The Journai of Emergency Medone, Vol. 7, pp 5-8, 1989 Prlnted in the USA l CopyrIght ‘: 1989 Peryamon Press pit

PEDESTRIAN ACCIDENTS: ADULT AND PEDIATRIC INJURiES

Robert W. Derlet, MD,* Joseph Silva, Jr., MD,t and James Holcrofi, MD$

*Dlvlslon of Emergency Medicine, tDepartment of Internal Medicine, and *Department of Surgery, Unwersity of Callfornla, Daws Medical Center, Sacramento, California

Reprint address: Robert W. Derlet, MD, Chief, Division of Emergency Medicine, University of California, Daws. Medical Center. 2315 Stockton Boulevard, Sacramento, CA 95817

cl Abstract-An epidemologic review of 217 pedestrian in- juries treated at a level one trauma center during a one-year period is presented. Injuries that occurred in pediatric age group patients were reviewed separately from adults. In both categories approximately 60% were admitted to the hospital. Hospital length of stay and severity of injuries was found to be much worse in adults. Seven percent of adults and 3% of children died after arrival at the hospital. The most common areas of injury in both groups were the head and the distal extremities. Nearly 25% of adults sustained tibia-fibular fractures. This study shows that the incidence of critical injuries in pedestrians is high, and adults sustain more severe injuries than children. We clarify types of inju- ries commonly seen in pedestrian trauma.

0 Keywords-trauma; pedestrian injuries; pediatric trauma

INTRODUCTION

Pedestrian injuries are serious medical and public health issues. However, little scientific data has been generated that details injuries and outcomes (1). It would be helpful if the emergency physician could anticipate what types of injuries hit pedestrians may have. We decided to review our experience with pedes- trian injuries. A retrospective study of all pedestrian injuries treated at our institution during a one-year period was conducted. This study describes pedestri- an injuries seen in a middle-sized urban area and clarifies and contrasts the differences between inju- ries occurring in adults and pediatric patients.

METHODS

The University of California, Davis, Medical Center

is a designated county trauma center and receives all major trauma for the county of Sacramento, Califor- nia (population base of 835,000). It has been desig- nated as a level one trauma center by the American College of Surgeons Trauma Committee. Charts of all patients seen at the UCDMC emergency depart- ment for the one-year period of April 1986 through March 31, 1987, were screened, and those patients treated as a result of a pedestrian injury had their charts separated and reviewed. The triage criteria for trauma patients brought to our center include physio- logic, anatomic, and etiologic criteria (Tables 1 and 2). It requires that all pedestrians struck by vehicles traveling faster than ten miles per hour be transported to the trauma center. Pedestrians were defined as those persons struck by a motor vehicle while on foot. Patients 15 years old and under were defined as pediatric patients. Treatment and diagnostic evalua- tions rendered to these pedestrians were analyzed in detail.

RESULTS

A total of 217 patients who were pedestrians injured by automobiles were reviewed.

Age and Sex: In the group of injured pedestrians, 154 (71%) were adults, and 63 (29%) were children, 15 years old or less (Table 3). Among pediatric age group patients, those treated for injuries were equally divided among age groups 0 to 5, 6 to 10, and 11 to 15. In adult patients, injuries were most common in the 16 through 30 age group. Among all patients, injuries in males predominated. In the pediatric age group, 72% of those seen were males, and in adults 69%.

RECEIVED: 24 December 1987; SECOND SUBMISSION RECEIVED: 8 April 1988 0736-4679/89 $3.00 + .OO ACCEPTED: 4 May 1988

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6 Robert W. Derlet, Joseph Silva, Jr, James Holcroff

Table 1. Trauma Triage Criteria Table 2. CRAMS Score

Patients will be transported to the trauma center who have: Physiological Criteria

Circulation

1. Any patient with a CRAMS score of eight or less **oFI **

Anatomical Criteria Any patient with any of the following injuries: 1. Any injury to the head which results in coma or a decreased

level of consciousness 2. Penetrating wounds to the head, neck, thorax, abdomen, or

pelvis, including stabbing or gunshot wounds or impalements with objects

3. Blunt injury to the chest with an unstable chest wall 4. Trauma which results in paralysis 5. Two or more long bone fractures (humerus, femur)

**oFI **

Etiological Criteria Any patient who was injured by any of the following mechanisms and who complains of injuries: 1. Surviving victims of any vehicular accident in which fatalities

Normal capillary refill and BP > 100 Delayed capillary refill or 85~ BP< 100 No capillary refill or BP< 85

