View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
ENJOYED BY MANY, all-terrain vehicles (ATVs) are widely used for recreation and as a means of transportation for farmers and hunters. But they also have a dark side. For those who don't adhere to safety guidelines for riding, they present opportunities for serious injury and even death.
The case study described in this article illustrates the risks and safety considerations associated with ATVs, including common injuries associated with ATV crashes. This article also discusses how nurses can help prevent serious injury and death by educating patients about the hazards.
During the evening shift, a trauma code is called. As staff members arrive in the trauma bay, the medic gives report on the patient. SB is a 24-year-old male observed by friends driving an ATV off-road at high speed in a rural area. According to witnesses, he'd consumed at least a six-pack of beer before the event. Riding without a helmet, he lost control, was ejected from his vehicle, and landed face down, unconscious and motionless.
An emergency medical service team arrived on the scene 6 minutes after receiving the call. Their initial assessment findings included minimal respiratory effort, eye opening to painful stimuli, decorticate posturing of the upper extremities, and minimal movement of the lower extremities. They immobilized the cervical spine, inserted a large-bore peripheral venous access device, and began an infusion of 0.9% sodium chloride. The patient was endotracheally intubated after rapid sequence induction.
SB was transferred to a level one trauma center, where the staff conducted a primary survey. (See Performing a primary and secondary survey.) Assessment revealed a controlled airway with clear, equal, bilateral breath sounds. Ventilation was maintained by bag-valve-mask device. Pulses were intact with no gross bleeding.
Neurologic assessment revealed pupils were equal and reactive to light. His Glasgow Coma Scale (GCS) score was a 3T (E1, V1, M1). (See Keeping score with the GCS.)
SB's vital signs were as follows: oral temperature 97.2 F (36.2[degrees] C), heart rate 90, assisted ventilation rate 12, BP 124/79, and oxygen saturation 99% via pulse oximeter.
The secondary survey revealed bilateral decorticate posturing of the upper extremities and no response to painful stimuli in the lower extremities. Abrasions were noted on the upper lip, abdomen, and right anterior lower extremity.
Based on a family member's report, SB's medical history included involvement in a motor vehicle crash in 2000 in which he'd sustained a traumatic brain injury (TBI) and multiple facial fractures.
A complete blood cell count, basic chemistry panel, and international normalized ratio were within normal range. His urine drug screen was positive for benzodiazepines, and his blood alcohol level was 199 mg/dL. A chest X-ray and focused assessment with sonography for trauma (FAST) exam were negative.1
Computed tomography (CT) of the head revealed a subdural hematoma along the falx, multiple intraparenchymal hemorrhages in the left temporal lobe and bilateral frontal lobes, and a subarachnoid hemorrhage in the right frontal lobe. Because of the multiple cerebral contusions and hemorrhages, a diagnosis of TBI was added to the patient's list of injuries.
CT of the cervical, thoracic, and lumbar spine was negative for fracture and subluxation. CT of the chest revealed a few scattered parenchymal opacities. CT of the abdomen and pelvis revealed a hepatic lobe laceration. SB was admitted to the ICU where he remained intubated with sedation and analgesia for the first 9 days.
The U.S. Consumer Product Safety Commission (CPSC) has been analyzing data on injuries from ATV crashes since the early 1980s. (See Many victims are children and ATV deaths, state by state.) The CPSC considers an ATV to be an off-road motorized vehicle with three or four low-pressure tires, a straddle seat, and handlebars for steering. Off-road vehicles with steering wheels and bucket or bench seats, such as golf carts and dune buggies, aren't considered ATVs, so injuries and fatalities associated with these vehicles aren't included in the data for ATV crashes.
