Alcohol is a risk factor for helmet non-use and fatalities in off-road vehicle and motorcycle crashes

Alcohol is a risk factor for helmet non-use and fatalities in off-road vehicle and motorcycle crashes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Alcohol is a risk factor for helmet non-use and fatalities in off-road vehicle and motorcycle crashes Nelofar Kureshi, Simon Walling, Mete Erdogan, Izabella Opra PCP, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4000958/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Jun, 2024 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Objectives: Off-road vehicle (ORV) and motorcycle use is common in Canada; however, risk of serious injury is heightened when these vehicles are operated without helmets and under the influence of alcohol. This study evaluated the impact of alcohol intoxication on helmet non-use and mortality among ORV and motorcycle crashes. Methods: Using data collected from the Nova Scotia Trauma Registry, a retrospective analysis (2002-2018) of ORV and motorcycle crashes resulting in major traumatic brain injury was performed. Patients were grouped by blood alcohol concentration (BAC) as negative (17.3 mmol/L). Logistic regression models were constructed to test for helmet non-use and mortality. Results: A total of 424 trauma patients were included in the analysis (220 ORV, 204 motorcycle). Less than half (45%) of patients involved in ORV crashes were wearing helmets and 65% were criminally intoxicated. Most patients involved in motorcycle crashes were helmeted at time of injury (88.7%) and 18% were criminally intoxicated. Those with criminal levels of intoxication had 3.7 times the odds of being unhelmeted and were 3 times more likely to die prehospital compared to BAC negative patients. There were significantly increased odds of in-hospital mortality among those with both legal (OR = 5.63), and criminal intoxication levels (OR = 4.97) compared to patients who were BAC negative. Conclusion: Alcohol intoxication is more frequently observed in ORV versus motorcycle crashes. Criminal intoxication is associated with helmet non-use. Any level of intoxication is a predictor of increased in-hospital mortality. traumatic brain injury off-road vehicles all-terrain vehicles motorcycles alcohol mortality INTRODUCTION Motorcycles and off-road vehicles (ORVs) such as all-terrain vehicles (ATVs), side-by-sides (SxSs), utility terrain vehicles (UTVs), and snowmobiles are commonly used for transportation, work, and recreation in Canada. Each year, there are approximately 180 motorcycle fatalities [ 1 ], 100 ATV fatalities [ 2 ], and 73 snowmobile fatalities across the country [ 3 ]. In Nova Scotia, motorcycles and ORVs are popular for both recreation and transportation/work purposes. Previous studies in Nova Scotia have shown that ATV injuries in children closely resemble injuries from motor vehicle collisions (MVCs) [ 4 ]. Legislation restricting ATV use by children led to a short-term decrease but no sustained effect on the frequency and severity of ATV injuries [ 5 ]. The risk of injury while operating these vehicles is heightened by numerous factors including driving unhelmeted, night driving, having multiple passengers, engaging in risky behavior (e.g., jumps, high speeds), and use of alcohol and/or drugs [ 6 – 8 ]. Use of alcohol/drugs has been reported in roughly half of ATV and snowmobile deaths [ 2 , 3 ], and in nearly one third of motorcycle fatalities [ 9 ] . Traumatic brain injury (TBI) is the primary cause of death from motorcycle and ORV crashes [ 10 , 11 ]. While some ORVs have safety features like seat belts and roll cages, helmets remain the best form of head protection and are associated with significantly lower risk of TBI and death among riders involved in a crash [ 12 , 13 ]. At least one-third of ATV fatalities in Canada involve unhelmeted riders [ 2 ]. Furthermore, there is evidence that use of alcohol/drugs is associated with increased odds of not wearing a helmet among those injured in motorcycle crashes [ 14 ] and ATV crashes [ 15 ]. The aim of this study was to assess the demographic and injury patterns of patients presenting with ORV- or motorcycle-related TBI to a Level I trauma centre. Specifically, we hypothesized that crashes involving alcohol are associated with increased risk of not wearing a protective helmet, as well as increased odds of prehospital and in-hospital mortality. METHODS Study Design and Time Period This was a retrospective cohort study of major TBI patients injured between January 1 2002 and March 31, 2015. Study data were collected from the Nova Scotia Trauma Registry (NSTR). The NSTR is a provincial population-based registry under the Nova Scotia Department of Health and Wellness and contains data on all major trauma patients with an Injury Severity Score (ISS) ≥ 12 and an appropriate International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) code. The NSTR also includes penetrating traumas with an ISS ≥ 9 or greater, all trauma team activations (TTAs) regardless of ISS, and traumas resulting in death prior to hospital arrival or in the ED. This study was performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies [ 16 ]. Study Setting All major trauma and adult neurosurgical services in the Nova Scotia are centralized at the Queen Elizabeth II Health Sciences Centre (QEII HSC) in Halifax. This centre services a population of 938,183 within 55,000 km 2 and receives all major neurotrauma cases from within the province as well as some cases from Prince Edward Island. Population We included all major TBI patients injured in an ORV or motorcycle crash during the study period. Consistent with the literature, major TBI was defined using the maximal Abbreviated Injury Scale (AIS) Head score [ 17 , 18 ] and ICD-10-CA injury codes. All patients in the NSTR with a maximum AIS Head score ≥ 3 and a primary ICD-10-CA diagnosis code consistent with blunt or penetrating trauma were included. For this study, ORVs included ATVs, UTVs, SxSs, and snowmobiles. Data Collection Data elements collected from the NSTR included age, sex, injury mechanism, use of helmet, maximum AIS Head score, ISS, Glasgow Coma Scale (GCS) score, TTA, blood alcohol concentration (BAC) testing, BAC level, and discharge status. Quantitative alcohol levels were determined during the initial ED visit or by post-mortem testing by the Nova Scotia Medical Examiner Service. BAC levels are reported as millimoles of ethanol per liter of blood (mmol/L). For patients admitted to a provincial ED, routine BAC testing for MVCs is performed. When a patient dies at the crash scene or before admittance to hospital, law enforcement or emergency medical personnel notify the provincial Medical Examiner who draws a blood sample and conducts a BAC test from all fatal crashes. Because post-mortem blood presents problems due to variable conditions and changes to concentrations from one place to another in the body after death, the Medical Examiner commonly analyzes vitreous humor for BAC. A BAC level of 0-1.9 mmol/L was coded as BAC negative (as defined by the National Trauma Registry); any BAC reported as ≥ 2mmol/L was considered positive. Positive BAC levels were further categorized as legal intoxication (2-17.3mmol/L) or criminal intoxication (> 17.3mmol/L). Throughout Canada, the maximum legal BAC for fully licensed drivers is < 80mg alcohol in 100ml of blood, or 0.08 gram% (0.08 grams alcohol/100 ml = 17.3 mmol/L). Driving with a BAC of 17.3 mmol/L or higher is a criminal offence. Outcome Measures Outcome measures included helmet non-use and mortality (prehospital, in-hospital). Prehospital mortality was defined as death at the scene or during transfer to hospital, while in-hospital mortality was defined as death occurring at any time after arrival to an ED. Data Analysis Demographic and injury characteristics were described using