Inova Regional Trauma Center

> Inova Fairfax Hospital Falls Church, VA
>
> Picture of Helicopter flying to Inova Regional Trauma Center

Honda Inova Fairfax Hospital CIREN Team

> Pictures of Honda Logo, Fairfax County Police Logo, Inova Regional
> Trauma Center Logo, Fairfax County Fire and Rescue Department logo,
> The CIREN logo, and the University of Virginia Center for Applied
> Biomechanics logo

Team Members:

> Honda Inova Fairfax Hospital CIREN Center

-   Samir M. Fakhry, MD, Principal Investigator

-   Anne Rizzo, MD, Co-Principal Investigator

-   Refaat Hanna, M.D., M.A., Epidemiologist

-   Christine Burke, CIREN Study Coordinator

-   Greg Stadter, Crash Reconstructionist

-   Rodney W. Rudd, Ph.D. CIREN Study Consultant

-   Christopher Sherwood, Auto Safety Lab, University of VA

-   Capt. Christine Woodard, Fairfax County Fire and Rescue

-   Detective J.J. Banachoski, Fairfax County Police CRU

-   Lt. Scott McLean, Prince William County Fire and Rescue

> Pedestrian Injuries: Analysis of the Burden with Case Illustrations
>
> Honda Inova Fairfax Hospital CIREN Center

CIREN Pedestrian Study Objectives

-   Address the unmet needs of the walking population

-   Identify patterns of injuries among pedestrians to better understand
    mechanism and develop efficient prevention methods

-   Identify vehicle features that cause or mitigate injuries

-   To educate pre-hospital healthcare providers to conduct on-scene
    triage based on certain crash criteria and injury criteria

> Honda Inova Fairfax Hospital CIREN Center
>
> Burden of Pedestrian Injuries

-   In the United States, annually, there are 8,000 pedestrians killed
    and another 100,000 injured in traffic accidents.

-   This accounts for 13% of the nation's total traffic fatalities and
    5% of injuries (FARS, NASS, GES).

-   On average, a pedestrian injury occurs every six minutes and a
    pedestrian fatality occurs every 107 minutes in the United States
    (1).

-   The proportion of pedestrian fatalities is a greater concern in many
    other countries, such as Japan, where pedestrians account for nearly
    27% of total traffic fatalities, and in Europe, where the percentage
    reaches nearly 30% in the United Kingdom (2)

-   U.S. Department of Transportation, National Highway Traffic Safety
    Administration, 2000.

> \(2\) Jason A. Stammen Roger A. Saul, National Highway Traffic Safety
> Administration

Pedestrian Injuries in the Washington DC Metropolitan Region (DCMR)

For the purposes of this study, the DC Metro Region (DCMR) is defined as
the counties and municipalities of:

-   Virginia (Northern Virginia)

-   District of Columbia (DC)

-   Maryland (Central Maryland)\
    \
    The following data sets were available and analyzed for the years
    1999-2004:

-   Police car crash data

-   Injury related hospital discharge data

-   Injury mortality data

-   The rates are calculated using 2000 population data obtained from US
    Census Bureau.

Summary

-   Approximately 3000 pedestrians are involved in crashes with motor
    vehicles every year in the DC Metro region.

-   The vast majority (92%) sustained one or more injuries.

-   A significant percentage of these (17%) required hospitalization of
    24 hours or longer.

-   Average hospital charges of \$17,000 to \$30,000 per patient
    depending on the region.

-   Approximately 80 pedestrians die each year.

Vehicle Type and Maneuver

> Honda Inova Fairfax Hospital CIREN Center
>
> Making left or right turn was the most common maneuver prior to
> pedestrian crashes by buses in
>
> both Northern Virginia and DC
>
> Four Bar Graphs- One showing Pedestrian Crashes by Vehicle Type, with
> passenger cars making up over 80% of all vehicles involved in crashes.
> Then there are three bar graphs showing pedestrian crashes by vehicle
> maneuver and type. Both passenger vehicles and trucks had the highest
> incidence of crashes occur while they were going strait, but busses
> most common time to hit pedestrians was when making a left or right
> hand turn.

