Recreational Motorized Vehicle Use Under the Influence of Alcohol or Drugs Significantly Increases Odds of Craniofacial Injury

Abstract

Study Design: Cross-sectional study. Objective: Concurrent substance-use, including alcohol and drugs, increases the risks of many recreational activities. Our purpose was to determine the relationship between substance use and craniofacial injuries in a large population of patients experiencing trauma due to recreational motorized vehicle use. Methods: We report a cross-sectional study of patients reported to the National Electronic Injury Surveillance System (NEISS) from January 1, 2019 to December 31, 2019, in the United States. Patients were included in our study if they were evaluated in the emergency department (ED) for a recreational motorized vehicle-related injury. Primary outcome was craniofacial injury. Results: There were a total of 6,485 adult patients who experience an injury after recreational motorized vehicle trauma reported by NEISS-participating EDs during the study period. Of this, 1,416 (21.8%) patients had a craniofacial injury, and 201 patients with craniofacial injuries were under the influence of alcohol/drugs (201/1,416; 14.2%). Injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a general craniofacial injury (OR 2.50, 95% CI: 2.07-3.01, P < .0001), including craniofacial fracture (OR: 2.98, 95% CI: 2.01-4.40, P < .0001), laceration (OR: 2.19, 95% CI: 1.51-3.16, P < .00001) and internal injury (OR: 2.33, 95% CI: 1.84-2.95, P < .00001) than injured patients not under the influence. Conclusions: Using recreational motorized vehicles under the influence of alcohol or drugs is not safe and increases the likelihood of craniofacial injuries, including fractures, lacerations, and internal injuries. As operating these recreational motorized vehicles under the influence is illegal, the law should be strictly enforced to prevent the occurrence of these injuries. Additional undertakings to increase helmet usage would be valuable.

1. Introduction

Injuries are commonly sustained while riding recreational motorized vehicles, like all-terrain vehicles (ATVs), dune buggies, go-carts, minibikes, dirt bikes, mopeds, tricycles, golf carts or utility vehicles,[1,2,3] due to the lack of standard safety features (airbags, seatbelts, enclosed walls) typically found in cars. Like cars, it is illegal to operate these recreational vehicles while intoxicated. However, the danger and illegality of operating these vehicles while under the influence of alcohol or drugs may not be well appreciated. The purpose of this study was to determine the extent to which alcohol or drug use contributes to craniofacial injuries sustained while using recreational motorized vehicles. We hypothesized that the odds of experiencing any craniofacial injury, including craniofacial fracture and laceration, were significantly greater in individuals using recreational motorized vehicles with alcohol or drugs (“substances”) compared to individuals using recreational motorized vehicles without alcohol or drugs. With these data, we aim to determine the odds ratio of craniofacial injuries between a group of recreational motorized vehicle trauma patients with and without substance use to improve the prevention of these terrible injuries.

2. Materials and Methods

2.1. Study Design and Sample

To address the research purpose, the investigators designed and implemented a cross-sectional study of consecutive cases reported to the United States, (US) Consumer Product Safety Commissions’ National Electronic Injury Surveillance System (NEISS) database between January 1, 2019, and December 31, 2019. Our institution did not require IRB approval for this population-based, retrospective descriptive study. The study population was composed of all patients presenting to the emergency department (ED) for evaluation and management of injuries sustained due to recreational motorized vehicles accident between January 1, 2019, and December 31, 2019. To be included in the study sample, patients had to have (a) been over the age of 18 years and (b) presented to the ED with a recreational motorized vehicles-related injury. Patients were excluded as study subjects if they were (a) under 18 years old, (b) did not present to the ED or (c) if their injury was not recreational motorized vehicles related. The NEISS database is comprised of a stratified probability sample of 100 hospitals in the United States and its territories and is maintained by the US Consumer Product Safety Commission (CPSC).[4,5] Stratification is by ED annual census and geographic region. Each participating ED is assigned a statistical weight to represent other non-participating EDs in a similar stratum. Each injury case from a participating ED represents the same number of injuries as the statistical weight of the ED, and weighted data are then summed to generate national estimates.