means ± standard deviations for continuous variables and counts and percentages for categorical variables. Between groups comparisons were performed with a chi-square (categorical data) and with Student's t-test or one-way ANOVA test (continuous data), as appropriate, with the following BAC levels: negative (BAC 0-1.9 mmol/L), legal intoxication (2-17.3 mmol/L), and criminal intoxication (> 17.3 mmol/L). An age and sex-adjusted regression model for the association of BAC with helmet use was created. Prehospital and in-hospital mortality were modelled with multivariate logistic regression using age, AIS Head, ISS, and BAC levels as covariates. We did not include sex in the multivariate logistic regression modeling given that the vast majority of the study sample were males. The resulting coefficients were exponentiated to obtain adjusted odds ratios (ORs). A p-value less than 0.05 was considered statistically significant. ORs were reported with 95% confidence intervals (CIs). All data were analyzed using SPSS software (version 27; SPSS Inc., Chicago) and R Statistical Software (version 4.2.5). Ethics Approval All study procedures were approved by the institutional research board (File #1018117). RESULTS A total of 5590 major TBI patients were seen in Nova Scotia during the 16-year study period. Of these, 220 patients were ORV drivers and 204 were motorcycle drivers. Characteristics of TBI patients injured in ORV and motorcycle crashes are compared in Table 1 . Patients injured in ORV crashes were younger (34 ± 15.5 vs. 44 ± 15.2, p < 0.001) and had lower mean ISS scores (27.7 ± 14.2 vs. 36.6 ± 19.0, p < 0.001) than those injured in motorcycle crashes. Less than half (45%) of patients injured in ORV crashes were wearing helmets compared with 89% of motorcycle crashes (p < 0.001). BAC testing was performed in 66% (146/220) of ORV crashes and 68% (138/204) of motorcycle collisions. BAC levels were significantly different between ORV and motorcycle crashes. Prehospital mortality was observed in 20% (85/424) of the study sample; the proportion of prehospital mortality was significantly greater than motorcycle crashes (29% vs. 18%, p = 0.01). Table 1 Characteristics of patients injured in ORV and motorcycle crashes in Nova Scotia, 2002–2015 Characteristic ORV trauma (n = 220) Motorcycle trauma (n = 204) p-value Age, mean ± SD 34 ± 15.5 44 ± 15.2 < 0.001 Male sex, n (%) 199 (90.5) 181 (87.7) 0.63 Helmet use, n (%) 99 (45.0) 181 (88.7) < 0.001 GCS on ED arrival, mean ± SD 10.9 ± 5.2 11.0 ± 4.9 0.53 Max AIS Head, mean ± SD 4.0 ± 0.8 4.0 ± 0.9 0.62 ISS, mean ± SD 27.7 ± 14.2 36.6 ± 19.0 < 0.001 TTA, n (%) 115 (52.3) 94 (46.1) 0.20 BAC testing performed, n (%) 146 (66.4) 140 (68.6) 0.62 BAC level, n (%) Negative (0-1.9 mmol/L) 37 (25.3) 107 (76.4) 17.3mmol/L) 95 (65.1) 25 (17.9) Mortality, n (%) Prehospital 35 (17.9) 50 (29.2) 0.01 In-hospital 23 (12.5) 31 (20.4) 0.05 ORV off-road vehicle; TBI traumatic brain injury; GCS Glasgow Coma Scale; AIS Abbreviated Injury Score; ISS Injury Severity Score; BAC blood alcohol concentration; TTA Trauma Team Activation Characteristics of patients injured in ORV or motorcycle crashes were compared by BAC level (Table 2 ). Helmet use was highest in BAC negative patients (80%, 115/144) and least frequent in drivers with criminal BAC levels (50%, 60/120). Mean ISS was statistically different between the three BAC categories, with the most severe injuries observed in the BAC negative group (mean ISS 35.5 ± 18.3) and the least severe injuries in the criminally intoxicated BAC group (mean ISS 29.6 ± 16.3). Table 2 Characteristics of patients by blood alcohol concentration Characteristic BAC Negative (n = 144) Legal Intoxication (n = 22) Criminal Intoxication (n = 120) p-value Age, mean ± SD 41 ± 15.2 28 ± 8.5 37 ± 12.7 < 0.001 Male sex, n (%) 127 (88.2) 17 (77.3) 113 (94.2) 0.035 Vehicle type, n (%) ORV 37 (25.7) 14 (63.6) 95 (79.2) < 0.001 Motorcycle 107 (74.3) 8 (36.4) 25 (20.8) Helmet use, n (%) 115 (79.9) 17 (77.3) 60 (50.0) < 0.001 GCS on ED arrival, mean ± SD 10.5 ± 5.2 12.4 ± 4.4 8.9 ± 5.4 0.20 Max AIS Head, mean ± SD 4.1 ± 0.9 4.1 ± 0.9 3.9 ± 0.9 0.37 ISS, mean ± SD 35.5 ± 18.3 35.9 ± 17.9 29.6 ± 16.3 0.02 TTA, n (%) 87 (60.4) 13 (59.1) 69 (57.5) 0.89 Mortality, n (%) Prehospital 33 (26.4) 5 (27.8) 33 (32.0) 0.64 In-hospital 16 (14.8) 4 (23.5) 17 (19.5) 0.54 ORV off-road vehicle; GCS Glasgow Coma Scale; AIS Abbreviated Injury Score; ISS Injury Severity Score; BAC blood alcohol concentration; TTA Trauma Team Activation; BAC Negative BAC 0-1.9 mmol/L; Legal Intoxication BAC 2-17.3 mmol/L; Criminal Intoxication BAC > 17.3 mmol/L To determine whether alcohol intoxication predicted helmet non-use in ORV and motorcycle drivers, two separate regression models were implemented, one for all crashes and one for fatal crashes (Table 3 ). After adjustment for age and sex, those with criminal BAC (> 17.3 mmol/L) had 3.7 times the odds of being unhelmeted at the time of injury (p < 0.001). Similarly, among fatal crashes, criminal intoxication was associated with nearly 4 times the odds of being unhelmeted at the time of the ORV or motorcycle crash (OR 3.9, p = 0.01). Table 3 Factors associated with helmet non-use among all crashes and fatal crashes Variable All Crashes Fatal Crashes Adjusted OR 95% CI p-value Adjusted OR 95% CI p-value Age 0.98 0.96-1.00 0.06 0.96 0.92–0.99 0.029 Male sex 0.99 0.40–2.45 0.99 0.59 0.12–2.84 0.51 BAC level Negative Reference - - Reference - - Legal intoxication 0.93 0.31–2.81 0.89 0.42 0.04–4.64 0.48 Criminal intoxication 3.77 2.17–6.52 17.3 mmol/L Multivariable logistic regression models were created to assess for factors associated with prehospital and in-hospital mortality (Table 4 ) where age, helmet use, maximum AIS Head score, ISS, and BAC levels were included as predictors. Prehospital mortality was associated with increasing ISS (OR 1.07, 95% CI 1.03–1.07) and patients with criminal intoxication were 3 times more likely to die in the pre-hospital setting than BAC negative patients. Variables positively associated with the odds of in-hospital mortality were age (OR 1.05, 95% CI 1.02–1.09), maximum AIS Head score (OR 3.86, 95% CI 1.91–7.81) and ISS (OR 1.05, 95% CI 1.01–1.08). Compared with BAC negative drivers, drivers with legal intoxication had over five times the odds of experiencing in-hospital mortality (OR 5.63 95% CI 1.19–26.59), while drivers with criminal intoxication had 5 times the odds of experiencing in-hospital mortality (OR 4.97 95% CI 1.81–13.67). Table 4 Factors associated with prehospital and in-hospital mortality Variable Prehospital Mortality In-hospital Mortality Adjusted OR 95% CI p-value Adjusted OR 95% CI p-value Age 1.00 0.99–1.04 0.21 1.05 1.02–1.09 0.002 Helmet use 2.47 1.12–5.46 0.03 2.06 0.77–5.54 0.15 Max AIS Head score 1.15 0.72–1.84 0.55 3.86 1.91–7.81 < 0.001 ISS 1.07 1.04–1.09 < 0.001 1.05 1.01–1.08 0.020 BAC level Negative Reference - - Reference - - Legal intoxication 1.31 0.34–4.95 0.69 5.63 1.19–26.59 0.029 Criminal intoxication 3.12 1.48–6.55 0.003 4.97 1.81–13.67 0.002 OR odds ratio; CI confidence interval; AIS Abbreviated Injury Score; ISS Injury Severity Score; TTA Trauma Team Activation; BAC blood alcohol concentration; ORV off-road vehicle; BAC Negative BAC 0-1.9 mmol/L; Legal Intoxication BAC 2-17.3 mmol/L; Criminal Intoxication BAC > 17.3 mmol/L DISCUSSION Interpretation of Findings This is the first population-based study to report on the demographics and injury patterns of ORV and motorcycle-related TBI in Nova Scotia. Alcohol intoxication was found to be a pervasive risk factor for helmet non-use and mortality. Nearly three quarters of those involved in ORV crashes tested positive for BAC. Patients with BAC levels above 17.3 mmol/L had nearly 4 times the odds of helmet non-use compared with those who were BAC negative. The study findings underscore the critical role of alcohol intoxication with