Mortality by Vehicle Type

> Pedestrian crashes involving trucks and buses resulted in 11% and 10%
> mortality in both Northern Virginia and DC respectively
>
> There is a bar graph showing the amount of moralities in Northern
> Virginia(NoVA), DC and Central Maryland (MD) based on vehicle type.
> Four pedestrians died in NoVA, 3 in DC, and 4 in MD from passenger
> vehicles. Eleven died in NoVA, 10 in DC, and 2 in MD from trucks.
> Eleven died in NoVA, 11 in DC, and 7 in MD from busses.

Pedestrian Crashes by Day of Week

> Pedestrian crashes are higher during weekdays with the peak on Friday
> (Northern Virginia and Central Maryland)
>
> Bar graph showing pedestrian crashes by day of week. There is a slight
> but steady increase in crashes from Monday to Friday and then the
> amount goes down over the weekend.

Time of the Crash

There are three line graphs showing pedestrian crashes by time of day in
Central MD, DC and Northern VA. All three graphs have a increase around
6-8 AM and then another increase from 4-6PM. After six PM the numbers of
crashes drop significantly.

Pedestrian Injury Hospitalization by State of Residence in DC

> Fifty-percent of the pedestrian injured in Washington DC are
> non-residents of the city
>
> This bar graph shows the state of residence for pedestrians stuck in
> DC that were hospitalized. 50% were from DC, 39% from MD, ,8% from VA
> and 3% unknown or other.

Pedestrian Age

> Children in DC aged 5 to 9 years were more than twice as likely as the
> same age group in both Northern Virginia and Central Maryland to be
> involved in a pedestrian crash
>
> Honda Inova Fairfax Hospital CIREN Center
>
> In Washington DC, pedestrian hospitalizations are significantly higher
> among children aged 0 to 9,
>
> compared to the same age group in both Northern Virginia and Central
> Maryland
>
> In Washington DC, pedestrian deaths are significantly higher among
> children aged 0 to 9,
>
> compared to the same age group in both Northern VA and Central MD
>
> In Washington DC, hospital charges are significantly higher for
> children aged 5 to 14 years
>
> There are four graphs showing age as a factor in pedestrian Crashes.
> The first graph shows average hospital charges by age in DC, MD and
> VA. DC had the highest charges across the board, but particularly high
> charges for children 5-19. In Central MD, ages 20-54 had the highest
> hospital charges. In Northern VA the charges were relatively similar
> across all age groups. The second graph shows pedestrian injury
> hospitalization by age. Ages 25-54 are the highest in MD, VA and DC
> but in DC there is also a large proportion of children aged 0-14 that
> were hospitalized as pedestrians. The third graph shows pedestrian
> deaths by age. The numbers are low from 0-24, but with pedestrians
> older than 25 had a much higher risk of death. The fourth graph shows
> that in general people 25-54 are at the highest risk of getting struck
> as a pedestrian but in DC there is also a high number of children aged
> 0-9 that were struck.

Pedestrian Injury By Race

> "Other" Races refers to: Hispanics, Native Hawaiian, Pacific Islander,
> American Indian, Alaska Native, Middle Eastern and Asians (in Central
> Maryland)
>
> Three graphs showing chances of pedestrian injury by race in Central
> MD, Northern VA, and DC. In DC there was a .021% chance for Blacks,
> .01% chance for Whites, .001% chance Asians and .033% chance for
> "Others" to be struck and hospitalized as pedestrians from 2001-2002.
> In Northern Virginia there was a .008% chance that Hispanics, .006%
> chance Blacks, .003 Whites% chance, .002% chance Asians and .004%
> chance "Others" were hospitalized between 1999-2003 as pedestrians. In
> Central MD there was a .011% chance Blacks, .007% chance Whites and a
> .014% chance that "Others" were stuck and hospitalized between
> 2000-2003.

