Trauma and motorcyclists; born to be wild, bound to be ...

REVIEW

Trauma and motorcyclists; born to be wild,bound to be injured?

John D. Hinds a, Gareth Allen b, Craig G. Morris c,*

a Specialist Registrar Anaesthetics, Motorcycle Union of Ireland (MCUI) Medical Team,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, County Antrim BT12 6BE, Irelandb Specialist Registrar Anaesthetics and Intensive Care Medicine, Altnagelvin Hospital,Londonderry BT476SB, United KingdomcConsultant Anaesthetist and Intensive Care Medicine, Derby Royal Infirmary, London Road,Derby DE12QY, United Kingdom

Accepted 18 June 2007

Injury, Int. J. Care Injured (2007) 38, 1131—1138

www.elsevier.com/locate/injury

KEYWORDSMotorcycle;Trauma;Injury;Prevention;Airway;Speed hump;Leathers;Helmet

Summary

Background: Regrettably motorcyclists frequently suffer related significant injuries.Doctors who manage trauma will encounter victims of motorcycle accidents andmanyaspects of care are unique to these patients due to the protective and performanceenhancing equipment used by motorcyclists. This review examines the patterns ofmajor injuries suffered bymotorcyclists, the unique aspects of airway, circulatory andspine management, and suggests some interventions, which may allow primary injuryprevention for the future.Data source: Literature searches of the PubMed, EMBASE and Cochrane library withhand searches and author’s experience.Interventions: None.Data synthesis and conclusions: The airway and (cervical and thoracolumbar) spinecannot be managed effectively in the helmeted patient with a speed hump in placeand intubation by direct laryngoscopy is almost impossible with a speed hump inplace. Helmets should be removed and the speed hump cut from the leathers.Leathers act as fracture splints, particularly for pelvis and lower extremities. Removalor extensive cutting away of the lower portion of leathers should be considered as partof ‘‘circulation’’, and only take place in a medical facility and in anticipation ofcirculatory deterioration.

Motorcyclists sustaining thoracic spinal damage more frequently than cervical andspinal fractures at multiple levels are common. Back protectors are used commonlyand these may be left in situ for extrication on a spinal board, but they should beremoved in-hospital to allow full assessment.

* Corresponding author.E-mail address: [email protected] (C.G. Morris).

0020–1383/$ — see front matter # 2007 Published by Elsevier Ltd.doi:10.1016/j.injury.2007.06.012

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133Motorcycling injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133

Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133Airway management and motorcycle helmets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133Techniques for helmet removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134‘‘Speed humps’’ during intubation and cervical spine control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134‘‘Total’’ spine management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134Back protectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136Circulatory management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137

Introduction

Most motorcyclists appreciate that riding a motor-cycle is a risky business.17 United Kingdom (UK)figures suggest that a motorcyclist is killed or ser-iously injured approximately every 665,894 km rid-den, compared to 18,661,626 km amongst cardrivers8; although this relative risk of 28—1 maybe falling with time Fig. 1.6

Therefore, if a motorcyclist attains a ridinglicense aged 17 and rides 13,500 km per year untilretirement lifetime risk of death or serious injuryapproaches 100%.

Doctors who regularly manage trauma will cer-tainly encounter victims ofmotorcycle accidents andmany aspects of care are unique to thesepatients dueto the protective and performance enhancing equip-ment, which is used by competitive, and increasinglynoncompetitive, motorcyclists.

In this clinical review we examine the patterns ofmajor injury suffered by motorcyclists, the uniqueaspects of airway, circulatory and spine manage-ment, and will suggest some interventions, whichmay allow primary injury prevention for the future.

Methods

A comprehensive literature search in PubMed,EMBASE and the Cochrane library supplemented

by hand searching bibliographies of retrieved arti-cles using the keywords above. The resulting narra-tive review of the typical patterns of major traumasuffered by motorcyclists is supplemented by theauthor’s extensive experiences in pre and in-hospi-tal trauma care.

