Helmet Use in Adults
The use of safety helmets in the adult population( 17.7 %) was much less than in those < 18 years( 41.7 %). There was a general trend of decreasing helmet use with increasing age. The protective effect of helmets in adults was demonstrated again using ICU admission as a surrogate for severe injury. Of the 407 adults wearing a helmet, 77( 18.9 %) required ICU admission, versus 528 of the 1,892( 27.9 %) who were not wearing a helmet( p-value =. 000187; Relative Risk-0.8; Odds Ratio 0.75). There were 26 deaths in the adult age group, only one of whom was wearing a helmet.
Substance Use in Adults
Substance use was common in the adult ATV crash victim population, with 45.7 % of crash victims having a positive EtOH and / or urine drug screen positive for THC, cocaine, amphetamines, and / or barbiturates. Ethanol was found in 872 crash victims; in 191 there was an additional substance found on the urine drug screen. THC was the next most common substance, found in 307 crash victims, as the sole substance in 113, and with EtOH in another 146.
There was a trend toward more substance use over the 13-year period, and substance use was most likely between ages 22 and 58.
Repeat Crash Victims and Helmet Use
There were 43 crash victims that presented to JMMTC on more than one occasion. There were 36 that were not wearing helmets during their first crash and 28 were again without helmet for their subsequent crash; 10 of these continued to go helmetless despite an ICU admission after their first crash. Of the seven that wore a helmet during the first crash, only one was wearing a helmet during his second crash( Table 2).
DISCUSSION
ATV accidents have caused significant morbidity and mortality since their introduction in the US in 1969. 5 Our institution reported 3,037 accidents with 778 pediatric patients involved over a 13-year span. WV has the third highest rate for ATV-related fatalities from 1982-2017 per US Consumer Product Safety Commission data 2 despite its 39th rank in population among the 50 states. 3 WV presents a unique opportunity for focused efforts on a small population, which can make a great impact on the state’ s morbidity and mortality when it comes to ATV fatalities / accidents.
Children under 16 years of age have 12 times greater risk than adults for significant ATV injuries. 6 The high risk for death is likely multifactorial, including physical immaturity, lack of training, size of ATV, helmet usage, and carrying / being a passenger. 6 Our data demonstrate that children under 4 years were least likely to wear a helmet, with only 6.2 % of patients wearing one. Helmet usage in the pediatric age group prevented severe( ICU admission) ATV related injuries. Our data suggest that helmet usage and substance use are modifiable risk factors that may be able to prevent severe ATV injuries. The repeat crash victims that continued to ride helmetless even after an ICU admission demonstrate that experience alone is not the answer.
WV law requires all ATV riders less than 18 years of age to wear an appropriately sized helmet that meets the standards of the US Department of Transportation and to obtain a certificate of completion for a vehicle rider safety awareness course( 2022 WV Code, Chapter 17F). Despite these requirements, the rate of helmet use in this age group in our study was 41.7 %, similar to the 44.7 % of Canadian youth less than 16 years, 7 where helmets are also required, but higher than the 30 % in Kansas where there is no helmet requirement. 8 One explanation for the low helmet use is that the law pertains to public lands, and there is an exemption for ATV use on private property. In addition, WV has no requirement for adults aged 18 and older to wear helmets, and helmet use is correspondingly much lower, falling below 20 % after age 25( Figure 1).
Most ATV injury studies that report helmet use are on riders who present for medical care. To get an estimate of all ATV users, not just those involved in crashes, surveys have been used. Helmet use in ATV crashes in young riders( less than age 16 or 17 years) ranged from 4 % to 39 % in reports of at least 100 patients published since 2000. 9 Other surveys of helmet use in the pediatric age group reveal similar numbers. In a multi-school survey of 4,320 mostly rural students in Iowa, 77 % reported having ridden an ATV. Of these, 64 % reported never using a helmet and another 12 % reported using a helmet less than half the time. More than half( 57 %) reported having been in a crash. 10 Survey participants in a Connecticut study reported helmet use in 60-90 %, decreasing with increasing age, and they also reported a high rate of risky driving behaviors such as racing, double riding( 70 %), riding alone without family or friends present( 59 %), and riding after dark( 46 %). Forty-four percent reported being in an ATV crash, and 14 % reported an emergency department visit as a result. 11 Helmet use has been demonstrated to reduce fatal head injury by 40 % and non-fatal traumatic brain injury by approximately 60 % or more. 12
The American Academy of Pediatrics( AAP) recently recommended against any child under 16 years being a passenger or operator of an ATV as a consensus-based practice to prevent ATV-related injury and death. 12 It is unlikely that ATV ridership in youth will cease despite the AAP recommendations. Parents, children, and adolescents will continue to utilize ATVs as a recreational / work vehicle especially in rural areas, where public transportation is lacking. Additionally, ATV riding is often a family recreational activity. There are ATV races for children starting as young as 4 years of age, 13 as well as ATV racing video games available for most gaming platforms. Education efforts are needed to provide instruction to parents as well as children to effectively mitigate behaviors associated with ATV-related injury and death. Riding with multiple riders, not wearing a helmet, appropriately sized ATVs, and riding on public roads are all risky behaviors associated with increased risk of injury. 12
Widespread education efforts have been postulated to aid in decreasing ATVrelated injuries in youth. 14-16 Survey
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