Driver age and Gender in Pedestrian Crashes

> Young drivers aged 15 to 24 were the third highest age group to be
> involved in pedestrian crashes
>
> Two Graphs. One is the age of drivers involved in pedestrian crashes
> by age in Northern Virginia. 8% of drivers were aged 15-19 in crashes,
> 10% of drivers 20-24, 21% of drivers 25-35, 19% of drivers 35-44, 14%
> of drivers 45-54, 8% of drivers 55-64 and 6% of drivers 65+. The other
> is a pie chart showing the gender of drivers in Northern Virginia in
> pedestrian crashes. 64% were male, 33% were female and 13% were
> unknown.

Driver Violation Prior to Pedestrian Crash

> A bar graph of drivers violation prior to pedestrian crashes in
> Northern Virginia. 48% had no violations, 13% were cited for driver
> inattention, 11% for hit and run, 8% for not having right-of-way, 9%
> for other violations, 5% was not stated, 3% for improper backing, and
> 1% for exceeding the speed limit.

Pedestrian Hospital Charges and Payments

> Pedestrian Injuries are the second most costly injuries after firearms
>
> Honda Inova Fairfax Hospital CIREN Center
>
> Medicaid and Self-Pay accounted for about 50% of payers in both
> Washington DC and Central Maryland
>
> Two graphs. One is the average hospital charges for different types of
> injuries in Northern Virginia. Firearms were number on with \$25,000
> on average, followed by pedestrians at number two with \$22,500. Motor
> Vehicle Crashes were number three at \$17,500. The second graph
> indicates how pedestrians pay for their hospital charges in Maryland,
> DC, and Northern Virginia. In Maryland, about 45% paid by commercial
> insurance, 10% by Medicare, 20% by Medicaid, 20% self-pay and 5%
> other. In DC about 38% paid by commercial insurance, 1% Medicare, 30%
> Medicaid, 20% self-pay, 3% were paid by charity and 8% were paid by
> other. In Northern Virginia, 62% paid by commercial insurance, 14%
> with Medicare, 10% by Medicaid, 4% by charity, 4% by self-pay and 5%
> other.

Maps of DC by Pedestrian Injury, Population Density, Race and Poverty

> Source: Center for Social Justice Research, Teaching and Service.
> 2000. DC Maps.
>
> Source: Inova Regional Trauma Center
>
> This page contains four maps of Washington DC. The first map shows
> pedestrian injury in DC, with the majority happening in Southeast,
> followed by Northeast. The second map shows population density in DC,
> with Southeast and Northeast having the highest density. The third map
> shows DC's African American population with the highest concentration
> (over 64%) in Southeast and Northeast. The forth map shows where
> poverty is strong in DC, with Southeast having the highest percentage
> followed by Northeast.

Methodology

-   Case Selection Criteria

-   Admitted to the trauma center

-   MAIS 2+ injury

-   Struck by the front of the vehicle

-   Upright when struck

-   Hit by a passenger car, SUV, minivan or small pickup truck

-   Pedestrians that are struck by a large vehicle such as a bus or
    tractor trailer, were run over or were sitting/lying down when they
    were struck are excluded from the study

Methodology

-   Enrollment & Consent

-   Eligible patients and families are approached by hospital personnel
    to obtain "Informed Consent"

-   Police are contacted to obtain a crash report to identify vehicle
    owner/driver

-   Vehicle owner is visited to obtain "Informed Consent"

-   Medical information and vehicle information is required to complete
    case

> Honda Inova Fairfax Hospital CIREN Center

Methodology

-   Data Collection

-   Medical

-   Pre-crash data from EMS reports and interviews

-   Full hospital medical records

-   Patient interview

-   Photographs of injuries

-   Anthropometric measurements

-   6 & 12 month follow-up health survey

-   Injuries & procedures are reviewed and coded

-   AIS, ICD-9, CPT codes

Methodology

-   Data Collection

-   Vehicle & Crash

-   Data is collected along PCDS protocols

-   Police report (vehicle & owner information, scene diagram & photos)

-   Impact speed estimation (skid mark analysis, throw distance
    calculation)

-   Vehicle inspection (damage/deformation profile, contact marks)

Methodology

-   Reconstruction & Simulation

-   MADYMO multi-body modeling

-   Pedestrian Model (anthropomorphic\
    measurements)