1132 J.D. Hinds et al.

Injury prevention will require coordinated research and development of a numberof key pieces of equipment and design in particular helmets, speed humps andclothing/textiles. In managing the injured motorcyclist in the pre or in-hospitalsettings, health professionals require greater awareness of the implications of suchdevices, which at the present time appears largely restricted to motorcyclingenthusiasts.# 2007 Published by Elsevier Ltd.

Fig. 1 Author JDHinds, on rapid responsemedical bike at2006 Ulster Grand Prix road race. Despite the main focus ofthis article on the negative aspects of injuries let us notforget why motorcyclists do what they do and why it is soaddictive! Motorcycles allow an immediate deployment ofmedical aid to injured riders at road races, being muchfaster and less intrusive than a car, and more convenientand less restrictive than a helicopter on the shorter Irishcircuits. Motorcycle medics on the MCUI team can triageand begin treatment, carrying equipment in the picturedpouch-system. Back up is available from fully stockedmedical cars and ambulances (David Anderson, 2006).

Interventions

None

Motorcycling injuries

Considerations

Motorcyclists typically suffer multiple injuries; headand lower limb/pelvic injuries being the most fre-quent.1,14 Head injuries sustained through motorcy-cling are proportionately more severe than thosefrom other road traffic or sporting accidents.9

Indeed, a motorcycle accident is in itself a predictorof poor outcome in patients presenting with acutesevere head injury.31 Unfortunately, injuries sus-tained by motorcyclists tend to have chronic con-sequences, particularly following brain injury,10 andthis is typically and most tragically among youngmales in the most productive years of their lives.

Airway management and motorcyclehelmets

Helmets reduce morbidity and mortality, reducehospitalisation and ICU admission and improve out-come compared to non-helmet users, as well asreducing the financial burden created by motor-cycle-related injuries.4,22,27 Head injury risk isreduced by around 72%16 and helmeted riders havea higher GCS at presentation3 and at discharge fromhospital.23 However, benefit is only gained fromwearing type-approved standard helmets (Britishstandard BS 6658:1985 or UN ECE regulation22.05). In fact, wearers of non-standard helmetssustain head injuries more frequently, and ofgreater severity, than those who wore no helmetat all.15,20 The benefit of wearing a helmet is onlyconferred if it is correctly fitting, and the chin-strapappropriately tightened, lest the helmet be dis-placed or completely removed on impact.24

It is common practice for pre-hospital medicalpersonnel to transport the helmet to the hospitalwith the patient, to allow inspection by the hospitalmedical team.

However, the helmet is designed to act like a car’scrumple-zone, and with high quality helmets theexterior is typically extensively damaged as theouter layers dissipate the forces of impact; indeedif the outer layer remains intact a greater force istransmitted to the patient’s head. Vital informationcan be gleaned if the inside of the helmet isinspected, where a dissection of the inner layersis a worrisome sign. However, the author also has

experience of severe closed-head injury where arider slid feet-first into a high kerb at speed, withsubsequent transmission of energy through the longbones and spine leaving the helmet unmarked Fig. 2.

Despite proven benefit in primary injury preven-tion, full-face helmets make the task of airwayevaluation and management extremely difficult.Hospital practitioners should not rely on the helmethaving been removed at the scene. In cases ofsignificant maxillofacial trauma, delay in first aid/retrieval and subsequent swelling may make itimpossible to remove the helmet safely at thescene. In addition, the tough weave in some chin-straps may preclude cutting with tools availableon-scene if the buckle has been damaged.