mortality resulting from ORV and motorcycle collisions; in the prehospital setting, BAC levels above 17.3 mmol/L independently predict prehospital mortality, while both legal and criminal levels of intoxication are linked to a fivefold increase in the odds of in-hospital mortality. Comparison to Previous Studies Alcohol has previously been identified as a risk factor in crashes involving ATVs [ 2 , 17 , 18 ], snowmobiles [ 9 , 18 ] and recreational watercraft [ 19 ]. Helmet use has been shown to be effective in reducing TBIs due to motorcycle and ORV crashes [ 10 , 11 ]. ATV riders who do not wear helmets are more likely to receive significant injuries to the head, face, and neck [ 12 ]. Our results demonstrate that alcohol intoxication is a significant risk factor for helmet non-use and mortality among ORV and motorcycle collisions. We found that helmet use among ORV crashes was just under 50% and that alcohol use decreased the likelihood of helmet use. A study from Newfoundland and Labrador reported similar results in their local study population [ 20 ]. Previous investigations have consistently shown a higher incidence of in-hospital mortality among motorcycle crash patients with elevated blood alcohol concentration compared to those who test negative [ 21 , 22 ]. A similar association exits between alcohol intoxication and ORV fatalities; in over half of ATV-related fatalities from 2013 to 2019, the drivers had consumed alcohol, cannabis or other drugs [ 2 ]. Our study findings align with the current literature. Specifically, prehospital mortality was observed in 20% of patients in our study. Patients with criminal BAC levels (> 17.3 mmol/L) had more than triple the risk of prehospital mortality after adjusting for helmet use, age, and injury severity. Drivers with any level of alcohol intoxication had over five times the risk of in-hospital mortality compared with BAC negative drivers. Strengths and Limitations Our findings are subject to the known limitations of retrospective data analysis and cannot be used to imply causality. Although data were collected from a robust prospective population-based registry, information was unknown or incomplete in some cases. Importantly, a large number of patients were not tested for alcohol use. Furthermore, this study was focused on a major TBI population treated at a single centre; thus, our results may not be generalizable to other patient populations. Clinical Implications Our findings underscore the significance of alcohol intoxication as a prevalent and independent risk factor associated with both helmet non-use and mortality in ORV and motorcycle crashes. It is imperative for frontline emergency providers and policymakers to recognize the widespread involvement of alcohol in these incidents, prompting the necessity for alcohol screening among crash-involved patients. This awareness can equip clinicians to engage patients in crucial injury prevention discussions. Additionally, studies advocate for the role of EDs in evaluating and referring at-risk patients to substance use disorder programs [ 23 ]. Implementing screening programs and establishing efficient referral pathways can effectively connect patients with the necessary resources and support to prevent the morbidity and mortality consequences of alcohol intoxication in ORV and motorcycle crashes. Research Implications Nova Scotians aged 16 years and older must complete a safety training program in order to legally operate an ORV and all drivers are required to wear an approved helmet. Although helmets are legally required for wheeled activities in Nova Scotia, there are challenges with enforcing this legislation, especially in rural areas, and there is limited information available on compliance with this law among ORV riders. Further research is required to understand the factors associated with alcohol misuse in this population which can then serve as a target to reduce injury through legislation and community-based education programs [ 6 ]. CONCULSIONS Our findings demonstrate that three quarters of TBI patients injured in ORV crashes were positive for blood alcohol. Less than half of patients involved in ORV crashes were wearing helmets, while helmet compliance was higher among motorcyclists. Alcohol intoxication is a significant risk factor for prehospital and in hospital mortality in ORV and motorcycle-related TBI. Declarations Competing interests: The authors declare that they have no conflict of interest. COMPETING INTERESTS The authors have no relevant financial or non-financial interests to disclose. Funding: This study was funded by a grant from the Nova Scotia Department of Health and Wellness. Author Contribution N.K, D.B.C, M.E., and R.G were involved in the conceptualization, methodology, analysis, and writing. S.W and I.O were involved in the methodology, analysis, and writing. All authors reviewed the final manuscript. Acknowledgements: The authors acknowledge the support provided by Beth Sealy and Karen Ssebazza, Registry Coordinators of the Nova Scotia Trauma Registry. Data used in this research was made available by the Nova Scotia Department of Health and Wellness. Any opinions expressed by the authors do not necessarily reflect the opinion of the Nova Scotia Department of Health and Wellness or the Nova Scotia Health Trauma Program. References Government of Canada SC. (2023) The Daily — Circumstances surrounding motorcycle fatalities in Canada, 2016 to 2020. https://www150.statcan.gc.ca/n1/daily-quotidien/230515/dq230515b-eng.htm . Accessed 21 Dec 2023. Government of Canada SC. (2021) The Daily — Circumstances surrounding all-terrain vehicle (ATV) fatalities in Canada, 2013 to 2019. https://www150.statcan.gc.ca/n1/daily-quotidien/210607/dq210607d-eng.htm . Accessed 21 Dec 2023. Government of Canada SC. (2021) Snowmobile fatalities in Canada, 2013 to 2019. https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2021002-eng.htm . Accessed 21 Dec 2023. Yanchar NL, Kennedy R, Russell C. ATVs: motorized toys or vehicles for children? Inj Prev. 2006;12:30–4. Jessula S, Murphy N, Yanchar NL. Injury severity in pediatric all-terrain vehicle-related trauma in Nova Scotia. J Pediatr Surg. 2017;52:822–5. Benham EC, Ross SW, Mavilia M, Fischer P, Christmas AB, Sing RF. Injuries from all-terrain vehicles: An opportunity for injury prevention. Am J Surg. 2017;214:211–6. Jennissen CA, Stange NR, Fjeld A, Denning GM. The dark side of nighttime all-terrain vehicle use. Inj Epidemiol. 2021. https://doi.org/10.1186/s40621-021-00316-y . Lord S, Tator CH, Wells S. Examining Ontario deaths due to allterrain vehicles, and targets for prevention. Can J Neurol Sci. 2010;37:343–9. Government of Canada SC. (2023) Motorcycle Fatalities in Canada, 2016 to 2020. https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2023024-eng.htm . Accessed 21 Dec 2023. Rattan R, Joseph DK, Dente CJ, Klein EN, Kimbrough MK, Nguyen J. Prevention of all-terrain vehicle injuries: A systematic review from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018;84:1017–26. Du RY, LoPresti MA, Garcia RM, Lam S. Primary prevention of road traffic accident-related traumatic brain injuries in younger populations: a systematic review of helmet legislation. J Neurosurg Pediatr. 2020. https://doi.org/10.3171/2019.10.PEDS19377 . Bowman SM, Aitken ME, Helmkamp JC, Maham SA, Graham CJ. Impact of helmets on injuries to riders of all-terrain vehicles. Inj Prev. 2009;15:3–7. Hassan A, Jokar TO, Rhee P, Ibraheem K, Kulvatunyou N, Anderson KT. More helmets fewer deaths: Motorcycle helmet legislation impacts traumatic brain injury-related mortality in young adults. Am Surg. 2017;83:541–6. Rossheim ME, Wilson F, Suzuki S, Rodriguez M, Walters S, Thombs DL. Associations between drug use and motorcycle helmet use in fatal crashes. Traffic Inj Prev. 2014;15:678–84. Bethea A, Samanta D, Willis JA, Lucente FC, Chumbe JT. Substance exposure and helmet use in all-terrain vehicle accidents: Nine years of experience at a level 1 trauma center. Journal of safety research; 2016. DG EE, SJ AME, PC P, Initiative GJPV STROBE. