Head Injury Risks in Pediatric E-Scooter Riders

Electric scooters (e-scooters) have become an extremely popular form of transportation, particularly among older children and adolescents, offering an affordable, easily available, and fun way to travel independently. But, compared to self-propelled transportation such as skateboards and bicycles, e-scooters present a higher risk of more severe injuries, primarily because they can travel at upwards of 30 miles per hour.1 This high speed of travel combined with the relative inexperience of older children and adolescents in navigating complex traffic situations, and the growing popularity of e-scooters in this demographic, has led to a rapid rise in injuries involving e-scooters. From 2012 to 2021, injuries related to electrically powered recreational transportation devices have increased by 700%, and the risk of head and craniofacial injuries in the pediatric population is of particular interest to emergency physicians.2 Unique Risks in Young Riders Emerging literature on the study of scooter injuries in pediatric patients show specific trends in this patient population. Studies highlight the increased risks of polytrauma and head trauma in older children and adolescents, compared to adults and to riders of skateboards or bicycles. For example, using data from the National Electronic Injury Surveillance System database, a study by Hirsch et al, identified an increased risk of craniofacial fractures and severe injury in adolescent riders of e-scooters.2 Other authors note the higher risk of severe traffic accidents and severe head injuries in this age group.3-5 Many factors may contribute to the severity and unique features of e-scooter injuries experienced in the adolescent population. Adolescents have minimal or no experience navigating traffic situations and may have limited knowledge on traffic laws and conventions, especially given a driver's license is not required to operate an e-scooter. Distraction and risk-taking behaviors, such as riding in a group with friends or use of smartphones while riding, can also be contributing factors. Finally, with respect to head injuries, in particular, a higher center of gravity and widespread lack of helmet use make these riders vulnerable.1,2 Helmet Use and Head Injuries Helmet use is limited in all riders of e-scooters, and a particular concern in the pediatric population, given the potential acute and long-term effects of head injuries. For example, studies have found most pediatric riders who experienced craniofacial injuries were not wearing a helmet at the time of injury, and a case series of injured riders in the United Kingdom aged 13-17 years found none of the injured riders were wearing a helmet.2,5 The American Academy of Pediatrics advocates for the use of helmets and limiting the use of e-scooters to those aged 16 years or older, but these recommendations are not consistently adopted or enforced across the United States.6 Dr Leticia Ryan, division chief, Pediatric Emergency Medicine at Johns Hopkins Children's Center, commented, “The most consistent and concerning pattern that I have seen is higher rates of serious head injuries in the e-scooter riders. I suspect that this relates to less helmet use, higher speeds, and more collisions that involve traffic. I've observed less helmet use in children and adolescents using e-scooters, which increases risk for more serious and severe head injuries.” Identifying High-Risk Presentations How does the propensity of pediatric riders to head injuries, and to severe injuries, affect management of these patients when they present to the emergency department? Assessment of the severity of acute head trauma and potential traumatic brain injury (TBI), and the need for computed tomography imaging to evaluate for injury is guided by clinical decision rules such as the PECARN, CATCH, and CHALICE rules.7 The PECARN rule, in particular, has a high sensitivity for identifying and stratifying patients at risk for clinically significant TBI who require neuroimaging and observation. In deciding which patients are at risk for TBI, one criterion used in the PECARN algorithm is the severity of the injury mechanism, such as the situation of a cyclist or pedestrian struck by a motor vehicle.8 Similar collisions can occur with e-scooters, and given the literature documenting craniofacial injuries and, rarely, epidural hematomas in pediatric e-scooter riders, early assessment to determine if imaging is needed is critical in these patients.2,3,9 Dr Katherine Douglas, clinical fellow in emergency medicine, and Dr Andrew Fine, senior attending physician, Pediatric Emergency Medicine, at Boston Children's Hospital have recently authored a commentary on the risk of e-scooter injuries in adolescents, highlighting the increased risk of serious traffic accidents and intracranial injuries in these riders. They noted, “E-scooters have changed the epidemiology of the injury mechanism we see in the ED. Severe collisions involving e-scooters, often with motor vehicles, are leading to more patients needing observation, or in some cases neuroimaging. Faster speeds and low helmet use are key factors.” Opportunities to Improve Safety As patients with e-scooter injuries continue to present to emergency departments, it is important for emergency physicians to understand the evolving injury patterns and the clinical significance of head injuries, particularly in the risk-taking and inexperienced pediatric rider population. Dr Douglas and Dr Fine said, “As front-line emergency medicine clinicians, we are uniquely positioned to recognize shifts in injury patterns and raise the alarm early.” Continued monitoring of injury trends by clinicians and researchers can also make a significant contribution to developing strategies to mitigate the risk of injury at a population level. Dr Douglas and Dr Fine noted the opportunity for partnership, “With ongoing research and active collaboration with key stakeholders such as policymakers, community leaders, schools, and primary care clinicians, we as emergency medicine clinicians can help drive awareness and strengthen safety practices around e-scooters, which are here to stay.” SARAH SNOBELEN is a clinical pharmacist and medical writer and editor. She specializes in writing continuing education content for health care professionals.