Because of their high center of gravity, all ATVs are inherently unstable, but three-wheeled ATVs are associated with a particularly high rate of injuries and deaths. In the early 1980s, the major manufacturers and distributors agreed to stop the distribution of three-wheel ATVs, so nearly all ATVs in use today have four wheels. However, some older three-wheeled vehicles are still in use.2
The three-wheel ATVs' lighter weight compared with their four-wheel counterparts makes them attractive to expert riders but also creates serious safety issues. Flipping backward when riding up a hill and rolling over when going downhill are significant risks. Rapid turns also increase the propensity for a rollover because of reduced stability with one front wheel as opposed to two.
In 1988, ATV manufacturers and distributors received a directive from CPCS that limited the sale of adult-sized vehicles for use by children. They also were obliged to provide safety awareness and education programs free of charge to the public.
Due to the inherent instability of ATVs, the CPCS issued new standards in 2008. Manufacturers are now required to place a certification label on all ATVs showing compliance with the new standards, which include maximum speed and pitch stability. ATV tires are designed for off-road use and product safety warnings by major tire manufacturers advise the rider to never use the ATV on a paved road.
An article by Sawyer et al., in the April 2011 issue of Journal of the American Association of Orthopaedic Surgeons, evaluates the new ATVs compared to the older farm models of the 1970s and 1980s.2 The early models generated about 7 horsepower with 89 cc engines weighing 160 to 200 pounds (72 to 90 kg). Today's vehicles boast 600 cc engines producing over 50 horsepower and weights of at least 400 pounds (180 kg). Speeds of 70 to 100 mph aren't uncommon, and the larger ATV can tow over 1,000 pounds (450 kg ).
Because most recreational riding takes place in rural areas, helmet laws and minimum age requirements aren't easily enforced and are largely ignored. Alcohol and drugs are also frequently part of the dangerous mix. Sawyer et al. also found that even after riders suffered a TBI from a crash, riders and parents of young riders weren't more inclined to use or encourage helmet use.2
The study also revealed a "vehicle-rider mismatch": Many young riders riding high-end heavy, fast vehicles. The researchers say these children don't possess the "body mass or the muscular strength to correct a rollover." In addition, children don't have "the cognitive capabilities, the depth perception, or emotional maturity and judgment to operate these vehicles." Yet most states don't require formal training on the safety and handling of an ATV.
Regulations vary from state to state regarding licensure, the minimum age to operate an ATV, and the necessity for wearing a helmet and eye protection. Despite this variation, many safety organizations recommend wearing a helmet approved by the U.S. Department of Transportation (DOT) and/or the Snell Memorial Foundation. Information on current state ordinances can be obtained from the ATV Safety website at http://www.ATVSafety.gov.
Unfortunately, SB's risky behaviors-consuming six or more beers before driving the ATV, speeding, and neglecting to wear a helmet-placed him at high risk for the serious injuries he sustained.
SB is a fairly typical victim of an ATV crash. He's in the 16 to 24 age range that comprise over one-third of ATV-related ED visits.3 In children, soft tissue injuries, extremity fractures, and head injuries are the most common types of injuries associated with ATV crashes, often accompanied by abdominal, pelvic, and spine injuries.4 SB sustained a TBI, liver laceration, and a right pulmonary contusion. Though he didn't sustain any extremity fractures, these are common in both younger and older riders.4,5 The exposure of the limbs and lack of safety gear, combined with the speed at which these vehicles are ridden, increase the chance for injury. Substance abuse, riding in the dark, and not wearing a helmet further raise the risk.
TBI is a leading cause of death and disability in the United States.6 Head, neck, and cervical spine injuries are the most common injuries in fatal ATV incidents and incidents resulting in major trauma center admissions.5-7 Devastating cervical spine injuries can result in quadriplegia.
After a 21-day hospital stay, SB was discharged to a rehabilitation hospital specializing in TBI recovery. At that time he was nonverbal and impulsive. He occasionally followed commands. His GCS at the time of discharge was 10 (E2, V2, M6).
SB's admission status to a TBI rehab hospital included impulsivity, decreased attention to tasks, restlessness and inattention, dysphagia, and apraxia. Expressive and receptive deficits were revealed in the speech and language evaluation.