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806–8. Hall AJ, Bixler D, Helmkamp JC, Kraner JC, Kaplan JA. Fatal all-terrain vehicle crashes: injury types and alcohol use. Am J Prev Med. 2009;36:311–6. Vanlaar W, McAteer H, Brown S, Crain J, McFaull S, Hing MM. Injuries related to off-road vehicles in Canada. Accid Anal Prev. 2015;75:264–71. O’Connor PJ, O’Connor N. Causes and prevention of boating fatalities. Accid Anal Prev. 2005;37:689–98. Black H, Whalen D, Alani S, Rogers P, MacLean C. All-terrain vehicle-related injuries and deaths in Newfoundland and Labrador between 2003 and 2013: a retrospective trauma registry review. CJEM. 2018;20:207–15. Ahmed N, Kuo Y-H, Sharma J, Kaul S. Elevated blood alcohol impacts hospital mortality following motorcycle injury: A National Trauma Data Bank analysis. Injury. 2020;51:91–6. Christophersen AS, Gjerde H. Prevalence of alcohol and drugs among motorcycle riders killed in road crashes in Norway during 2001–2010. Accid Anal Prev. 2015;80:236–42. Hann J, Wu H, Gauri A, Dong K, Lam N, Bakal JA, Kirkham A. Identification of emergency department patients for referral to rapid-access addiction services. Can J Emerg Med. 2020;22:170–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Jun, 2024 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 08 May, 2024 Reviews received at journal 02 May, 2024 Reviewers agreed at journal 30 Mar, 2024 Reviewers invited by journal 10 Mar, 2024 Editor assigned by journal 10 Mar, 2024 Submission checks completed at journal 02 Mar, 2024 First submitted to journal 29 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4000958","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275954186,"identity":"ccc0ab92-ce25-4121-a3c6-768b9596bfeb","order_by":0,"name":"Nelofar Kureshi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIie3OsWrDMBCA4RMGd0k6XzC4r6BgKBn6MDIFe/LUpUMoCgFNqefkLTJ2lCjEiyCrp9ZaOrdLiJdQuVBoC1LWDvon3cEnCSAU+odRGXG4twccJsIxhWHjayYJB/2DZDBsfN38IZDzs6RZLDo5f4HJujKmf5qVdaM4HOducq3VksrdHSRYZtlYY7XROSernYe0uUjeYwYpFnFCBFZbmfMIYjfJXo1AefoiF30vsKR7Y8nJTaatvVkJZj9WxDAWyGhrXyHCQ3S+pKpmo8nqLUosmW5aw9Vj7Sa0eVadPLAUm4J89OLh6nJ/q7rjwU2+G/2a5HkQCoVCIV+fJgBbJm+zpEoAAAAASUVORK5CYII=","orcid":"","institution":"Dalhousie University","correspondingAuthor":true,"prefix":"","firstName":"Nelofar","middleName":"","lastName":"Kureshi","suffix":""},{"id":275954187,"identity":"84d84c38-a962-4b12-8c4e-0ed4f5aebf66","order_by":1,"name":"Simon Walling","email":"","orcid":"","institution":"Dalhousie University","correspondingAuthor":false,"prefix":"","firstName":"Simon","middleName":"","lastName":"Walling","suffix":""},{"id":275954188,"identity":"8c91cbad-6244-4c13-854e-c51d0679640c","order_by":2,"name":"Mete Erdogan","email":"","orcid":"","institution":"Nova Scotia Trauma Program","correspondingAuthor":false,"prefix":"","firstName":"Mete","middleName":"","lastName":"Erdogan","suffix":""},{"id":275954189,"identity":"0a1ab3dc-9b91-4af4-8f9e-55ea5f81479f","order_by":3,"name":"Izabella Opra PCP","email":"","orcid":"","institution":"Nova Scotia Trauma Program","correspondingAuthor":false,"prefix":"","firstName":"Izabella","middleName":"Opra","lastName":"PCP","suffix":""},{"id":275954190,"identity":"2731bce9-53fd-4881-b736-3a5129b9e6d1","order_by":4,"name":"Robert S. Green","email":"","orcid":"","institution":"Dalhousie University","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"S.","lastName":"Green","suffix":""},{"id":275954191,"identity":"16196278-a5ca-446f-857f-c0d7e8584e2d","order_by":5,"name":"David B. Clarke","email":"","orcid":"","institution":"Dalhousie University","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"B.","lastName":"Clarke","suffix":""}],"badges":[],"createdAt":"2024-02-29 19:29:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4000958/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4000958/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-024-02572-1","type":"published","date":"2024-06-18T15:26:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58823190,"identity":"69a4170a-3105-463a-bfba-21f8aecc6d47","added_by":"auto","created_at":"2024-06-21 16:54:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":596248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4000958/v1/ad6b136c-c0ce-4258-afe0-2d4177a3ffde.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Alcohol is a risk factor for helmet non-use and fatalities in off-road vehicle and motorcycle crashes","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMotorcycles and off-road vehicles (ORVs) such as all-terrain vehicles (ATVs), side-by-sides (SxSs), utility terrain vehicles (UTVs), and snowmobiles are commonly used for transportation, work, and recreation in Canada. Each year, there are approximately 180 motorcycle fatalities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], 100 ATV fatalities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and 73 snowmobile fatalities across the country [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In Nova Scotia, motorcycles and ORVs are popular for both recreation and transportation/work purposes. Previous studies in Nova Scotia have shown that ATV injuries in children closely resemble injuries from motor vehicle collisions (MVCs) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Legislation restricting ATV use by children led to a short-term decrease but no sustained effect on the frequency and severity of ATV injuries [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The risk of injury while operating these vehicles is heightened by numerous factors including driving unhelmeted, night driving, having multiple passengers, engaging in risky behavior (e.g., jumps, high speeds), and use of alcohol and/or drugs [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Use of alcohol/drugs has been reported in roughly half of ATV and snowmobile deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and in nearly one third of motorcycle fatalities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eTraumatic brain injury (TBI) is the primary cause of death from motorcycle and ORV crashes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While some ORVs have safety features like seat belts and roll cages, helmets remain the best form of head protection and are associated with significantly lower risk of TBI and death among riders involved in a crash [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. At least one-third of ATV fatalities in Canada involve unhelmeted riders [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Furthermore, there is evidence that use of alcohol/drugs is associated with increased odds of not wearing a helmet among those injured in motorcycle crashes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and ATV crashes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The aim of this study was to assess the demographic and injury patterns of patients presenting with ORV- or motorcycle-related TBI to a Level I trauma centre. Specifically, we hypothesized that crashes involving alcohol are associated with increased risk of not wearing a protective helmet, as well as increased odds of prehospital and in-hospital mortality.