Abstract

Objective:

To analyze factors associated with mortality from traumatic injuries among motorcyclists.

Methods:

This was a prospective cohort conducted at the Municipal Hospital of São José dos Campos, Brazil, in 2015. Motorcyclists with traumatic injuries, ≥14 years old and hospitalized were included. Sociodemographic, accident and hospitalization variables were analyzed by applying a Poisson regression model showing relative risk (RR) and 95% confidence intervals (95%CI).

Results:

Among 190 motorcyclists, 161 (84.7%) young men were found to have 422 (41.8%) injuries to the lower and upper extremities. Incidence of death increased as physiological injury severity (RR=9.67 [95%CI 1.46;64.26] and RR=4.71 [95%CI 1.36;16.26]), and anatomical injury severity (RR=31.49 [95%CI 3.72;266.38]) increased, but was lower within up to one week of hospitalization (RR=0.39 [95%CI 0.15;0.98]).

Conclusion:

Injury severity and length of hospital stay were associated with motorcyclist deaths. Further studies should be conducted to confirm these findings and to analyze the relationships in greater detail.

Keywords:
Accidents, Traffic; Motorcycles; Injury Severity Score; Mortality; Cohort Studies

Introduction

Traffic accidents are a Public Health problem globally and also in Brazil given the large number of deaths and post-injury consequences. According to a 2018 World Health Organization (WHO) report, 1.35 million people are victims of traffic accidents every year globally, principally in low-income countries. They are the leading cause of death among young people aged 15-29. In the same report, WHO estimated that deaths related traffic accidents would reach 1.9 million globally by 2020 if measures were not taken immediately.¹1. World Health Organization - WHO. Global status report on road safety 2018 [Internet]. Geneva: World Health Organization; 2018 [cited 2020 Aug 8]. Available from: https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
https://www.who.int/violence_injury_prev...

With effect from 1990, the progressive improvement in the Brazilian economy has enabled increased purchasing of durable goods by people from less-favored social classes as well as greater access to credit.²2. Seerig LM, Bacchieri G, Nascimento GG, Barros AJD, Demarco FF. Use of motorcycle in Brazil: users profile, prevalence of use and traffic acidentes occurrence – a population-based study. Ciênc Saúde Coletiva [Internet]. 2016 Dec [cited 2020 Aug 8];21(12):3703-10. Available from: http://dx.doi.org/10.1590/1413-812320152112.28212015
http://dx.doi.org/10.1590/1413-812320152... The fact of motorcycles costing less, together with the reduction in tax on industrialized products, has led to a considerable increase in the number of motorcycles in circulation in Brazil. Between 2003 and 2012, there was an increase of almost 500% in the number of these vehicles in Brazil.³3. Senado Federal (BR). Mortes em motos minam a saúde e a juventude. Rev Em Discussão [Internet]. 2012 nov [citado 2017 jan 19];3(13):6-78. Disponível em: http://www.senado.gov.br/noticias/jornal/emdiscussao/Upload/201204%20-%20novembro/pdf/em%20discuss%C3%A3o!_novembro_2012_internet.pdf
http://www.senado.gov.br/noticias/jornal... The increase in the fleet of motorcycles has resulted in increased traffic accidents, especially because Brazilian legislation allows motorcycles to be driven between cars on the lanes of public highways and, consequently, opens the way for disrespect for the highway code and speed limits, in addition to little highway code enforcement.¹1. World Health Organization - WHO. Global status report on road safety 2018 [Internet]. Geneva: World Health Organization; 2018 [cited 2020 Aug 8]. Available from: https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
https://www.who.int/violence_injury_prev... ^,33. Senado Federal (BR). Mortes em motos minam a saúde e a juventude. Rev Em Discussão [Internet]. 2012 nov [citado 2017 jan 19];3(13):6-78. Disponível em: http://www.senado.gov.br/noticias/jornal/emdiscussao/Upload/201204%20-%20novembro/pdf/em%20discuss%C3%A3o!_novembro_2012_internet.pdf
http://www.senado.gov.br/noticias/jornal... ^,44. Marín-Léon M, Belon AP, Barros MBA, Almeida SDM, Restitutti MC. Tendência dos acidentes de trânsito em Campinas, São Paulo, Brasil: importância crescente dos motociclistas. Cad Saúde Pública [Internet]. 2012 jan [citado 2020 ago 8];28(1):39-51. Disponível em: http://dx.doi.org/10.1590/S0102-311X2012000100005
http://dx.doi.org/10.1590/S0102-311X2012...