After 2 months of intense TBI rehabilitation, SB required supervision to initiate basic activities of daily living and verbal cues for memory. He was still limited by expressive aphasia. He was discharged to a residential brain injury program for ongoing therapy.
SB had been a working, independent young adult. This tragedy could have been prevented had he followed the recommendations for riding ATVs or if his family or friends had intervened before the crash.
Like young riders, those age 50 and above are at increased risk for serious injury in ATV crashes. Age-related changes in physical reserve and sensory limitations, preexisting medical conditions, and medication use can all raise the risk of injury in older ATV riders. Helmkamp and Carter concluded that "an increasing propensity for older adults to engage in activities associated most often with younger age groups have led to an increase in fatality patterns."8 As a result, ATV deaths increased 155% between the periods studied: 1985 to 1998 and 1999 to 2007. Sixty-two percent of injuries involved the chest and abdomen, the most common injuries in this age group. Injuries to the head and neck accounted for 28% of the total trauma to this population.8
Patients in this age group typically present with a higher systolic BP and a lower GCS score. Clinical outcomes are generally worse, with longer ICU and hospital stays compared with their younger counterparts.9,10
How can nurses promote ATV safety? We can make the most impact by presenting safety information to children in schools, churches, and other community organizations involved with children. Level one trauma centers are required to have an injury prevention coordinator, and part of that individual's role involves presenting safety programs to the public. Creative means that would spark an interest in the subject of safety on an ATV could involve the use of a video or role playing.
Once an injured patient enters the hospital and can process information, nurses, NPs, and other healthcare providers can educate not only the patient, but also the patient's family and friends, about strategies to prevent injuries in the future. When alcohol or drugs are involved, an alcohol counselor can help the patient seek treatment for substance abuse.
Encourage patients who use ATVs to attend an approved ATV driver's course. This provides hands-on training in a controlled environment where instructors provide the driver with the necessary tools to reduce accidents and injury. Training courses are also offered online by some organizations.
Various agencies including the Injury-Free Coalition for Kids, ATV Safety Institute (ASI), American Academy of Pediatrics, and http://ATVSafety.gov offer concise recommendations that complement the state regulations already identified.
The not-for-profit ASI, formed in 1988, has a mission to implement an expanded national program on ATV safety. The ASI lists these eight golden rules for using ATVs safely.11
* Always wear a DOT-approved helmet with eye protection. Long sleeve shirts, pants, gloves, and over-the-ankle boots provide protection in the event of a crash or fall.
* Never ride on paved roads.
* Never ride under the influence of alcohol or drugs.
* Don't ride with passengers. Most ATVs are designed for one person.
* Ride an ATV that's right for your age. Children shouldn't operate ATVs intended for adults.
* Supervise riders under age 16.
* Ride only on designated trails at a safe speed.
* Take an ATV rider safety course.
* Follow state regulations regarding the supervision of children and the use of lights on the ATV to enhance visibility.
The ASI provides free public safety announcements on its website. These could be posted in schools and other community settings to remind ATV users about safe riding practices.
Think about a child, grandchild, niece, nephew, or the child of a friend who rides an ATV. How would you feel if you hadn't taken the time to make sure that they were adequately instructed before they went for a ride and this story was about them? It's our responsibility as adults and professional healthcare providers to make sure that education is provided to prevent devastating injuries from ATV crashes. You can have a real impact in preventing future ATV-related injuries.
A: airway. Can the patient talk? Check for the tongue obstructing the airway, loose teeth, foreign objects, blood, vomitus, edema.
B: breathing. Note spontaneous breathing, rise/fall of chest, accessory muscle use, skin color, bilateral breath sounds. All patients should receive oxygen via nonrebreather mask at 12 to 15 L/min. If patient is intubated, check breath sounds bilaterally and over epigastrium. ETC02 should be 35-40 mm Hg.
C: circulation. Check central pulses (carotid, femoral, brachial in patients less than 1 year) and pulse rate and strength. Note bleeding, BP, skin color, and temperature.