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Time Period\u003c/h2\u003e \u003cp\u003eThis was a retrospective cohort study of major TBI patients injured between January 1 2002 and March 31, 2015. Study data were collected from the Nova Scotia Trauma Registry (NSTR). The NSTR is a provincial population-based registry under the Nova Scotia Department of Health and Wellness and contains data on all major trauma patients with an Injury Severity Score (ISS)\u0026thinsp;\u0026ge;\u0026thinsp;12 and an appropriate International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) code. The NSTR also includes penetrating traumas with an ISS\u0026thinsp;\u0026ge;\u0026thinsp;9 or greater, all trauma team activations (TTAs) regardless of ISS, and traumas resulting in death prior to hospital arrival or in the ED. This study was performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eAll major trauma and adult neurosurgical services in the Nova Scotia are centralized at the Queen Elizabeth II Health Sciences Centre (QEII HSC) in Halifax. This centre services a population of 938,183 within 55,000 km\u003csup\u003e2\u003c/sup\u003e and receives all major neurotrauma cases from within the province as well as some cases from Prince Edward Island.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePopulation\u003c/h2\u003e \u003cp\u003eWe included all major TBI patients injured in an ORV or motorcycle crash during the study period. Consistent with the literature, major TBI was defined using the maximal Abbreviated Injury Scale (AIS) Head score [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and ICD-10-CA injury codes. All patients in the NSTR with a maximum AIS Head score\u0026thinsp;\u0026ge;\u0026thinsp;3 and a primary ICD-10-CA diagnosis code consistent with blunt or penetrating trauma were included. For this study, ORVs included ATVs, UTVs, SxSs, and snowmobiles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData elements collected from the NSTR included age, sex, injury mechanism, use of helmet, maximum AIS Head score, ISS, Glasgow Coma Scale (GCS) score, TTA, blood alcohol concentration (BAC) testing, BAC level, and discharge status. Quantitative alcohol levels were determined during the initial ED visit or by post-mortem testing by the Nova Scotia Medical Examiner Service. BAC levels are reported as millimoles of ethanol per liter of blood (mmol/L).\u003c/p\u003e \u003cp\u003eFor patients admitted to a provincial ED, routine BAC testing for MVCs is performed. When a patient dies at the crash scene or before admittance to hospital, law enforcement or emergency medical personnel notify the provincial Medical Examiner who draws a blood sample and conducts a BAC test from all fatal crashes. Because post-mortem blood presents problems due to variable conditions and changes to concentrations from one place to another in the body after death, the Medical Examiner commonly analyzes vitreous humor for BAC. A BAC level of 0-1.9 mmol/L was coded as BAC negative (as defined by the National Trauma Registry); any BAC reported as \u0026ge;\u0026thinsp;2mmol/L was considered positive. Positive BAC levels were further categorized as legal intoxication (2-17.3mmol/L) or criminal intoxication (\u0026gt;\u0026thinsp;17.3mmol/L). Throughout Canada, the maximum legal BAC for fully licensed drivers is \u0026lt;\u0026thinsp;80mg alcohol in 100ml of blood, or 0.08 gram% (0.08 grams alcohol/100 ml\u0026thinsp;=\u0026thinsp;17.3 mmol/L). Driving with a BAC of 17.3 mmol/L or higher is a criminal offence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003eOutcome measures included helmet non-use and mortality (prehospital, in-hospital). Prehospital mortality was defined as death at the scene or during transfer to hospital, while in-hospital mortality was defined as death occurring at any time after arrival to an ED.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eDemographic and injury characteristics were described using means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations for continuous variables and counts and percentages for categorical variables. Between groups comparisons were performed with a chi-square (categorical data) and with Student's t-test or one-way ANOVA test (continuous data), as appropriate, with the following BAC levels: negative (BAC 0-1.9 mmol/L), legal intoxication (2-17.3 mmol/L), and criminal intoxication (\u0026gt;\u0026thinsp;17.3 mmol/L). An age and sex-adjusted regression model for the association of BAC with helmet use was created. Prehospital and in-hospital mortality were modelled with multivariate logistic regression using age, AIS Head, ISS, and BAC levels as covariates. We did not include sex in the multivariate logistic regression modeling given that the vast majority of the study sample were males. The resulting coefficients were exponentiated to obtain adjusted odds ratios (ORs). A p-value less than 0.05 was considered statistically significant. ORs were reported with 95% confidence intervals (CIs). All data were analyzed using SPSS software (version 27; SPSS Inc., Chicago) and R Statistical Software (version 4.2.5).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eEthics Approval\u003c/h2\u003e \u003cp\u003eAll study procedures were approved by the institutional research board (File #1018117).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 5590 major TBI patients were seen in Nova Scotia during the 16-year study period. Of these, 220 patients were ORV drivers and 204 were motorcycle drivers. Characteristics of TBI patients injured in ORV and motorcycle crashes are compared in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients injured in ORV crashes were younger (34\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5 vs. 44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and had lower mean ISS scores (27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2 vs. 36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than those injured in motorcycle crashes. Less than half (45%) of patients injured in ORV crashes were wearing helmets compared with 89% of motorcycle crashes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). BAC testing was performed in 66% (146/220) of ORV crashes and 68% (138/204) of motorcycle collisions. BAC levels were significantly different between ORV and motorcycle crashes. Prehospital mortality was observed in 20% (85/424) of the study sample; the proportion of prehospital mortality was significantly greater than motorcycle crashes (29% vs. 18%, p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients injured in ORV and motorcycle crashes in Nova Scotia, 2002\u0026ndash;2015\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eORV trauma\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMotorcycle trauma (n\u0026thinsp;=\u0026thinsp;204)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199 (90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHelmet use, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (88.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS on ED arrival, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMax AIS Head, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTA, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (46.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAC testing performed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146 (66.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 (68.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAC level, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative (0-1.9 mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (76.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegal intoxication (2-17.3mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (5.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriminal intoxication (\u0026gt;\u0026thinsp;17.3mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (65.