1996; Loo et al., 1996; Swierzewski et al., 1994), the use of particular safety measures such as seatbelts or airbags in cars, or helmets in cyclists and motorcyclists, with the production of injuries. It will be possible to overcome these limitations when it becomes possible to link city hospital and police information sources, currently in an experimental phase (Cirera et al., 1999).

Despite these limitations, the present study shows the principal characteristics, in demographic and injury pattern terms, of injured traffic victims treated in hospital emergency services in a Southern European city, indicating that out of all traffic victims, it is the group of motorcycle and moped users, mainly young males, who have the highest probability of suffering injuries, with lower limbs being the most affected anatomical region, as well as the important contribution by elderly pedestrians sustaining injuries to the lower limbs and the head. This knowledge will contribute to interventions aimed at prevention and reduction of traffic accident injury rates in our city.

(Presenter: Maria Segui-Gomez)

Narayan Yoganandan: This was done in Barcelona. Do you have any plans to do this is other parts of Spain?

M. Segui-Gomez: Unfortunately, I’m not aware of any other plans in other parts of Spain to establish a similar surveillance system. We pioneered this back in 1993 and since then no one has approached us with any comments to do something similar.

N. Yoganandan: Is there any interest from the EU or from the Spain Government?

M. Segui-Gomez: You’re asking the wrong person. As you can see, I spend most of my time here so I don’t really know the politics internally between the first author and the European Union. I know they are members of the European safety commission team, but I don’t know if there are any plans to enlarge this. If I remember correctly, the only similar project in Europe is a Greek project that takes emergency department data and has a wonderful injury surveillance system. They do not only include motor vehicles; they include any type of injury, but as far as I can tell, and maybe the Italians in the audience can confirm this, those two would be the only two surveillance systems that I’m aware of.

Carl Clark: One of the main means to reduce bicycle injuries, both in Europe and in the United States, is to give separate bicycle lanes. Denmark is so impressive on this, but in New England they’re doing a great deal of it now. How is that progressing in Barcelona? Is there government pressure to do this?

M. Segui-Gomez: I would actually love to do a field trip and come back with a precise answer. There have been some developments, mostly over the last 8 or 10 years. Some areas of the city have designated bike lanes, although if you walk through Barcelona, you will notice that it’s not really the most bike friendly city, both in terms of the topography and in terms of the layout. What they have done actually is they have designated bike days to encourage people to use their bikes as an alternative mode of transportation. So for particular days in the year they will close a number of streets, and actually let those become bike streets and those seem to be very popular and have very high acceptance.

Unidentified questioner: Were the head injuries study with helmets and without helmets?

M. Segui-Gomez: We cannot tell precisely because, as I said, data is not collected by the EDs. I can tell you that at the time of the study, helmet use among motorcyclists was around 80% so the presumption is that and obviously a slightly larger per cent of those who are in a crash are unhelmeted, if I can use that word, but the presumption is that would be higher than you would have thought and higher than the United States helmet rate.