Motorcyclists are among the victims of severe injuries caused by traffic accidents. Both driver and passenger, when colliding with another object, suffer a high-energy impact generated by the collision; motorcycle drivers absorb this energy and, as a result, frequently suffer injuries to the head and brain, the spine and the lower and upper limbs.⁵5. Besse M, Denari R, Villani A, Roque MS, Rosado J, Sarotto AJ. Accidentes de moto: costo médico/económico en un hospital municipal de la ciudad de Buenos Aires. Medicina (B. Aires) [Internet]. 2018 jun [citado 2019 fev 6];78(3):158-62. Disponível em: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0025-76802018000300003
http://www.scielo.org.ar/scielo.php?scri... ^,66. Rubin G, Peleg K, Giovon A, Goup IT, Rozon N. Upper extremity fractures among hospitalized road traffic accidents adults. Am J Emerg Med [Internet]. 2015 Feb [cited 2020 Aug 8];33(2):250-3. Available from: https://doi.org/10.1016/j.ajem.2014.11.048
https://doi.org/10.1016/j.ajem.2014.11.0... As such, motorcyclists are seven times more at risk of dying and four times more at risk of having body injuries, when compared to other types of traffic accidents.²2. Seerig LM, Bacchieri G, Nascimento GG, Barros AJD, Demarco FF. Use of motorcycle in Brazil: users profile, prevalence of use and traffic acidentes occurrence – a population-based study. Ciênc Saúde Coletiva [Internet]. 2016 Dec [cited 2020 Aug 8];21(12):3703-10. Available from: http://dx.doi.org/10.1590/1413-812320152112.28212015
http://dx.doi.org/10.1590/1413-812320152... In 2017 and 2018, 114,497 deaths arising from motorcycle accidents were recorded in Brazil.⁷7. Ministério da Saúde (BR). DATASUS. Óbitos por causas externas do grupo de causas: motociclistas traumatizados em acidentes de transporte [Internet]. Brasília: Ministério da Saúde; 2018 [citado 2010 fev 6]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/fiuf.def
http://tabnet.datasus.gov.br/cgi/tabcgi....

People injured in motorcycle accidents can have sequelae resulting from their injuries, impairment of cognition and/or mobility, with impact on their professional and everyday lives, social relationships, physical and mental health.⁶6. Rubin G, Peleg K, Giovon A, Goup IT, Rozon N. Upper extremity fractures among hospitalized road traffic accidents adults. Am J Emerg Med [Internet]. 2015 Feb [cited 2020 Aug 8];33(2):250-3. Available from: https://doi.org/10.1016/j.ajem.2014.11.048
https://doi.org/10.1016/j.ajem.2014.11.0... This scenario generates high expenditure on hospitalization, rehabilitation and indemnity payments for Insurance for Personal Injury Caused by Motor Vehicles on Overland Thoroughfares.³3. Senado Federal (BR). Mortes em motos minam a saúde e a juventude. Rev Em Discussão [Internet]. 2012 nov [citado 2017 jan 19];3(13):6-78. Disponível em: http://www.senado.gov.br/noticias/jornal/emdiscussao/Upload/201204%20-%20novembro/pdf/em%20discuss%C3%A3o!_novembro_2012_internet.pdf
http://www.senado.gov.br/noticias/jornal...

The growing use of motorcycles and the growing number of motorcyclists involved in traffic accidents highlight the relevance of the subject. Analysis and interpretation of data related to this phenomenon can contribute to the formulation of programs to prevent these accidents, promotion of safer driving behaviors, as well as identification of factors related to hospital mortality that could be reduced through good care practices.

The objective of this study was to analyze factors associated with motorcyclist hospital mortality from traumatic injuries.

Methods

This is a prospective cohort study of motorcyclists hospitalized owing to traumatic injuries caused by land transport accidents.

This study is part of a larger project entitled ‘Injury information and quality indicator system: analysis of morbidity and mortality arising from traumatic injuries caused by traffic accidents: Research for SUS – shared health management (PPSUS-SP)’.

The data it is based on were collected at the Dr. José de Carvalho Florence Municipal Hospital (HMJCF). It is a reference center for medium and high complexity hospital care, especially emergency services, and is the largest hospital unit in São José dos Campos city and surrounding region. This municipality is located in the state of São Paulo, is part of the Vale do Paraíba Paulista region and had 629,921 inhabitants in 2010, according to data provided by the city administration.⁸8. Prefeitura de São José dos Campos. São José em dados 2016: informações sobre a cidade de São José dos Campos [Internet]. São José dos Campos: Prefeitura; 2016 [citado 2020 abr 10]. 128 p. Disponível em: http://servicos2.sjc.sp.gov.br/media/667370/sjdados_2016.pdf
http://servicos2.sjc.sp.gov.br/media/667... The HMJCF is part of a health system organized in a regionalized and hierarchized manner, providing comprehensive care to the population on diverse levels of complexity.⁸8. Prefeitura de São José dos Campos. São José em dados 2016: informações sobre a cidade de São José dos Campos [Internet]. São José dos Campos: Prefeitura; 2016 [citado 2020 abr 10]. 128 p. Disponível em: http://servicos2.sjc.sp.gov.br/media/667370/sjdados_2016.pdf
http://servicos2.sjc.sp.gov.br/media/667...

The study participants were motorcyclists (drivers and passengers) who needed to be hospitalized because of traumatic injuries, resulting from Transport Accidents, as defined by the International Statistical Classification of Disease and Related Health Problems, 10^th Version (ICD-10: V20-V29). The accidents studied occurred throughout 2015. The study included motorcyclists aged 14 years old or over who received care at the emergency room of the HMJCF Emergency Department. Individuals receiving care in the same period due to sequelae resulting from traumatic injuries caused by accidents involving motorcycles, or who returned to this health service for complementary treatment of their injuries, were not included in the study.