2.2. Variables

Our study sample is consecutive patients who presented to NEISS-participating EDs after experiencing a recreational motorized vehicle-related accident. Recreational motorized vehicles included, but not limited to, all-terrain vehicles (ATVs), dune buggies, go-carts, minibikes, dirt bikes, mopeds, tricycles, and utility vehicles. The predictor variable is categorical (yes or no) alcohol or drug use before or at the time of the accident, and the primary outcome is general craniofacial injury, which was further specified as fracture, laceration, contusion, etc. Demographic information including age and sex were collected for each included patient. Other variables of interest including ED disposition (left without being seen, treated and released, treated and admitted, treated and transferred, held for observation, treated and died), type of injury (laceration, contusion, abrasion, fracture, etc.), and location of injury (forehead, nose, orbit, mandible, etc.) were collected as well. “Internal injury” for the cranium was defined specifically as cerebral contusion, subdural hematoma, or no other specific diagnosis for the head injury.

2.3. Data Collection

The NEISS database collects information on the date of treatment, age, sex, diagnosis, involved body part, patient disposition from the ED, consumer products involved, location and free-text description for each unintentional injury treated in the ED. This information is entered into computers in the EDs and uploaded each night into the Consumer Product Safety Commission computer database. For this study, the authors queried the NEISS database for all entries related to “ATV’S, MOPEDS, MINIBIKES, ETC.” in patients over the age of 18 years during the study period. Patients had alcohol use recorded if they were found to be intoxicated or admitted to alcohol use at the time of ED evaluation. Patients had drug use recorded if they were found to be under the influence of illicit moodaltering substance or admitted to being under the influence at the time of ED evaluation. Though legal in some states, marijuana was included as a “drug”; cigarettes and nicotine were not considered a “drug.” Further specifics on what type of alcohol or drug was being used were not provided.

2.4. Data Analyses

Descriptive statistics were reported as a mean or median and standard deviation for continuous variables or frequency and percentage for categorical variables, respectively. Comparisons of means were performed with a 2-tailed T-test; comparisons of proportions were performed with an “N-1” Chi-squared test. Odds ratios were calculated and evaluated according to Altman[6] and Sheskin.[7] 95% confidence intervals were reported when necessary. Before performing any tests, statistical significance was defined with a P-value < 0.05. All statistical analyses were performed using commercially available software.

3. Results

3.1. Overall Characteristics

There were 6,485 total patients with recreational motorized vehicles-related injury reported from NEISS-participating EDs during the study period. The mean (+standard deviation [SD]) age was 38.4 (+17.5) years. Seventy-three percent of patients with injury after recreational motorized vehicle trauma were male (n = 4,771). Of these total 6,485 patients, 516 patients had alcohol/drug use recorded (516/6485; 7.96%). The most common type of injury among all patients was fracture (1,905/6,485; 29.4%), and the most common disposition from the ED was treated and released (4,906/ 6,485; 75.6%). These results are summarized in

Table 1. Baseline Clinical Profile for the Study Population of Patients With Recreational Motorized Vehicle Trauma.

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3.2. Alcohol or Drug Use and Craniofacial Injuries

There were 1,416 patients with craniofacial injuries after recreational motorized vehicles trauma, determining a prevalence of 21.8%. Of these 1,416 craniofacial injury patients, 201 patients had alcohol/drug use recorded (201/1,416; 14.2%). The average age of craniofacial injury patients with alcohol/drug use was not different than the average age of craniofacial injury patients without alcohol/ drug use (37.2 years vs 38.7 years, respectively; P = .2866). The most common type of craniofacial injury was internal injury (644/1,416; 45.6%) (Figure 1). The proportion of males sustaining craniofacial injuries was higher in the alcohol/drug use group than the no alcohol/drug group (82.1% vs. 69.7%, respectively; P = .0003). The only difference between the types of injuries sustained between the alcohol/drug and the no alcohol/drug groups was craniofacial fractures (16.4% vs 11%, respectively; P < .0278). The proportion of patients who were treated and released from the ED was higher in the no alcohol/drug group than the alcohol/ drug group (72.8% vs 61.2%, respectively; P = .0008). Lastly, the proportion of patients who were treated and admitted was higher in the alcohol/drug group than the no alcohol/drug group (28.9% vs 20.4%, respectively; P = .0067). These results are summarized in

Table 2. Comparison of Clinical Profile of Craniofacial Injury (n = 1,416) Patients With (n = 201) and Without (n = 1,215) Alcohol or Drug Use.