The chin bar of full-face helmets restricts manip-ulation of the jaw for simple airway manoeuvres,and precludes the insertion of oropharngeal airwaysand oral suction devices, occasionally necessitatingthe use of the nasal route in a group at risk of basalskull fracture. We have experienced difficult helmetremoval following multiple facial fractures, wherebilateral nasopharyngeal airways combined withlog-rolling the patient to the lateral positionallowed both a source of suction via a fine borecatheter for profuse airway bleeding, and a patentairway to provide oxygen through the visor aperturevia an inverted Hudson mask thus avoiding hypox-aemia and airway soiling prior to helmet removaland tracheal intubation.

Though a surgical airway would theoretically bethe gold standard in these cases, it may be extre-mely difficult given the degree of cervical flexionassociated with helmeted patients lying in the neu-tral position, distorting the anatomy. Coupled withthe presence of chinstrap and chin bar overlying thesurface anatomy, surgical airways in the helmetedpatient may be extremely challenging.

Trauma and motorcyclists; born to be wild, bound to be injured? 1133

Fig. 2 Though examination of the helmet may provideclues as to themechanism, degree of injurymay be over orunder estimated (motorcycle union of Ireland medicalteam photo archive, 2005).

Techniques for helmet removal

Modern helmets are quite amenable to removalusing a bone-saw, since once the hard outer cara-pace is breached the inner layers are easily dis-sected, though this can be a time consuming task.If the tools are available, a technique for cutting thechin-bar from the helmet —effectively converting afull-face helmet into an open-face helmet— hasbeen described,5 allowing rapid and definitiveaccess to the airway.

Helmet removal is a safe procedure if performedcorrectly by experienced personnel5 and is free fromsecondary neurological sequlae Box 1.

‘‘Speed humps’’ during intubation andcervical spine control

There remains a great degree of confusion about therole of speed humps, even within the motorcyclingfraternity itself. They were initially conceived to

improve the aerodynamics of a helmeted rider in aracing crouch on a competition motorcycle. In someinstances they contain data-logging devices to allowrace teams to collect information on the variousforces acting on rider and motorcycle, and in hotterclimates they have beenmodified to contain fluid. Inrecent years they have become a fashion item forthe non-competitive motorcyclist, and are now acommon feature on leathers. They are not, andnever have been, a safety device, and indeed makemanagement of the airway and spine more difficultin the injured motorcyclist Figs. 3 and 4.

The effect of a speed hump in the supine positionis analogous to having two firm pillows placed underthe shoulder-blades, that is, thoracic flexion withcervicothoracic junction hyperextension and poten-tially craniocervical junction flexion as helmettouches ground. This risks gross spinal displace-ment, and direct laryngoscopy and intubationbecome virtually impossible. It is the author’s opi-nion that for spine protection and airway control thespeed hump must be removed as soon as possible.The easiest method is to logroll the patient into thelateral position, and run a scalpel blade around theoutline of the hump; allowing rapid separation fromthe leathers. The patient can then be returned tothe supine, and now neutral, position Fig. 5.

It is hoped that designers and manufacturers willrecognise the problems faced by medical staff inthese instances and modify the design of humps inthe future. Possible solutions include filling humpswith air rather than foam to allow deflation ormaking humps externally detachable, for instancewith a zipper or Velcro.

‘‘Total’’ spine management

While cervical spine control is quite rightly empha-sised alongside airway management in moderntrauma care,2 in fact motorcyclists sustain thoracicspinal injuries more commonly.12,25,26 The mechan-ism typically involves flexion injury.7,25 Some work-ers advocate performing an over penetrated upperthoracic film as part of the ‘‘motorcyclist traumascreen’’7, although a strong case for CT can bemade. Non-contiguous spinal injuries are common,and protocols concentrating on the clearing thecervical spine may miss a significant proportion ofthoracolumbar spinal injuries.11,25,26

Helmets do not in themselves confer protectionagainst cervical spine injury, but neither do theyincrease the risk.15,16,19,28 Certainly managementof the spine is complicated by the presence of ahelmet; indeed the injured adult helmet-wearingmotorcyclist can be thought of much like a neonate,

1134 J.D. Hinds et al.

Box 1. Helmet removal

General principles, based on the recommen-dations of the Trauma working party of thejoint colleges ambulance liaison committee(JRCALC),5 ATLS guidelines2 and our ownclinical experience of around 200 helmetremovals per year:! It is safest to allow the conscious motorcy-clist to remove his own helmet, if alert andcooperative. While this may encouragespinal flexion, alert patients should be lim-ited and protected by pain.29

! If not, the principle of ‘‘two people usingtwo hands’’, with the patient lying flat, isrequired for optimal technique. One per-son should remove the helmet in a cepha-loid direction, the other controlling thehead and cervical spine.