The outcome ‘death’ during hospitalization was defined as the dependent variable. The demographic variables, incident variables and hospitalization variables were defined as independent variables.

The demographic variables considered were age (in years, later categorized into 14-29, 30-39, 40-49 and 50 or over) and sex (male; female). The variables of the ‘incident’ category included the position of the victim on the vehicle (driver; passenger), use of crash helmet (yes; no), day of the week on which incident occurred (from Sunday to Saturday) and prehospital care (yes; no). The ‘hospitalization’ category included length of hospital stay (in days, later categorized into 1-7, 8-14 and 15 or more), clinical conditions (severity of injury and trauma), subsequent complications (yes; no) and recovery after discharge from hospital.

Injury severity was measured using the Abbreviated Injury Scale (AIS).⁹9. Association for the Advancement of Automotive Medicine – AAAM. The abbreviated injury scale (AIS): 2005 revision, update 2008 [Internet]. Des Plaines, Illinois: Association for the Advancement of Automotive Medicine; 2008 [cited 2020 Aug 8]. Available from: https://www.aaam.org/abbreviated-injury-scale-ais/
https://www.aaam.org/abbreviated-injury-... Each injury recorded on the medical records was coded according to the affected region or regions of the body and level of severity. The AIS scores, corresponding to the levels of severity, varied from 1 to 6: level 1 for minor severity; 2, moderate; 3, serious; 4, severe; 5, critical; and level 6 for maximum severity (currently untreatable).

Based on the AIS coding for each injury, injury severity, from the anatomical point of view, was determined by the Injury Severity Score (ISS). The ISS is obtained by taking the highest AIS severity code in each of the three most severely injured body regions, squaring each AIS code and adding the three squared numbers together. It is a numerical variable, with scores varying from 1 to 75: higher ISS scores indicate greater injury severity, related to greater lethality, whereby the maximum score is nearly always fatal.⁹9. Association for the Advancement of Automotive Medicine – AAAM. The abbreviated injury scale (AIS): 2005 revision, update 2008 [Internet]. Des Plaines, Illinois: Association for the Advancement of Automotive Medicine; 2008 [cited 2020 Aug 8]. Available from: https://www.aaam.org/abbreviated-injury-scale-ais/
https://www.aaam.org/abbreviated-injury-... For the purposes of this study, the ISS score was consolidated into two categories: 1-15 and ≥16. From the physiological point of view, injury severity was measured using the Glasgow Coma Scale (GCS) at the time of admission to the Emergency Department. GCS assesses level of consciousness using three indicators: eye opening, verbal response and best motor response. GCS scores vary between 3 and 15, and they were later categorized into 13-15; 9-12; 3-8.

Motorcyclist recovery after hospital discharge was measured using the Glasgow Outcome Scale-Extended,¹⁰10. Sousa RMC, Koizumi MS. Recuperação das vítimas de traumatismo crânio-encefálico no período de 1 ano após o trauma. Rev Esc Enf USP [Internet]. 1996 dez [citado 2020 ago 8];30(3):484-500. Disponível em: http://dx.doi.org/10.1590/S0080-62341996000300010
http://dx.doi.org/10.1590/S0080-62341996... also classified by scores ranging from 0 to 7: 0 for good recovery (+), corresponding to individuals whose life returned to normal without any changes or complaints following injury; 1, good recovery (-), for individuals with resumption of normal life with minor physical or mental deficits; 2, moderate disability (+), for individuals who were not able to resume all activities they did before suffering injury; 3, moderate disability (-), for those capable of carrying out activities with the aid of devices or in adapted environments; 4, severe disability (+), among the basic activities for remaining independent, at least one activity needs the assistance of someone else; 5, severe disability (-), when the person is not able to perform basic self-care activities without the help of another person; 6, persistent vegetative state, unresponsive and speechless; and 7, death. These conditions were summarized into four categories: good recovery (0 and 1); moderate disability (2 and 3); severe disability (4, 5 and 6); and death (7).

Medical records were the main source for data collection on the motorcyclists, taking the data for each day of hospitalization. Data on prehospital care were taken from the care forms, and the telephone number for contact was confirmed with the individual or their family members. Motorcyclists who were discharged from hospital were contacted by telephone, between three and six months after leaving hospital, in order to administer the Glasgow Outcome Scale-Extended.

The qualitative variables were described in absolute numbers and percentages; while the quantitative variables were expressed as average, standard deviation (SD), minimum and maximum values, and median. Fisher's exact test was used to verify association of the ‘sex’, ‘motorcyclist position’, ‘use of crash helmet’, ‘day of the week on which incident occurred’, ‘prehospital care’ and ‘complications’ variables with mortality. Fisher's exact test was used in the analysis of association of age, GCS, length of hospital stay and injury severity score (ISS) with mortality, after using the Shapiro-Wilk to check for absence of normality of the continuous variables. The power of the sample, assessed a posteriori, considering a 95% confidence interval (95%CI), was found to be 71.5% for ISS and 72.4% for GCS, while the power of the other variables was below these values. Poisson regression was used to identify factors associated with death. A 5% statistical significance level was used.