D: disability. Perform a brief neurologic exam and document:
A-alert and responsive
V-responds only to verbal stimuli.
P-no response to verbal stimuli but responds to pain
E: exposure/environment. Remove all clothing/keep patient warm.
F: full set of vital signs and focused adjuncts, such as nasogastric or orogastric tube placement, FAST exam, indwelling urinary catheter insertion. F also stands for family presence during the resuscitation.
G: give analgesia and comfort measures.
H: obtain history and perform a complete head-to-toe exam. History includes mechanism and extent of injury, vital signs en route to hospital, and treatment.
I: inspect posterior surfaces. This includes logrolling the patient, palpating the entire spine, checking the anal sphincter for tone, and assessing the rectum for gross blood.
The CPSC reports that in 2010, an estimated 115,000 patients were treated in EDs for injuries related to ATV crashes; 28,300 (about 25%) were under age 16, and 14,000 (12%) were under age 12. In 2006, the most recent year for which data on ATV fatalities are complete, an estimated 17% of ATV fatalities were children younger than 16. According to the American Academy of Pediatrics, children younger than age 16 are four times more likely to sustain a serious injury than an older rider because of many variables, including height, weight, muscle strength, cognitive ability, and immature reflex development.
1. http://Trauma.org. Focused assessment with sonography for trauma (FAST). http://www.trauma.org/index.php/main/article/214. [Context Link]
2. Sawyer JR, Kelly DM, Kellum E, Warner WC Jr. Orthopaedic aspects of all-terrain vehicle-related injury. J Am Acad Orthop Surg. 2011;19(4):219-225. [Context Link]
3. Garland S. 2008 Annual Report of ATV-related Deaths and Injuries. Consumer Product Safety Commission. 2010:1-23. http://www.cpsc.gov/library/foia/foia10/os/atv2008.pdf. [Context Link]
4. Kellum E, Creek A, Dawkins R, Bernard M, Sawyer JR. Age-related patterns of injury in children involved in all-terrain vehicle accidents. J Pediatr Orthop. 2008;28(8):854-858. [Context Link]
5. Kirkpatrick R, Puffinbarger W, Sullivan JA. All-terrain vehicle injuries in children. J Pediatr Orthop. 2007;27(7):725-728. [Context Link]
6. Coronado VG, Xu L, Basavaraju SV, et al. Surveillance for traumatic brain injury-related deaths-United States, 1997-2007. MMWR Surveill Summ. 2011;60(5):1-32. [Context Link]
7. Krauss EM, Dyer DM, Laupland KB, Buckley R. Ten years of all-terrain vehicle injury, mortality and healthcare costs. J Trauma. 2010:69(6):1338-1343. [Context Link]
8. Helmkamp JC, Carter MW. ATV deaths among older adults in West Virginia: evidence suggesting that "60 is the new 40." South Med J. 2009;102(5):465-469. [Context Link]
9. Deladisma AM, Parker W, Medeiros R, Hawkins ML. All-terrain vehicle trauma in the elderly: an analysis of a national database. Am Surg. 2008;74(8):767-769. [Context Link]
10. O'Neill S, Brady RR, Kerssens JJ, Parks RW. Morality associated with traumatic injuries in the elderly: a population-based study. Arch Gerontol Geriatr. 2012;54(3):e426-430. [Context Link]
11. ATV Safety Institute. The ATV Safety Institute's golden rules. http://www.atvsafety.org/. [Context Link]
12. Garland S. 2010 Annual Report of ATV-Related Deaths and Injuries. Consumer Product Safety Commission. 2011:1-27. http://www.cpsc.gov/library/foia/foia12/os/atv2010.pdf. [Context Link]
13. Moore S, Sabella J. Young riders: all-terrain vehicle use in North Texas. J Trauma Nurs. 2007;14(4):203-205. [Context Link]
14. Trauma Nursing Core Course Provider Manual. 6th ed. Des Plaines, Ill.: Emergency Nurses Association; 2007:34-49. [Context Link]
Back to Top