Respirations Normal Abnormal (labored or shallow) Absent

Abdomen Abdomen and thorax nontender Abdoment or thorax tender Abdomen rigid or flail chest

Motor Normal Responds only to pain (other than decerebrate) No response (or decerebrate)

Speech Normal Confused No intelligible words

occurred 2. Persons who fell from heights greater than two stories or 20

feet 3. Pedestrians who were struck by automobiles at greater than

Table 3. Age of Injured Pedestrians

10 miles per hour 4. Persons who were ejected from vehicles 5. Persons requiring extrication from vehicles when the extrica-

tion procedure took longer than 30 minutes

Mode of Arrival: The majority of our patients ar- rived by ambulance (89.9% of adults and 76.0% of children). The remainder were brought in by private vehicle, helicopter, or social agencies.

Age Number Percent

o-15 63 29.0 16-30 66 30.4 31-45 43 19.8 46-60 26 12.0 61 + 19 8.8

TOTAL 217 100

Injuries: The most common injuries involved ex- tremities; 82% of adults and 60% of children sus- tained extremity injuries ranging from minor abra- sions and bruising to open fractures (Table 4). Actual fractures were seen in 46% of adults and 22% of chil- dren. The second most frequent injury was head inju- ries; 48% of all adults sustained head injuries and 57% of all children. The contrast between adult and child chest injuries should be noted; 23% of adults had some type of chest injury, whereas only 8% of children did. Back, abdomen, and pelvic injuries were less common (12: 8%, 12: 17%, and 11 : 14% respectively).

hospital. Admission percentages of both pediatric and adult patients was similar, as 56% of adults (n = 87) and 60% of children (n = 37) were admitted to the hospital. Of these, the median length of stay was 8 days (mean 19.1) for adults and 4.2 days (mean 6.8) for children. Of the admitted group, 25% of adults and 40% of children were discharged within 48 hours. After admission to the hospital, no children died and 6 additional adults died from their injuries. Disabling injuries of those discharged were seen in 7.5% of adults and 5 % of children.

Alcohol Use: Blood alcohol was measured incon- sistently. Blood alcohol levels were done on 24 (16%) of the adult patients. In this subgroup, all had elevat- ed blood alcohol levels; the mean level was 224 pgl mL. Injuries and mortality in this group were not significantly different from those of adults as a whole.

Treatment Outcome: Of the 217 patients reviewed, two pediatric and five adults were pronounced dead in the emergency department after attempts at resus- citation. A total of 124 patients were admitted to the

After admission to the hospital, 63.2% of adults and 37% of children were taken to the operating room. As shown in Table 5, most operations involved fixation of fractures. In the adult group, 23.0% of all admissions underwent a laparotomy with nearly half (45%) of these having positive findings requiring re- pair. This included liver and spleen lacerations, me- senteric lacerations, perforated small bowel, retro- peritoneal hematomas, and a ruptured bladder. The number of fractures seen in admitted adults is shown in Table 5. Of patients who had fractures, half had two or more fractures.

Of the 12 children who went to the operating room, three had exploratory laparotomies, six had

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

Pedestrian Accidents 7

Table 4. Injury Sustained (Percent with Specific lniury) Table 5. Outcome of Admitted Adult Patients (N = 87)

Adults Children (n=154) (n=63)

Percent

Extremities, Total 82 60 Extremity Fracture 40 22 Non fracture Extremity Injury 42 38

Head 48 57 Chest 23 8 Abdomen 17 12 Pelvis 14 11 Back 8 12 Neck 7 6

orthopedic surgery, and three had neurosurgical procedures.

No operation Single OR procedure Two or more OR procedures Types of procedures

Orthopedic Laparotomy Neurosurgical

Types of fractures TibialFibula Pelvic Femur Humerus/radius/ulna Clavicle Hip Ankle

36.8 44.8 18.4

54.0 23.0

4.6

24.1 8.0 9.2 9.2 4.6 4.6 3.4

__-

DISCUSSION

This review of 220 cases treated in one year focuses on those patients whose injuries were severe enough that they required transport to our trauma center preferen- tially over transport to “the closest hospital.” Qpes of trauma triage scoring methods vary among emergen- cy medical service agencies (2). Our local emergency medical services agency’s trauma triage criteria com- bines the CRAMS physiologic scoring system and other anatomical and mechanism-of-injury scores (3) (Tables 1 and 2). In essence, anyone who could have a potentially life-threatening injury is included in this scoring system despite appearing well at the scene of the accident. Injury and outcome scores were not ad- dressed in this study, as the purpose is to describe the overall epidemiology of pedestrian injuries.