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrehospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eORV\u003c/em\u003e off-road vehicle; \u003cem\u003eTBI\u003c/em\u003e traumatic brain injury; \u003cem\u003eGCS\u003c/em\u003e Glasgow Coma Scale; \u003cem\u003eAIS\u003c/em\u003e Abbreviated Injury Score; \u003cem\u003eISS\u003c/em\u003e Injury Severity Score; \u003cem\u003eBAC\u003c/em\u003e blood alcohol concentration; \u003cem\u003eTTA\u003c/em\u003e Trauma Team Activation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCharacteristics of patients injured in ORV or motorcycle crashes were compared by BAC level (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Helmet use was highest in BAC negative patients (80%, 115/144) and least frequent in drivers with criminal BAC levels (50%, 60/120). Mean ISS was statistically different between the three BAC categories, with the most severe injuries observed in the BAC negative group (mean ISS 35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3) and the least severe injuries in the criminally intoxicated BAC group (mean ISS 29.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients by blood alcohol concentration\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBAC\u003c/p\u003e \u003cp\u003eNegative\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLegal Intoxication\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCriminal Intoxication\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;120)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127 (88.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (77.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113 (94.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVehicle type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotorcycle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (74.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (20.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHelmet use, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (77.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS on ED arrival, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMax AIS Head, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTA, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69 (57.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrehospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eORV\u003c/em\u003e off-road vehicle; \u003cem\u003eGCS\u003c/em\u003e Glasgow Coma Scale; \u003cem\u003eAIS\u003c/em\u003e Abbreviated Injury Score; \u003cem\u003eISS\u003c/em\u003e Injury Severity Score; \u003cem\u003eBAC\u003c/em\u003e blood alcohol concentration; \u003cem\u003eTTA\u003c/em\u003e Trauma Team Activation; \u003cem\u003eBAC Negative\u003c/em\u003e BAC 0-1.9 mmol/L; \u003cem\u003eLegal Intoxication\u003c/em\u003e BAC 2-17.3 mmol/L; \u003cem\u003eCriminal Intoxication\u003c/em\u003e BAC\u0026thinsp;\u0026gt;\u0026thinsp;17.3 mmol/L\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo determine whether alcohol intoxication predicted helmet non-use in ORV and motorcycle drivers, two separate regression models were implemented, one for all crashes and one for fatal crashes (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After adjustment for age and sex, those with criminal BAC (\u0026gt;\u0026thinsp;17.3 mmol/L) had 3.7 times the odds of being unhelmeted at the time of injury (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, among fatal crashes, criminal intoxication was associated with nearly 4 times the odds of being unhelmeted at the time of the ORV or motorcycle crash (OR 3.9, p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with helmet non-use among all crashes and fatal crashes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eAll Crashes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eFatal Crashes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96-1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.92\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.40\u0026ndash;2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.12\u0026ndash;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAC level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegal intoxication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31\u0026ndash;2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.04\u0026ndash;4.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriminal intoxication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.17\u0026ndash;6.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.37\u0026ndash;11.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eBAC\u003c/em\u003e blood alcohol concentration; \u003cem\u003eOR\u003c/em\u003e odds ratio; \u003cem\u003eCI\u003c/em\u003e confidence interval; \u003cem\u003eBAC Negative\u003c/em\u003e BAC 0-1.9 mmol/L; \u003cem\u003eLegal Intoxication\u003c/em\u003e BAC 2-17.3 mmol/L; \u003cem\u003eCriminal Intoxication\u003c/em\u003e BAC\u0026thinsp;\u0026gt;\u0026thinsp;17.3 mmol/L\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariable logistic regression models were created to assess for factors associated with prehospital and in-hospital mortality (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) where age, helmet use, maximum AIS Head score, ISS, and BAC levels were included as predictors. Prehospital mortality was associated with increasing ISS (OR 1.07, 95% CI 1.03\u0026ndash;1.07) and patients with criminal intoxication were 3 times more likely to die in the pre-hospital setting than BAC negative patients. Variables positively associated with the odds of in-hospital mortality were age (OR 1.05, 95% CI 1.02\u0026ndash;1.09), maximum AIS Head score (OR 3.86, 95% CI 1.91\u0026ndash;7.81) and ISS (OR 1.05, 95% CI 1.01\u0026ndash;1.08). Compared with BAC negative drivers, drivers with legal intoxication had over five times the odds of experiencing in-hospital mortality (OR 5.63 95% CI 1.19\u0026ndash;26.59), while drivers with criminal intoxication had 5 times the odds of experiencing in-hospital mortality (OR 4.97 95% CI 1.81\u0026ndash;13.67).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with prehospital and in-hospital mortality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePrehospital Mortality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eIn-hospital Mortality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u0026ndash;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.02\u0026ndash;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHelmet use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.12\u0026ndash;5.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.77\u0026ndash;5.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMax AIS Head score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.72\u0026ndash;1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.91\u0026ndash;7.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.04\u0026ndash;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.01\u0026ndash;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAC level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegal intoxication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.34\u0026ndash;4.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.19\u0026ndash;26.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriminal intoxication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.48\u0026ndash;6.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.81\u0026ndash;13.