		Alcohol/drug use (n = 201)	No alcohol/drug use (n = 1,215)	P-value
Average age (+SD) [years]		37.2 (+13.3)	38.7 (+19.2)	.2866
Sex	Males	165 (82.1%)	847 (69.7%)	.0003*
Most common types of injury	Bleeds	3 (1.5%)	28 (2.3%)	.4727
	Contusions/abrasions	13 (6.5%)	115 (9.5%)	.1703
	Fractures	33 (16.4%)	134 (11.0%)	.0278*
	Internal injury	98 (48.8%)	546 (44.9%)	.3038
	Lacerations	36 (17.9%)	198 (16.3%)	.5717
Disposition from ED	Treated and released	123 (61.2%)	885 (72.8%)	.0008*
	Treated and admitted	58 (28.9%)	248 (20.4%)	.0067*
	Left without being seen	8 (4.0%)	28 (2.3%)	.1562
	Treated and transferred	9 (4.5%)	34 (2.8%)	.1937
	Held for observation	3 (1.5%)	16 (1.3%)	.8186
	Fatality incl. DOA or died in ED	0 (0%)	4 (0.3%)	.4370

Abbreviations: SD, standard deviation; ED, emergency department; DOA, dead on arrival.

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Overall, injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a craniofacial injury than injured patients not under influence (OR 2.50, 95% CI: 2.07-3.01, P < .0001). When stratifying by sex, injured males under the influence of alcohol/drugs experienced greater odds of sustaining a craniofacial injury than injured males not under the influence (OR 2.72, 95% CI: 2.21-3.36, P < .0001), and injured females under the influence of alcohol/drugs also experienced greater odds of sustaining a craniofacial injury than injured females not under the influence (OR: 1.90, 95% CI: 1.25-2.91, P < .0001) (

Table 3. Odds Ratios of General Craniofacial Injury (n = 1,416) After Recreational Motorized Vehicle-Related Trauma With Alcohol or Drugs Involved Compared to No Alcohol or Drugs Involved for Overall and Stratified Male and Female Cohorts.

).

Alcohol or Drug Use and Craniofacial Fractures, Lacerations, and Internal Injuries

There were 167 patients with a craniofacial fracture after recreational motorized vehicle trauma (167/1,416; 11.8%). Of these 167 craniofacial fracture patients, 33 had alcohol/ drug use recorded (33/167; 19.8%). Overall, injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a craniofacial fracture than injured patients not under the influence (OR: 2.98, 95% CI: 2.01-4.40, P < .0001).

There were 234 patients with a craniofacial laceration after recreational motorized vehicle trauma (234/1,416; 16.5%). Of these 234 craniofacial laceration patients, 36 had alcohol/drug use recorded (36/234; 15.4%). Overall, injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a craniofacial laceration than injured patients not under the influence (OR: 2.19, 95% CI: 1.51-3.16, P < .00001).

There were 644 patients with craniofacial internal injuries after recreational motorized vehicle trauma (644/1,416; 45.5%). Of these 644 craniofacial internal injury patients, 98 had alcohol/drug use recorded (98/644; 15.2%). Overall, injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a craniofacial internal injury than injured patients not under the influence (OR: 2.33, 95% CI: 1.84-2.95, P < .00001) (

Table 4. Odds Ratios of Craniofacial Fracture (n = 167), Internal Injury (n = 644) and Laceration (n = 234) After Recreational Motorized Vehicle-Related Trauma With Alcohol or Drugs Involved Compared to No Alcohol or Drugs Involved.

).

Discussion

For this study, we hypothesized that the odds of experiencing any craniofacial injury, including craniofacial fracture and laceration, were significantly greater in individuals using recreational motorized vehicles with alcohol or drugs (“substances”) compared to individuals using recreational motorized vehicles without alcohol or drugs. With these data, we aim to determine the odds ratio of craniofacial injuries between a group of recreational motorized vehicle trauma patients with and without substance use to improve the prevention of these terrible injuries. There were a total of 6,485 adult patients who experience an injury after recreational motorized vehicle trauma reported by NEISS-participating EDs during the study period. Of those, 1,416 patients had a craniofacial injury, a 21.8% prevalence. Injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a general craniofacial injury (OR 2.50, 95% CI: 2.07-3.01, P < .0001), craniofacial fracture (OR: 2.98, 95% CI: 2.01-4.40, P < .0001), laceration (OR: 2.19, 95% CI: 1.51-3.16, P < .00001) and internal injury (OR: 2.33, 95% CI: 1.84-2.95, P < .00001) than injured patients not under the influence.