Moreover, extremity fractures were more than twice as common in adults than children. We might expect adults to have this higher incidence, as the legs are at bumper level. Indeed, tibiajfibula, femur, and pelvic fractures were common in adults. However, other variables such as differences in speed of the vehicle in each group may contribute to our findings.

The vast majority of persons arrived by ambu- lance, with no statistical difference between the num- ber of pediatric patients and the number of adults. Although chest and abdominal injuries were relative- ly uncommon overall, a contrast between adults and children is seen here as chest injuries were three times as common in adults as compared with children (24% v 8 X). The overall low incidence of chest and abdom- inal injuries is consistent with other studies (4,5).

Over half the pedestrian patients seen at our insti- tution were hospitalized. In reviewing data from our trauma registry, we find fewer than 25% of nonpe- destrian trauma patients require hospitalization here. Thus, pedestrians injured are much more likely to be hospitalized than nonpedestrian auto accident vic- tims. This has been shown in other studies (1).

In this series, head and lower extremity injuries are clearly the most frequent injuries seen in pedestrians who are struck by motor vehicles. Although the inci- dences of body regions injured are similar in adults and children, adults tended to have more severe inju- ries. Adults frequently had one or more major frac- tures requiring operative intervention.

The percentage of admitted adults who underwent exploratory laparotomy (23.0%) after pedestrian ac- cidents is similar to the percentage of laparotomies done at UCDMC in trauma patients from motor ve- hicle accidents (MVA). Furthermore, the incidence of laparotomies revealing pathology requiring repair (45%) in pedestrian injuries is similar to the overall incidence of intraabdominal repairs done here on MVA trauma patients undergoing laparotomies.

Adults did worse than children when struck by mo- tor vehicles. Deaths were higher, hospitalization long- er, and incidence of fractures higher. Adults are sized differently, and it is possible that the kinetic energy that fractured bones in adults may have been trans- ferred in children causing them to “bounce” off cars.

Since blood alcohol levels were not determined in all patients, no firm conclusions can be drawn, other than that 15% of adult pedestrians were intoxicated. Other studies have found that alcohol intoxication may be a factor in injured pedestrians (6).

Reasons for the relatively large proportion (29%) of pedestrian accidents involving children are unclear. Factors responsible for childhood pedestrian acci- dents involve a multitude of social, psychological, traffic, and behavioral issues that have recently been the subject of analysis (7,8,9).

Of patients hospitalized, the course of patients

8 Robert W. Derlet, Joseph Silva, Jr, James Holcroft

was quite variable. Many patients (adults, 25%; chil- dren, 40%) were discharged after 48 hours of obser- vation, while others had a more protracted course consistent with their injuries. This is similar to the course of other trauma patients who are in motor vehicle accidents and hospitalized at this institution.

Our review confirms some commonly held beliefs about pedestrian trauma that have received little sci-

entific discussion in the medical literature. They in- clude (1) children generally have better outcomes than adults, (2) head and lower extremity injuries predomi- nate, (3) chest and abdominal injuries are less com- mon, and (4) orthopedic procedures are the most common operative intervention. These facts should help when planning resources to care for patients in- jured as pedestrians.

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2. Morris JA Jr, Auerbach PS, Marshall GA, et al. The trauma score as a triage tool in the prehospital setting. JAMA. 1986; 256:1319-25.

3. Gormican SP. CRAMS scale: field triage of trauma victims. Ann Emerg Med. 1982;11:29-32.

4. Civil ID. Patterns of injury in motor vehicle trauma. NZ Med J. 1986;99:905-906.

5. Ashton SJ: Vehicle design and pedestrian injuries, in Pedestrian Accidents. Chapman A. (ed). John Wiley and Sons; 1982:

134-58. 6. Muller R, van Rensburg LC. Alcohol levels in trauma victims. S

Afr Med J. 1986;70:592-593. 7. Christoffel KK, Schafer JL, Jovanis PP, Brandt B, White B,

Tanz R. Childhood pedestrian injury: a pilot study concerning etiology. Accid Anal Prev 1986;18:25-35.

8. Seargeant JC, Hodge E. California pedestrian accidents. In: Proceedings of the 19th Conference of the American Associa- tion for Automotive Medicine: San Diego, California, Novem- ber 1975. 136-48.

9. Illingworth C. 227 road accidents to children. Acta Paediatr Stand 1979;66:869-873.