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eOR\u003c/em\u003e odds ratio; \u003cem\u003eCI\u003c/em\u003e confidence interval; \u003cem\u003eAIS\u003c/em\u003e Abbreviated Injury Score; \u003cem\u003eISS\u003c/em\u003e Injury Severity Score; \u003cem\u003eTTA\u003c/em\u003e Trauma Team Activation; \u003cem\u003eBAC\u003c/em\u003e blood alcohol concentration; \u003cem\u003eORV\u003c/em\u003e off-road vehicle; \u003cem\u003eBAC Negative\u003c/em\u003e BAC 0-1.9 mmol/L; \u003cem\u003eLegal Intoxication\u003c/em\u003e BAC 2-17.3 mmol/L; \u003cem\u003eCriminal Intoxication\u003c/em\u003e BAC\u0026thinsp;\u0026gt;\u0026thinsp;17.3 mmol/L\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation of Findings\u003c/h2\u003e \u003cp\u003eThis is the first population-based study to report on the demographics and injury patterns of ORV and motorcycle-related TBI in Nova Scotia. Alcohol intoxication was found to be a pervasive risk factor for helmet non-use and mortality. Nearly three quarters of those involved in ORV crashes tested positive for BAC. Patients with BAC levels above 17.3 mmol/L had nearly 4 times the odds of helmet non-use compared with those who were BAC negative. The study findings underscore the critical role of alcohol intoxication with mortality resulting from ORV and motorcycle collisions; in the prehospital setting, BAC levels above 17.3 mmol/L independently predict prehospital mortality, while both legal and criminal levels of intoxication are linked to a fivefold increase in the odds of in-hospital mortality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparison to Previous Studies\u003c/h2\u003e \u003cp\u003eAlcohol has previously been identified as a risk factor in crashes involving ATVs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], snowmobiles [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and recreational watercraft [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Helmet use has been shown to be effective in reducing TBIs due to motorcycle and ORV crashes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. ATV riders who do not wear helmets are more likely to receive significant injuries to the head, face, and neck [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our results demonstrate that alcohol intoxication is a significant risk factor for helmet non-use and mortality among ORV and motorcycle collisions. We found that helmet use among ORV crashes was just under 50% and that alcohol use decreased the likelihood of helmet use. A study from Newfoundland and Labrador reported similar results in their local study population [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious investigations have consistently shown a higher incidence of in-hospital mortality among motorcycle crash patients with elevated blood alcohol concentration compared to those who test negative [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A similar association exits between alcohol intoxication and ORV fatalities; in over half of ATV-related fatalities from 2013 to 2019, the drivers had consumed alcohol, cannabis or other drugs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Our study findings align with the current literature. Specifically, prehospital mortality was observed in 20% of patients in our study. Patients with criminal BAC levels (\u0026gt;\u0026thinsp;17.3 mmol/L) had more than triple the risk of prehospital mortality after adjusting for helmet use, age, and injury severity. Drivers with any level of alcohol intoxication had over five times the risk of in-hospital mortality compared with BAC negative drivers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eOur findings are subject to the known limitations of retrospective data analysis and cannot be used to imply causality. Although data were collected from a robust prospective population-based registry, information was unknown or incomplete in some cases. Importantly, a large number of patients were not tested for alcohol use. Furthermore, this study was focused on a major TBI population treated at a single centre; thus, our results may not be generalizable to other patient populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eOur findings underscore the significance of alcohol intoxication as a prevalent and independent risk factor associated with both helmet non-use and mortality in ORV and motorcycle crashes. It is imperative for frontline emergency providers and policymakers to recognize the widespread involvement of alcohol in these incidents, prompting the necessity for alcohol screening among crash-involved patients. This awareness can equip clinicians to engage patients in crucial injury prevention discussions. Additionally, studies advocate for the role of EDs in evaluating and referring at-risk patients to substance use disorder programs [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Implementing screening programs and establishing efficient referral pathways can effectively connect patients with the necessary resources and support to prevent the morbidity and mortality consequences of alcohol intoxication in ORV and motorcycle crashes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eResearch Implications\u003c/h2\u003e \u003cp\u003eNova Scotians aged 16 years and older must complete a safety training program in order to legally operate an ORV and all drivers are required to wear an approved helmet. Although helmets are legally required for wheeled activities in Nova Scotia, there are challenges with enforcing this legislation, especially in rural areas, and there is limited information available on compliance with this law among ORV riders. Further research is required to understand the factors associated with alcohol misuse in this population which can then serve as a target to reduce injury through legislation and community-based education programs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCULSIONS","content":"\u003cp\u003eOur findings demonstrate that three quarters of TBI patients injured in ORV crashes were positive for blood alcohol. Less than half of patients involved in ORV crashes were wearing helmets, while helmet compliance was higher among motorcyclists. Alcohol intoxication is a significant risk factor for prehospital and in hospital mortality in ORV and motorcycle-related TBI.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests: \u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e \u003ch2\u003eCOMPETING INTERESTS\u003c/h2\u003e \u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was funded by a grant from the Nova Scotia Department of Health and Wellness.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.K, D.B.C, M.E., and R.G were involved in the conceptualization, methodology, analysis, and writing. S.W and I.O were involved in the methodology, analysis, and writing. All authors reviewed the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eThe authors acknowledge the support provided by Beth Sealy and Karen Ssebazza, Registry Coordinators of the Nova Scotia Trauma Registry. Data used in this research was made available by the Nova Scotia Department of Health and Wellness. Any opinions expressed by the authors do not necessarily reflect the opinion of the Nova Scotia Department of Health and Wellness or the Nova Scotia Health Trauma Program.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGovernment of Canada SC. (2023) The Daily \u0026mdash; Circumstances surrounding motorcycle fatalities in Canada, 2016 to 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www150.statcan.gc.ca/n1/daily-quotidien/230515/dq230515b-eng.htm\u003c/span\u003e\u003cspan address=\"https://www150.statcan.gc.ca/n1/daily-quotidien/230515/dq230515b-eng.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Dec 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovernment of Canada SC. (2021) The Daily \u0026mdash; Circumstances surrounding all-terrain vehicle (ATV) fatalities in Canada, 2013 to 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www150.statcan.gc.ca/n1/daily-quotidien/210607/dq210607d-eng.htm\u003c/span\u003e\u003cspan address=\"https://www150.statcan.gc.ca/n1/daily-quotidien/210607/dq210607d-eng.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Dec 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovernment of Canada SC. (2021) Snowmobile fatalities in Canada, 2013 to 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2021002-eng.htm\u003c/span\u003e\u003cspan address=\"https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2021002-eng.