We identified many further trends worth discussion. Unsurprisingly, the mean age of patients with craniofacial trauma was young and overwhelmingly male. Though the mean age of patients between the substance use and no substance use groups were not different, the substance use group was proportionally more male (82.1% vs 69.7%, respectively; P = .0003). Despite this difference, when stratifying by sex, both male (OR: 2.72, 95% CI: 2.213.36, P < .00001) and female (OR: 1.90, 95% CI: 1.25-2.91, P < .00001) patients experienced significantly greater odds of experiencing craniofacial injury when using recreational motorized vehicle under the influence than not under the influence of alcohol or drugs. Regarding ED disposition, patients not under the influence were more likely to be treated and released from the ED than patients under the influence (72.8% vs 61.2%, respectively; P = .0008), and patients under the influence were more likely to be admitted that their sober counterparts (28.9% vs 20.4%, respectively; P = .0067).

Though alcohol has been implicated in the risks associated with many recreational activities, there are limited data on the specific risk of substance use while operating a recreational motorized vehicle use, which include ATVs, dirt bikes, mopeds, go-carts, and dune buggies among others. There is evidence that implicates recreational motorized vehicle use in craniofacial injuries, especially in children,[8] and frequently their drivers are using alcohol.[9] A study from Richards and Loder in 2019 found that there are almost 150,000 ED visits for ATV related injuries each year with fractures occurring in over 25% of patients. Alcohol use was most frequently co-present with cranial fractures (13.2%), and patients with craniofacial fractures were unhelmeted 88% of the time.[10] Additional study from Rostas et al has found that helmet use was associated with lower rates of intracranial hemorrhage and alcohol use was associated with increased incidence of intracranial hemorrhage and facial or rib fracture.[11]

We are unable to accurately comment on helmet status for the patients in our study population, but past studies of helmet use during various recreational activity and sport participation under the influence have found utilization to be low.[12,13] We attempted to circumvent this by comparing the likelihood of craniofacial injury in patients using “helmeted” vehicles (e.g. ATVs, dirt bikes, mopeds, gocarts, dune buggies) to patients using “unhelmeted” vehicles (e.g. golf carts, motorized wheelchairs). However, over 90% of patients from our study population were injured due to “helmeted” vehicles, so formal stratification of “unhelmeted” vehicles was not able to be performed. Though we recognize the challenge associated with ensuring helmeted use of recreational motorized vehicle, we strongly recommend continued interventions to increase their use, which have been shown to be successful in the past.[14]

A study from Touma et al found that Injury Severity Scores (ISS) were worse for those patients with maxillofacial injuries, as well as for those patients who had been drinking alcohol.[15] Furthermore, they report that most patients with maxillofacial injuries occurring at night had been drinking alcohol. This study raises the question that in certain communities, especially rural settings, ATV or other recreational motorized vehicle use may replace car driving as a mode of transportation when inebriated. As this study shows, driving a recreational motorized vehicles when under the influence of alcohol or drugs is not a safe alternative to driving a car when under the influence of alcohol or drugs, and the illegality of recreational motorized vehicle use while inebriated should be emphasized and enforced to help reduce these injuries.

Limitations

We have limitations in this present study. Though the large numbers afforded by the nationwide database provides strength to this study, there is documented evidence that large databases maintained my humans can have missing or inaccurate data, including subjective assignment of diagnosis classifications by individual practitioners which may introduce bias.[16,17] Furthermore, certain valuable pieces of data, including accurate helmet status and type of cranial fractures, are not collected, which would provide opportunities for further analyses. This data base was not designed with researchers in mind but is a useful tool for computing population health care trends and has been of great importance to many specialties in numerous prior analyses.[18,19,20,21,22,23] However, only patients who present to the emergency department for emergency care are recorded, which can introduce biases against minor injuries, uninsured patients, or patients who prefer to use outpatient or urgent care settings.[24] Nevertheless, our study reports strong evidence to support the increased likelihood of craniofacial injuries, including fractures, lacerations and internal injuries, while using recreational motorized vehicles under the influence of alcohol or drugs.

Conclusions

Using recreational motorized vehicles, including ATVs, dirt bikes, mopeds, go-carts, and golf carts, while under the influence of alcohol or drugs is not safe and significantly increases the likelihood of craniofacial injuries, including craniofacial fractures, lacerations, and internal injury. Participating in this activity while under the influence of alcohol or drugs should be illegal and the law enforced, especially among young men. Additional undertakings to increase helmet usage would be meaningful for further decreasing the incidence of craniofacial injuries in this population.