The analyses were performed with the aid of the International Business Machines Corporation Statistical Package for the Social Sciences (SPSS), version 23.0. The study project was approved by the Federal University of São Paulo Research Ethics Committee (Certificate of Submission for Ethical Appraisal [CAAE] No. 34303814.6.0000.5505; Opinion No. 795.233) and by the Dr. José de Carvalho Florence Municipal Hospital Research Ethics Committee (CAAE No. 34303814.6.3001.5451; Opinion No. 832.745). All participants signed a Free and Informed Consent form.

Results

The study sample was comprised of 190 motorcyclists and, as shown in Table 1, 161 (84.7%) were male and average age was 30 years. The incidents happened most frequently on Saturdays (46; 24.2%) and Sundays (41; 21.6%). The majority of the motorcyclists were drivers rather than passengers (144; 88.9%) and 20 (10.5%) were not wearing a crash helmet at the time of the accident. Of the total of motorcyclists who suffered accidents, 174 (91.6%) received prehospital care. The average GCS score was 14.3; and the average ISS score was 8.8. Average length of hospital stay was 8.6 days, 32 cases (16.8%) had complications during hospitalization and hospital mortality was 5.3%. Among the motorcyclists who survived, it was possible to make contact by telephone with 86 (47.7%) of them after they had been discharged from hospital, whereby 42 (48.8%) of them achieved good recovery and 27 (31.4%) were left with severe disability.

The most frequent traumatic injuries were found in the lower limbs, 272 (27.1%), followed by the external region, 222 (22.1%), upper limbs, 148 (14.7%), and head, 136 (13.6%), as shown in Table 2.

Most frequent among total injuries were those classified as minor, 347 (34.6%), and moderate, 408 (40.6%). Injuries classified as serious, severe and critical, although less frequent, i.e. 221 (22.0%), 26 (2.6%) and 2 (0.2%) respectively, were found in the lower extremities, head, thorax, abdomen and spine (Table 2).

Table 3 shows that frequency of death was highest on Wednesdays (2; 8.3%) and Saturdays (4; 8.7%) (p<0.001). Greater injury severity, whether anatomical (ISS >16; p<0.001), or physiological (GCS of between 9 and 12; p<0.001), and presence of complications (10; 31.2%) (p<0.001), were more frequent in the group that died.

In the Poisson regression model (Table 4), injury severity, measured by ISS and GCS, was associated with greater incidence of death, except for the amplitude of the 95%CIs at range 9-12 on the GCS and range ≥16 on the ISS. Occurrence of death within a week after being admitted to hospital was lower when compared with hospitalization >15 days.

Discussion

The findings of this study conducted in the city of São José dos Campos in relation to the year 2015 show that motorcyclists hospitalized as a consequence of traumatic injuries resulting from traffic accidents were predominantly young males who suffered minor and moderate injuries on the extremities of the body. It is noteworthy that part of the injured motorcyclists were not wearing crash helmets. In this context, the greater the physiological and anatomical injury severity and the greater the length of hospital stay, the greater the occurrence of death in the sample studied.

It has been found in several different countries that being a young male single adult are characteristics of the majority of motorcycle accident victims. In the majority of these cases, risk behaviors have been found, such as using cell phones and not wearing crash helmets when riding a motorcycle.¹¹11. Truong LT, Nguyen HTT, Gruyter CD. Correlations between mobile phone use and other risky behaviours while riding a motorcycle. Accid Anal Prev [Internet]. 2018 Sep [cited 2020 Aug 8];118:125-30. Available from: https://doi.org/10.1016/j.aap.2018.06.015
https://doi.org/10.1016/j.aap.2018.06.01... ^–1313. Galanis DJ, Castel NA, Wony LL, Steinemann S. Imapact of helmet use on injury and financial burden of motorcycle and moped crashers in Hawaii: analys of a linked statedwide database. Hawaii J Med Public Health [Internet]. 2016 Dec [cited 2020 Aug 8];75(12):379-85. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5146975/
https://www.ncbi.nlm.nih.gov/pmc/article... Among university students who drove motorcycles in Vietnam in 2016, the most prevalent risk behaviors found were using cells phones while driving, driving on footpaths, speeding, driving on the wrong side of the road, not wearing a crash helmet and drinking alcohol.¹¹11. Truong LT, Nguyen HTT, Gruyter CD. Correlations between mobile phone use and other risky behaviours while riding a motorcycle. Accid Anal Prev [Internet]. 2018 Sep [cited 2020 Aug 8];118:125-30. Available from: https://doi.org/10.1016/j.aap.2018.06.015
https://doi.org/10.1016/j.aap.2018.06.01... In the state of Arizona, United States, between 2008 and 2014, analysis of alcohol and cannabis consumption among young vehicle drives involved in accidents showed that in that state they were more prone to not wearing crash helmets and suffering more severe injuries.¹²12. Shults RA, Jones JM, Komatsu KK, Sauber-Schatz EK. Alcohol and marijuana use among young injured drivers in Arizona, 2008-2014. Traffic Inj Prev [Internet]. 2019 [cited 2020 Aug 8];20(1):9-14. Available from: https://doi.org/10.1080/15389588.2018.1527032
https://doi.org/10.1080/15389588.2018.15...