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Dec 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYanchar NL, Kennedy R, Russell C. ATVs: motorized toys or vehicles for children? Inj Prev. 2006;12:30\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJessula S, Murphy N, Yanchar NL. Injury severity in pediatric all-terrain vehicle-related trauma in Nova Scotia. J Pediatr Surg. 2017;52:822\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenham EC, Ross SW, Mavilia M, Fischer P, Christmas AB, Sing RF. Injuries from all-terrain vehicles: An opportunity for injury prevention. Am J Surg. 2017;214:211\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJennissen CA, Stange NR, Fjeld A, Denning GM. The dark side of nighttime all-terrain vehicle use. Inj Epidemiol. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40621-021-00316-y\u003c/span\u003e\u003cspan address=\"10.1186/s40621-021-00316-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLord S, Tator CH, Wells S. Examining Ontario deaths due to allterrain vehicles, and targets for prevention. Can J Neurol Sci. 2010;37:343\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovernment of Canada SC. (2023) Motorcycle Fatalities in Canada, 2016 to 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2023024-eng.htm\u003c/span\u003e\u003cspan address=\"https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2023024-eng.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Dec 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRattan R, Joseph DK, Dente CJ, Klein EN, Kimbrough MK, Nguyen J. Prevention of all-terrain vehicle injuries: A systematic review from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018;84:1017\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDu RY, LoPresti MA, Garcia RM, Lam S. Primary prevention of road traffic accident-related traumatic brain injuries in younger populations: a systematic review of helmet legislation. J Neurosurg Pediatr. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3171/2019.10.PEDS19377\u003c/span\u003e\u003cspan address=\"10.3171/2019.10.PEDS19377\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowman SM, Aitken ME, Helmkamp JC, Maham SA, Graham CJ. Impact of helmets on injuries to riders of all-terrain vehicles. Inj Prev. 2009;15:3\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan A, Jokar TO, Rhee P, Ibraheem K, Kulvatunyou N, Anderson KT. More helmets fewer deaths: Motorcycle helmet legislation impacts traumatic brain injury-related mortality in young adults. Am Surg. 2017;83:541\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRossheim ME, Wilson F, Suzuki S, Rodriguez M, Walters S, Thombs DL. Associations between drug use and motorcycle helmet use in fatal crashes. Traffic Inj Prev. 2014;15:678\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBethea A, Samanta D, Willis JA, Lucente FC, Chumbe JT. Substance exposure and helmet use in all-terrain vehicle accidents: Nine years of experience at a level 1 trauma center. Journal of safety research; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDG EE, SJ AME, PC P, Initiative GJPV STROBE. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall AJ, Bixler D, Helmkamp JC, Kraner JC, Kaplan JA. Fatal all-terrain vehicle crashes: injury types and alcohol use. Am J Prev Med. 2009;36:311\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanlaar W, McAteer H, Brown S, Crain J, McFaull S, Hing MM. Injuries related to off-road vehicles in Canada. Accid Anal Prev. 2015;75:264\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Connor PJ, O\u0026rsquo;Connor N. Causes and prevention of boating fatalities. Accid Anal Prev. 2005;37:689\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack H, Whalen D, Alani S, Rogers P, MacLean C. All-terrain vehicle-related injuries and deaths in Newfoundland and Labrador between 2003 and 2013: a retrospective trauma registry review. CJEM. 2018;20:207\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed N, Kuo Y-H, Sharma J, Kaul S. Elevated blood alcohol impacts hospital mortality following motorcycle injury: A National Trauma Data Bank analysis. Injury. 2020;51:91\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristophersen AS, Gjerde H. Prevalence of alcohol and drugs among motorcycle riders killed in road crashes in Norway during 2001\u0026ndash;2010. Accid Anal Prev. 2015;80:236\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHann J, Wu H, Gauri A, Dong K, Lam N, Bakal JA, Kirkham A. Identification of emergency department patients for referral to rapid-access addiction services. Can J Emerg Med. 2020;22:170\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"traumatic brain injury, off-road vehicles, all-terrain vehicles, motorcycles, alcohol, mortality","lastPublishedDoi":"10.21203/rs.3.rs-4000958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4000958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eOff-road vehicle (ORV) and motorcycle use is common in Canada; however, risk of serious injury is heightened when these vehicles are operated without helmets and under the influence of alcohol. This study evaluated the impact of alcohol intoxication on helmet non-use and mortality among ORV and motorcycle crashes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eUsing data collected from the Nova Scotia Trauma Registry, a retrospective analysis (2002-2018) of ORV and motorcycle crashes resulting in major traumatic brain injury was performed. Patients were grouped by blood alcohol concentration (BAC) as negative (\u0026lt;2 mmol/L), legally intoxicated (2-17.3 mmol/L) or criminally intoxicated (\u0026gt;17.3 mmol/L). Logistic regression models were constructed to test for helmet non-use and mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 424 trauma patients were included in the analysis (220 ORV, 204 motorcycle). Less than half (45%) of patients involved in ORV crashes were wearing helmets and 65% were criminally intoxicated. Most patients involved in motorcycle crashes were helmeted at time of injury (88.7%) and 18% were criminally intoxicated. Those with criminal levels of intoxication had 3.7 times the odds of being unhelmeted and were 3 times more likely to die prehospital compared to BAC negative patients. There were significantly increased odds of in-hospital mortality among those with both legal (OR = 5.63), and criminal intoxication levels (OR = 4.97) compared to patients who were BAC negative.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAlcohol intoxication is more frequently observed in ORV versus motorcycle crashes. Criminal intoxication is associated with helmet non-use. Any level of intoxication is a predictor of increased in-hospital mortality.\u003c/p\u003e","manuscriptTitle":"Alcohol is a risk factor for helmet non-use and fatalities in off-road vehicle and motorcycle crashes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 10:53:59","doi":"10.21203/rs.3.rs-4000958/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-08T12:15:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-02T10:20:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a56f2319-c924-41ab-a368-1da9287f137f","date":"2024-03-30T06:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-10T16:29:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-10T16:24:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-02T09:42:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-02-29T19:16:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5df40855-b0b4-4f19-a8b5-42b80b1eed3b","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T15:26:04+00:00","versionOfRecord":{"articleIdentity":"rs-4000958","link":"https://doi.org/10.1007/s00068-024-02572-1","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2024-06-18 15:26:04","publishedOnDateReadable":"June 18th, 2024"},"versionCreatedAt":"2024-03-06 10:53:59","video":"","vorDoi":"10.1007/s00068-024-02572-1","vorDoiUrl":"https://doi.org/10.1007/s00068-024-02572-1","workflowStages":[]},"version":"v1","identity":"rs-4000958","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4000958","identity":"rs-4000958","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}