! The chin-bar of the helmet should be heldby the assistant at the top of the bed, sincethis allows better control of the head thanthe temporal or occipital portion of thehelmet; which may be slick with blood,mud or rainwater.

! While the helmet must be manipulated offthe head, there is little room for medio-lateral movement, but sufficient scopeantero-posteriorly if the head is stabilised.

! The helmet edges should be pulled in alateral direction, deforming the helmet car-cass and allowing further loosening priorto removal.

with relatively large occiput and disproportionatelylarge head compared to bodyweight, and the smoothsurface of the helmet promotes a significant degreeof rotation of the head. In what may appear to be the‘‘neutral’’ position, the helmet causes flexion of thecervical spine, and may be further compromised bythe presence of a speed hump, where mid-thoracicflexion and pseudo-extension of the cervicothoracicoccurs. Furthermore, the application of a cervicalcollar is impossible in the presence of a full-facehelmet and risks further airway compromise.

Therefore, spinal immobilisation in the injuredmotorcyclist requires helmet and speed humpremoval, and the patient returned to the neutralposition on a firm surface (we advocate a spinalmattress or firm mattress of a transfer trolley)with cervical collar, sandbags and tapes or manualin-line immobilisation.2 The efficacy of spinal immo-

Trauma and motorcyclists; born to be wild, bound to be injured? 1135

Fig. 3 2006 Irish road race superbike crash, where the mechanism of injury was exacerbated by the motorcycle‘‘following’’ the rider and impacting rear of helmet. Note ‘‘speed hump’’ on leathers and how this complicated attainingin-line immobilisation in this instance. (Stephen Davidson—Pacemaker Press, 2006).

Fig. 4 Helmet off, in-line immobilisation, speed humpcut from rear of leathers and only then spinal-boardedwith collar/tapes/sandbags (Stephen Davidson—Pace-maker Press, 2006).

bilisation techniques has been considered else-where,13,18,29 and the ubiquitous use of spinal boardsrisks cutaneous necrosis and malalignment of thespine. They were designed as a pre-hospital extrica-tion device and patients should be removed fromthem following the primary survey.2,30

Back protectors

Back protectors have yet to be studied as a protectiveitem, but circumstantial evidence abounds, and al-most no competitive motorcyclist participates with-out one. Back protectors come in a range of designs,but the philosophy is similar between brands.

Essentially they are a piece of armour, eitherstrapped to the body, or attached to the inside ofthe leathers, extending from the upper thoracic tolower lumbar region. Some designs also incorporatesacral portions or kidney protectors. Back protec-tors tend to be rigid on the outside and padded onthe inside, and the design of some brands also limitsextension of the spine, thereby theoretically pro-viding a degree of protection against penetrative,impact and hyperextension mechanisms.

Due to their ergonomic shape, back protectorsmay be left in place for transport to hospital, alongwith standard spinal precautions, to avoid having toremove the riders’ leathers (see below), but theyshould be removed as part of the riders ‘‘exposure’’during the in-hospital primary survey. It is notuncommon for healthcare staff unfamiliar withmotorcycling paraphernalia to mis-diagnose injuryand ‘‘steps’’ at several spinal levels when a back-protector is palpated underneath a rider’s t-shirt!