With regard to the activities of motorcycle couriers, other vulnerability factors can be frequently observed, related to work conditions with long working hours that contribute to distraction and tiredness,¹⁴14. Borham MN, Ibrahim ANH, Azis A, Yazid MRM. The relationship between the demographic, personal, and social factors of Malaysian motorcyclists and risk taking behavior at signalized intersections. Accid Anal Prev [Internet]. 2018 Dec [cited 2020 Aug 8];121:94-100. Available from: https://doi.org/10.1016/j.aap.2018.09.004
https://doi.org/10.1016/j.aap.2018.09.00... in addition to the pressure to deliver goods and transport people rapidly, which is capable of favoring negligence and lack of safe attitudes. Greater exposure of these individuals to risk behavior may be influenced by cultural issues, in addition to employability status: whereas the unemployed may take on risk behaviors due to anxiety, stress and depression, those who are employed tend to be more impatient and not obey the highway code, breaking speed limits when they are late for work and pressured to increase productivity.¹⁴14. Borham MN, Ibrahim ANH, Azis A, Yazid MRM. The relationship between the demographic, personal, and social factors of Malaysian motorcyclists and risk taking behavior at signalized intersections. Accid Anal Prev [Internet]. 2018 Dec [cited 2020 Aug 8];121:94-100. Available from: https://doi.org/10.1016/j.aap.2018.09.004
https://doi.org/10.1016/j.aap.2018.09.00...

Motorcyclists are more vulnerable to traffic accidents. Generally, when colliding with larger vehicles, motorcycles do not have sufficient size and resistance to protect the driver and passenger. This inferior motorcycle security results in their drivers absorbing all the energy of the impact and usually being catapulted over a distance.³3. Senado Federal (BR). Mortes em motos minam a saúde e a juventude. Rev Em Discussão [Internet]. 2012 nov [citado 2017 jan 19];3(13):6-78. Disponível em: http://www.senado.gov.br/noticias/jornal/emdiscussao/Upload/201204%20-%20novembro/pdf/em%20discuss%C3%A3o!_novembro_2012_internet.pdf
http://www.senado.gov.br/noticias/jornal... ^,55. Besse M, Denari R, Villani A, Roque MS, Rosado J, Sarotto AJ. Accidentes de moto: costo médico/económico en un hospital municipal de la ciudad de Buenos Aires. Medicina (B. Aires) [Internet]. 2018 jun [citado 2019 fev 6];78(3):158-62. Disponível em: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0025-76802018000300003
http://www.scielo.org.ar/scielo.php?scri... ^,66. Rubin G, Peleg K, Giovon A, Goup IT, Rozon N. Upper extremity fractures among hospitalized road traffic accidents adults. Am J Emerg Med [Internet]. 2015 Feb [cited 2020 Aug 8];33(2):250-3. Available from: https://doi.org/10.1016/j.ajem.2014.11.048
https://doi.org/10.1016/j.ajem.2014.11.0...

With regard to crash helmets, despite the legal obligation to use this safety equipment, it can be seen that some motorcyclists still do not adhere to their use.⁵5. Besse M, Denari R, Villani A, Roque MS, Rosado J, Sarotto AJ. Accidentes de moto: costo médico/económico en un hospital municipal de la ciudad de Buenos Aires. Medicina (B. Aires) [Internet]. 2018 jun [citado 2019 fev 6];78(3):158-62. Disponível em: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0025-76802018000300003
http://www.scielo.org.ar/scielo.php?scri... This fact is of concern, given that wearing a crash helmet can reduce the risk of head and brain injuries and the risk of death. Analysis of the cost of hospitalization of motorcyclists who did not wear crash helmets in the United States showed that it reached approximately US$2.2 billion dollars in 2010;¹⁵15. Dua A, Wei S, Safarik J, Furlough C, Desai SS. National mandatory helmet laws may save $2 billion annually: Na inpatient and value of statistical analysis. J Trauma Acute Care Sug [Internet]. 2015 Jun [cited 2020 Aug 8];78(6):1182-6. Available from: https://doi.org/10.1097/TA.0000000000000601
https://doi.org/10.1097/TA.0000000000000... while one billion dollars a year could be saved if all motorcyclists in that country wore a crash helmet.¹⁶16. Centers for Diseases Control and Prevention. Motor vehicle safety: motorcycle safety [Internet]. Atlanta: Centers for Diseases Control and Prevention; 2017 [cited 2010 Aug 14]. Available from: https://www.cdc.gov/motorvehiclesafety/mc/index.html
https://www.cdc.gov/motorvehiclesafety/m... Increased law enforcement could be a considerably effective means of reducing this risk behavior.¹⁷17. Bao J, Bachani AM, Viet CP, Quang LN, Nguyen N, Hyder AA. Trends in motorcycle helmet use in Vietnam: results from a four-year study. Puplic Health [Internet]. 2017 Mar [cited 2020 Aug 8];144(Suppl):S39-44. Available from: https://doi.org/10.1016/j.puhe.2017.01.010
https://doi.org/10.1016/j.puhe.2017.01.0...