-   Vehicle Model (facet or ellipsoid model,\
    UVA database)

-   Simulation Matrix

-   Multiple orientations & speeds to match witness marks and injury
    outcome

Challenges

-   Case Enrollment

-   47 Cases Investigated

-   Socioeconomic challenges

-   Homelessness

-   Physiological and dependency issues

-   Legal concerns & other repercussions

-   Inability to consent

-   Vehicle owner consent is very difficult

-   Concerned about legal issues

-   Guilt over the event

-   Vehicles are often repaired soon after the event

-   Necessary to inspect the vehicle

-   Currently necessary vehicle data and photos are obtained from police
    when inspection is not possible

**Case Illustrations**

Case #1

> Honda Inova Fairfax Hospital CIREN Center

-   Male age 17 attempting to cross at an intersection against the light
    at 22:40. Clear & dry condition on a Saturday evening in the fall.

-   Driver of 2003 Chrysler Town & Country van did not observe
    pedestrian until impact.

-   The pedestrian was struck on the left side.

> POI
>
> POI
>
> POI
>
> Diagram and pictures of the scene of crash. The vehicle is going
> strait and the pedestrian attempts to cross right to left in front of
> the vehicle at an intersection, where Point of Impact (POI) happens.

Pedestrian Wrap Measurements

> Honda Inova Fairfax Hospital CIREN Center
>
> 162cm
>
> 134 cm
>
> 90 cm
>
> 47 cm
>
> 45 cm
>
> 55 cm
>
> 80 cm
>
> 93 cm
>
> 165 cm
>
> 275 cm
>
> 237 cm
>
> Picture of a Mannequin showing measurements of a pedestrian's knee,
> hip, shoulder, and overall height. This picture is next to a picture
> of a vehicle showing bumper height, hood height, cowl height and
> windshield header height.

# Vehicle

Picture showing damage to the left side of the vehicle, starting at the
left front bumper, going to the left front hood and ending on the left
front A-pillar.

Case Summary

> Honda Inova Fairfax Hospital CIREN Center
>
> Case Summary:

-   On scene: pedestrian unconscious, fixed and dilated pupils,

-   Transported by air to the trauma center - intubated by flight crew

> ? In trauma bay: pupils sluggishly reactive but equal, GCS 3T

-   Physical examination notable for:

-   positive for alcohol consumption, contusions lower extremities

-   Radiological examination significant for:

-   left frontoparietal and temporal subdural hematoma

-   right subdural and frontotemporal contusion

-   left lateral superior and inferior pubic rami & acetabulum fractures

-   To OR for:

-   right-sided hemicraniectomy

-   evacuation of subdural hematoma

-   debridement of contused brain

Case Summary Continued

> Honda Inova Fairfax Hospital CIREN Center
>
> Case Summary (continued):
>
> ? Admitted to TICU, remained intubated & sedated on TBI protocol

-   HD \# 5 underwent tracheostomy and PEG

-   Slowly improved, sedation weaned down, to IMC on HD \# 7

-   Neurological status slowly improving, to floor on HD \# 10

-   Received cognitive evaluation along with PT and OT

-   Returned to OR on HD \# 58 for cranioplasty - reimplant bone flap

-   Due to financial issues could not be transferred to rehabilitation

-   Discharged home with family on HD \# 62

-   RLAS at discharge was VI; able to communicate in his native
    language, following some commands, able to ambulate with some
    assistance, able to eat a regular diet

-   Hospital Charges: \$151,736

MADYMO Simulation 56 km/h (35 mph), Struck Limb Back, Without Braking

> A MADYMO Simulation video showing a pedestrian getting struck on their
> left side by the left front of a minivan. The simulation shows the
> pedestrian's head contacting the mid portion of the A-pillar.

Injuries

> CT scan of subdural hemotoma and a picture of the damage to the
> vehicle's A-Pillar.

Injuries Continued

> CT scan of Pubic Rami fracture, CT scan of Acetabulum Fracture,
> Picture of damage to vehicle's hood and front quarter panel.