Circulatory management

Wearing a goodquality set of leathers proffers a greatdeal of protection to themotorcyclist. Despite devel-opments of space-age materials, no synthetic fibrehas yet been developed to match the friction resis-tant qualities of leather. While cow-hide had pre-

vailed, there has been a trend towards kangarooleather, since it offers similar abrasive-resistant qua-lities with the benefit of being significantly lighter.

In combination with internal armour and Kevlarreinforcing competition riders have walked away un-scathed from what would otherwise have been fatalaccidents. The Kawasaki rider Shinyo Nakano walkedaway from his 2005 Moto Grand Prix accident at 200miles-per-hour, and his kangaroo-skin leathers with-stood sliding to a standstill on highly abrasive tarmac.

Leathers help to prevent or reduce injury byabrasion and impact, but they may also serve asan effective splinting system when injury doesoccur. This is of particular importance if traumahas occurred below the waist, where a good fittingset of leathers can effectively splint otherwise openpelvis and femoral shaft fractures. Considering thehigh incidence of this type of bony injury in motor-cyclists,3,21,22 removal of motorcycle leathersshould be considered as part ‘‘circulation’’ in theprimary trauma survey, and should certainly only beconsidered after establishing adequate intravenousaccess and in anticipation of circulatory deteriora-tion. Complete removal of leathers outside of adedicated medical facility in the motorcyclist withtrauma below the waist is contraindicated.

The authors have experienced complete circula-tory collapse of a previous awake and alert patientfollowing the cutting-away of the lower portion of aset of one-piece race leathers, which had stabilisedan open-book pelvic fracture and bilateral fracturedfemurs.

Ideally, leathers should be removed by cuttingalong thenatural seams; this avoids thetough reinfor-cedpanels common innewer suits, andallows the suitto be repaired for future use since good leathers arehand-made to measure and typically very expensive.

Summary

All motorcyclists who suffer significant trauma willrequire helmet removal if only for assessment, andtechniques for doing so are described.

1136 J.D. Hinds et al.

Fig. 5 Scalpel used to remove foam from speed humpwith minimal manipulation of patients position (motorcycle unionof Ireland photo archive, 2007).

The airway and (cervical and thoracolumbar)spine cannot be managed effectively in the hel-meted patient with a speed hump in place andintubation by direct laryngoscopy is almost impos-sible with a speed hump in place. The helmetshould be removed and the patient logrolled tothe lateral position, where the speed hump can becut from the leathers quickly and effectively usinga scalpel.

Leathers act as fracture splints, particularly forpelvis and lower extremities. Removal or extensivecutting away of the lower portion of leathers shouldbe considered as part of ‘‘circulation’’, and onlytake place in a medical facility with adequatelyestablished IV access and in anticipation of circu-latory deterioration. Cutting along the naturalseams avoids reinforced panels common in newersuits, and allows the suit to be repaired for futureuse.

Motorcyclists sustaining thoracic spinal damagemore frequently than cervical and spinal fracturesat multiple levels are common. Whilst back protec-tors have not been formally evaluated in the pre-vention of spinal injuries, few competition ridersparticipate without one. It is quite acceptable toleave these in situ for immobilisation on a spinalboard, but they should be removed in-hospital toallow full assessment of the spine.

Injury prevention will require coordinatedresearch and development of a number of key piecesof equipment and design in particular helmets,speed humps and clothing/textiles.

In managing the injured motorcyclist in the pre orin-hospital settings, health professionals requiregreater awareness of the implications of suchdevices, which at the present time appears largelyrestricted to motorcycle enthusiasts Box 2.

Acknowledgements

We thank Dr Fred MacSorley, Dr David McManus ofthe Motorcycle Union of Ireland Medical Team fortheir input.

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! Recommendations of the trauma workingparty of the joint colleges ambulance liai-son committee (JRCALC)5

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! Ambulance service association/Institutehealth and care development ambulanceservice basic training manual, 3rd Edition2003 (Revised April 2006), Section 10.8

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