Predominance of motorcycle accidents at weekends has been reported,¹⁸18. Mascarenhas MDM, Souto RMCV, Malta DC, Silva MMA, Lima CM, Montenegro MM. Characteristics of motorcyclists involved in road traffic accidents attended at public urgent and emergency services. Ciên Saúde Coletiva [Internet]. 2016 Dec [cited 2020 Aug 8];21(12):3661-71. Available from: http://dx.doi.org/10.1590/1413-812320152112.24332016
http://dx.doi.org/10.1590/1413-812320152... and the sample studied confirmed this. This result may indicate additional use of motorcycles for leisure and after consuming alcohol over the limit established by law. The times of day when these incidents occur vary but it is important to highlight that attitudes such as increased speed, going over crossroads without obeying traffic lights and not wearing crash helmets have been found more frequently at night.¹⁹19. Wu CY, Loo BP. Motorcycle safety among motorcycle taxi drivers and nonoccupational motorcyclists in developing countries: a case study of Maoming, South China. Traffic Inj Prev [Internet]. 2016 [cited 2020 Aug 8];17(2):170-5. Available from: https://doi.org/10.1080/15389588.2015.1048336
https://doi.org/10.1080/15389588.2015.10... It is possible that breaking the highway code and alcohol abuse over the permitted limit are factors related to greater frequency of accidents at weekends.¹⁸18. Mascarenhas MDM, Souto RMCV, Malta DC, Silva MMA, Lima CM, Montenegro MM. Characteristics of motorcyclists involved in road traffic accidents attended at public urgent and emergency services. Ciên Saúde Coletiva [Internet]. 2016 Dec [cited 2020 Aug 8];21(12):3661-71. Available from: http://dx.doi.org/10.1590/1413-812320152112.24332016
http://dx.doi.org/10.1590/1413-812320152... ^,2020. Misra P, Majumdar A, Misra MC, Kant S, Gupta SK, Gupta A, et al. Epidemiological study of patients of road traffic injuries attending emergency department of a trauma center in New Delhi. Indian J Crit Care Med [Internet]. 2017 Oct [cited 2020 Aug 8];21(10):678-83. Available from: https://doi.org/10.4103/ijccm.IJCCM_197_17
https://doi.org/10.4103/ijccm.IJCCM_197_... In view of this study focusing on hospital mortality, the data retrieved from prehospital care forms referred essentially to clinical conditions and treatment procedures at the site of the incident; information about alcohol consumption, failure to use safety equipment and other risk behaviors was not recorded systematically. For a more accurate analysis of motorcycle accident risk behaviors, data on the incidents themselves would need to be consulted, recorded by police and traffic personnel, as well as the accounts of surviving motorcyclists.

The majority of motorcyclists who suffered injuries were sent to the HMJCF by those who provided prehospital care. Ever since the implementation of the Urgency and Emergency Network and the standardization of the Mobile Urgent Care Service (SAMU 192), prehospital care has increased throughout Brazil, although regional differences can be seen with regard to the availability of these services. Difficulties include equipment maintenance, team composition and resource distribution, in addition to the public not being aware of the purpose of this service which means that sometimes it is called out unnecessarily.²¹21. Mata KSS, Ribeiro ÍAP, Pereira PSL, Nascimento MVF, Carvalho GCN, Macedo JB, et al. Entraves no atendimento pré-hospitalar do SAMU: percepção dos enfermeiros. Rev Enferm UFPE [Internet]. 2018 ago [citado 2020 ago 8];12(8):2137-45. Disponível em: https://doi.org/10.5205/1981-8963-v12i8a236537p2137-2145-2018
https://doi.org/10.5205/1981-8963-v12i8a... These factors can compromise the functionality of this service and it is important to highlight the important of specialized and quality care, at the site of the incident, in order to achieve better results.