# Injuries Continued

> Picture of pedestrian's knee abrasion

Case #2

> Honda Inova Fairfax Hospital CIREN Center

-   Male age 35 attempting to cross a 7-lane roadway at 19:00. Clear &
    dry conditions, on a Sunday evening in the winter.

-   Driver of 1997 Honda Accord did not observe pedestrian until impact.

-   Pedestrian was struck on his right side

> POI
>
> POI
>
> POI
>
> Scene Diagram depicting the pedestrian crossing left to right in front
> of the vehicle and getting struck. Two scene pictures depicting the
> pedestrian crossing left to right in front of the vehicle.

Pedestrian Wrap Measurements

> Honda Inova Fairfax Hospital CIREN Center
>
> 172 cm
>
> 148 cm
>
> 100cm
>
> 48 cm
>
> 40cm
>
> 50 cm
>
> 71 cm
>
> 78cm
>
> 180 cm
>
> 270cm
>
> Picture of a Mannequin showing measurements of a pedestrian's knee,
> hip, shoulder, and overall height. This picture is next to a picture
> of a vehicle showing bumper height, hood height, cowl height and
> windshield header height.

# Vehicle 1

> Picture of the vehicle that struck the pedestrian, damage to center of
> the hood extending longitudinally to the center of the windshield.

Case Summary

> Honda Inova Fairfax Hospital CIREN Center
>
> Case Summary:

-   On Scene: pedestrian found conscious and alert, deformities to the
    left arm & right lower extremity as well as laceration to the left
    scalp

-   Immobilized and transported to the Trauma Center by air

-   Physical examination notable for:

-   left temporal scalp laceration, swelling of right shoulder, deformed
    right lower extremity, positive for alcohol consumption

-   Radiological examination identified:

-   right comminuted tibia and fibula fractures

-   right comminuted proximal humerus fracture

-   CT scan of head negative for intracranial injury

-   Right lower extremity splinted, right arm placed in sling

-   Admitted to IMC

-   To the OR on HD \# 2 for:

-   four-compartment fasciotomy

-   external fixator to the right lower extremity

Case Summary Continued

> Honda Inova Fairfax Hospital CIREN Center
>
> Case Summary (continued):

-   Remained stable, transfer to the ward on HD \# 3

-   Returned to the OR on HD \# 4 for:

-   ORIF of the right proximal humerus fracture

-   debridement and irrigation of the right lower extremity

-   Returned to the OR on HD \# 10 for:

-   removal of external fixator

-   plating of the right fibula with wound closure

-   PM&R evaluation diagnosed cerebral concussion - RLAS of VII

-   Discharged home with home health services on HD \# 15

-   Hospital Charges: \$78,965

MADYMO Simulation Struck Limb Back, Without Braking

> MADYMO Simulation of a pedestrian getting struck on the right side by
> a vehicle. The pedestrian hits the center of the bumper and their head
> contacts the center of the windshield.

# Injuries

> Picture of the pedestrian's scalp laceration and a picture from the
> left of the striking vehicle.

**Injuries Continued**

> Xray of the pedestrian's humerus fracture and front left oblique
> picture of the striking vehicle.

**Injuries Continued**

> Picture of pedestrian's tibia and fibula fractures in a cast and a
> picture of the front of the striking vehicle.

Examples of Lessons Learned

> 1\. Head Injuries

-   Comparison of PCDS and CIREN data

-   Risk of head injury significantly decreases when the head strikes
    the center of the windshield

-   Risk of head injury (AIS \> 2) is two (2) times more likely when the
    head strikes around the edge of the windshield

-   . Humerus Fractures

-   Comparison of PCDS and CIREN data could not be done for humerus
    fractures based on selection criteria

-   CIREN pedestrians are at an increased risk for humerus fractures;
    23% of CIREN pedestrian cases involve a humerus fracture compared
    with 7% of PCDS cases

Conclusion

We would like to thank the following agencies for making this project a
success:

The Fairfax County Police Crash Reconstruction Unit

## Fairfax County EMS

Prince William County EMS

Honda R&D