Injured motorcyclists frequently have injuries to their extremities, external body areas and heads.⁵5. Besse M, Denari R, Villani A, Roque MS, Rosado J, Sarotto AJ. Accidentes de moto: costo médico/económico en un hospital municipal de la ciudad de Buenos Aires. Medicina (B. Aires) [Internet]. 2018 jun [citado 2019 fev 6];78(3):158-62. Disponível em: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0025-76802018000300003
http://www.scielo.org.ar/scielo.php?scri... ^,66. Rubin G, Peleg K, Giovon A, Goup IT, Rozon N. Upper extremity fractures among hospitalized road traffic accidents adults. Am J Emerg Med [Internet]. 2015 Feb [cited 2020 Aug 8];33(2):250-3. Available from: https://doi.org/10.1016/j.ajem.2014.11.048
https://doi.org/10.1016/j.ajem.2014.11.0... Analysis of the occurrence of fractures resulting from traffic accidents in Israel between 1997 and 2012 indicated that motorcyclists were more likely to suffer multiple fractures than victims of accidents involving other types of vehicles.⁶6. Rubin G, Peleg K, Giovon A, Goup IT, Rozon N. Upper extremity fractures among hospitalized road traffic accidents adults. Am J Emerg Med [Internet]. 2015 Feb [cited 2020 Aug 8];33(2):250-3. Available from: https://doi.org/10.1016/j.ajem.2014.11.048
https://doi.org/10.1016/j.ajem.2014.11.0... Apart from the frequency of the most affected regions of the body, it should be noted that injury severity is greater with regard to the head, spine, thorax, abdomen and lower limbs, as found in the sample studied. Moreover, in the case of motorcycle accidents, the probability of ISS scores over 16, attributed to severe injuries, is greater than for automobile accidents.²²22. Pinicus D, Wassertein D, Nathens AB, Bai YQ, Redelmeir DA, Wodcheis WP. Direct medical costs of motorcycle crashes in Ontario. CMAJ [Internet]. 2017 [cited 2020 Aug 8];189(46):E1410-5. Available from: https://doi.org/10.1503/cmaj.170337
https://doi.org/10.1503/cmaj.170337...

The average GCS score, indicative of severity from the physiological point of view, found in this study, indicated that the majority of motorcyclists were conscious²³23. Chichom-Melfire A, Atashili J, Tsiagadigui JG, Fon-Nuwah C, Ngowe-Ngowe M. A prospective pilot cohort analysis of crash characteristics and pattern of injuries and riders and pillion passangers involved in motorcycle crashes in na urban área in Cameroon: lessons for prevention. BMC Public Health [Internet]. 2015 [cited 2020 Aug 8];15(915). Available from: https://doi.org/10.1186/s12889-015-2290-4
https://doi.org/10.1186/s12889-015-2290-... during initial care in the emergency room. The protective effect of crash helmets among motorcyclists and cyclists in Taiwan between 2009 and 2015 shows that the average GCS score is higher among those wearing crash helmets, resulting in shorter length of hospital stay.²⁴24. Kwo SCH, Kuo PJ, Rau CS, Chen YC, Hsieh HY, Hsieh CH. The protective effect of helmet use in motorcycle and bicycle accidents: a propensity score-matched study based on a trauma registry system. BMC Public Health [Internet]. 2017 [cited 2020 Aug 8];17:639. Available from: https://doi.org/10.1186/s12889-017-4649-1
https://doi.org/10.1186/s12889-017-4649-...

As association of demographic and clinical variables was found with mortality in individuals with severe traumatic brain injury, GCS revealed itself to be one of the independent factors for predicting death.²⁵25. Ziadeirad M, Alimohammadi N, Irajpour A, Aiminmansour B. Association between outcome of severe traumatic brain injury and demographic, clinical, injury-related variables of patients. Iran J Nurs Midwifery Res [Internet]. 2018 May-Jun [cited 2020 Aug 8];23(3):211-6. Available from: https://doi.org/10.4103/ijnmr.IJNMR_65_17
https://doi.org/10.4103/ijnmr.IJNMR_65_1... In this study in São José dos Campos, the finding that lower GCS scores increased the risk of death in the emergency room confirms the importance of assessing level of consciousness and use of GCS when providing initial care to those who have suffered injury.

The mortality rate found in the São José dos Campos sample may appear to be low, however it should be pointed out that this study did not take into consideration deaths at the site of the accident, nor deaths before or after hospitalization. In this context, prevalence of death was greater in motorcyclists with low GCS, high ISS and longer length of hospital stay.

With regard to analyses of the relationship between length of hospital stay and mortality among those who have suffered injury, it is prudent to note that in the case of those with severe injuries, shorter length of hospital stay may occur due to early mortality. Longer hospitalizations, in turn, may be associated with the occurrence of complications during the course of treatment.²⁶26. Araujo GL, Whitaker IY. Morbidade hospitalar de motociclistas acidentados: fatores associados ao tempo de internação. Acta Paul Enferm [Internet]. 2016 abr [citado 2020 ago 8];29(2):178-84. Disponível em: http://dx.doi.org/10.1590/1982-0194201600025.
http://dx.doi.org/10.1590/1982-019420160...

It is also important to highlight that the greater the injury severity, the greater the systemic repercussion and probability of progression to systemic inflammatory response syndrome, leading to multiple organ failure and culminating in death.²⁷27. Ingraham AM, Xiong W, Hemmila MR, Shafi S, Goble S, Neal ML, et al. The attributable mortality and length of stay of trauma-related complications: a matched cohort study. Ann Surg [Internet]. 2010 Aug [cited 2020 Aug 8];252(2):358-62. Available from: https://doi.org/10.1097/SLA.0b013e3181e623bf
https://doi.org/10.1097/SLA.0b013e3181e6... Intracranial injury, pupillary abnormalities and shock at the time of admission to the intensive care unit (ICU) were found to be factors associated with this unfavorable outcome in Mexico in 2014,²⁸28. Sanz LDB. Análisis de los acidentes y las lesiones de los motociclistas em México. Gac Med Méx [Internet]. 2017 [citado 2020 ago 8];153:662-71. Disponível em: https://doi.org/10.24875/GMM.017002812
https://doi.org/10.24875/GMM.017002812... and in Tunisia between 2009 and 2012.²⁹29. Chelly H, Bahloul M, Ammar R, Dhouib A, Mahfoudh KB, Boudawara MZ, et al. Clinical characteristics and prognosis of traumatic head injury following road traffic accidentsadmitted in ICU “analysis of 694 cases”. Eur J Trauma Emerg Surg [Internet]. 2017 Apr [cited 2020 Aug 8];45(2):245-53. Available from: https://doi.org/10.1007/s00068-017-0885-4.
https://doi.org/10.1007/s00068-017-0885-... In our study, there was total or good recovery among a considerable proportion of surviving motorcyclists, but also considerable amount of injured motorcyclists with some type of disability, whether moderate or severe. These results regarding motorcyclists of working age involved in traffic and hospitalized for long periods of time draw attention to the high costs for the health system of prehospital care and rehabilitation.⁵5. Besse M, Denari R, Villani A, Roque MS, Rosado J, Sarotto AJ. Accidentes de moto: costo médico/económico en un hospital municipal de la ciudad de Buenos Aires. Medicina (B. Aires) [Internet]. 2018 jun [citado 2019 fev 6];78(3):158-62. Disponível em: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0025-76802018000300003
http://www.scielo.org.ar/scielo.php?scri... ^,1313. Galanis DJ, Castel NA, Wony LL, Steinemann S. Imapact of helmet use on injury and financial burden of motorcycle and moped crashers in Hawaii: analys of a linked statedwide database. Hawaii J Med Public Health [Internet]. 2016 Dec [cited 2020 Aug 8];75(12):379-85. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5146975/
https://www.ncbi.nlm.nih.gov/pmc/article... ^,2222. Pinicus D, Wassertein D, Nathens AB, Bai YQ, Redelmeir DA, Wodcheis WP. Direct medical costs of motorcycle crashes in Ontario. CMAJ [Internet]. 2017 [cited 2020 Aug 8];189(46):E1410-5. Available from: https://doi.org/10.1503/cmaj.170337
https://doi.org/10.1503/cmaj.170337... ,³⁰30. Harmon KJ, Marshall SW, Proecholdbell SK, Nawmann RB, Waller AE. Motorcycle crash-related emergency departamento visist and hospitalization for traumatic brain injury in North Carolina. J. Head Trauma Rehabil [Internet]. 2015 May-Jun [cited 2020 Aug 8];30(3):175-84. Available from: https://doi.org/10.1097/HTR.0000000000000096
https://doi.org/10.1097/HTR.000000000000... Consequently, motorcycle accident prevention is the most effective policy for reducing years of potential life lost, hospital care expenditure, morbidity and mortality related to accidents.

The limitations of this study include the fact of it having been conducted in an emergency department of a single municipal Public Health hospital. However, the data found and analyzed corresponded to a one-year period in order to avoid seasonality as well as accounting for almost all hospitalized motorcyclists. There were signs of variables associated with mortality; however, based on the results obtained, it is important to consider the limitation of the sample power with regard to inferences. Other limitations relate to not observing deaths that occurred at the scene of the accident and, consequently, to the analysis of possible precipitating factors, such as: (i) consumption of alcoholic beverages, not using safety equipment and/or other risk behaviors; (ii) lack of data on motorcyclists cared for and discharged at the emergency department; (iii) difficulties in obtaining secondary data, both from medical records and from prehospital care forms; (iv) the fact of telephone contact after hospital discharge only having been possible for half the sample; and (v) absence of data on comorbidities and sociodemographic data.

Brazil is one of the countries that complies with all the traffic safety recommendations established by WHO;¹1. World Health Organization - WHO. Global status report on road safety 2018 [Internet]. Geneva: World Health Organization; 2018 [cited 2020 Aug 8]. Available from: https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
https://www.who.int/violence_injury_prev... however their enforcement needs to be intensified nationwide along with educational traffic accident prevention campaigns.

Furthermore, in the sample studied, low GCS scores, high ISS scores and long length of hospital stay were associated with hospital mortality. These are data that can contribute to highlighting the need for and the importance of good care practices by multiprofessional teams, right from prehospital care through to rehabilitation.

In conclusion, preventive public policies and actions to reduce traffic accidents, together with the recovery of motorcyclists with traumatic injuries, favor the reduction of the impacts of accidents on quality of life and productivity of those who suffer accidents. Motorcyclists need to be made aware of the importance of safe driving, especially with regard to wearing crash helmets as a preventive measure against injuries to the head region. New research should be conducted to confirm the findings of this study and analyze in greater detail the relationships we have found.

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