Trauma involving motorcycles accounts for 2% to 5% of all motor vehicle trauma, but there is a higher proportion of death and serious injury because of the relative exposure of the motorcycle rider to the environment. Factors such as youth, high speed, and intoxication contribute to motorcycle collisions just as they do for automobiles. Motorcycle riders also are much more susceptible to factors beyond their own control, such as lack of vigilance on the part of automobile and truck drivers, road conditions (oil or debris), and the weather.

Factors that can reduce the seriousness of motorcycle collisions when they do occur include helmets and protective clothing. Reenactment of a mandatory helmet law in the state of Washington in 1990 resulted in a decline in serious brain injury in motorcycle trauma victims from 20% to 9% and a reduction in mortality from 10% to 6%. Full leather or synthetic “armor” reduces the risk of massive skin and soft-tissue injuries in the event of a high-speed collision.

Motorcycle collisions are high-energy trauma that can result in injury to any organ system or region of the body. This patient will need a complete head-to-toe assessment and a number of diagnostic studies to establish the full extent of injury. Common injuries in motorcyclists include brain trauma from direct impact with the road and with other vehicles, pelvic fractures
from impact with the frame of the motorcycle, abdominal trauma from impact with the handlebars, and lower extremity orthopedic and soft-tissue trauma from impact with the road.

The initial management of trauma patients is best described by the tenets of the Advanced Trauma Life Support course, written by the American College of Surgeons Committee on Trauma. This course provides a unified philosophy and common language to organize practitioners from different specialties in the care of complex patients with the potential for multiple injuries. Assessment of the seriously injured patient begins with the ABCs: Airway, Breathing, and Circulation; followed by a brief neurologic examination and a catalogue of visible injuries. This “primary survey” is followed by diagnostic testing and a more detailed secondary survey to discover all of the patient’s injuries. One important principle of Advanced Trauma Life Support is interruption of the diagnostic sequence as necessary to provide life-saving resuscitative care, up to and including surgery for airway management or hemorrhage control prior to completion of diagnostic studies.

On first contact with the patient, the provider should attempt verbal communication: “How are you?” A patient who answers coherently in a normal voice has no immediate airway issue, adequate circulatory function, and minimal traumatic brain injury. In an unconscious patient, initial assessment is by looking, listening, and feeling for airflow. If airflow is absent, the airway should be opened by jaw thrust (not head tilt, as this may exacerbate a cervical spinal column injury), cleared of any visible foreign bodies or secretions, and should have the placement of an oral or nasopharyngeal airway.

Breathing is assessed by observation of the chest wall and diaphragm once the airway is open and by immediate placement of a pulse oximeter probe. Patients who are not breathing adequately should be assisted with bag-valve-mask ventilation while preparations are made for securing a definitive airway and instituting mechanical ventilation.

Initial assessment for shock is by vital signs (HR, blood pressure, pulse oximetry) and physical examination (pallor, diaphoresis, peripheral circulation, visible or suspected hemorrhage). Mental status is also a useful sign; the patient in hemorrhagic shock will be first agitated and then lethargic. Young patients have significant compensatory reserves and will maintain a normal systolic blood pressure even in the face of hemorrhage as great as 40% of their blood volume. This state of compensated shock can be diagnosed by a narrowed pulse pressure (especially on automated sphygmomanometers), elevated HR, pallor, abnormal lactate, and a base deficit. Shock in this patient could be the result of hemorrhage from chest or abdominal trauma (including a great vessel injury associated with the impalement) or tension pneumothorax in either side of the chest.

The quick neurologic examination consists of questions to determine alertness and orientation (assuming the patient is responsive) followed by gross assessment of voluntary motion in all extremities. In the less responsive patient, the Glasgow Coma Score (GCS) (Table 33.1) is
used to stratify the degree of impairment: GCS 3 to 8 is a severe injury, GCS 9 to 13 is moderate traumatic brain injury, and GCS 14 to 15 is mild injury. Cranial nerve, spinal cord, and peripheral nervous system function is assessed by specific motor and sensory testing of each extremity during the secondary survey.

Because of the high energy mechanism of injury, this patient must be assessed from head to toe. Ultrasonography examination of the abdomen and chest is used to diagnosis free peritoneal fluid, pneumothorax (in the hands of a skilled operator), and pericardial tamponade. Chest and pelvis plain-film radiography will reveal fractures, pneumothoraces, and hemothorax. CT scanning should include the head, neck, chest, abdomen, and pelvis; newer technology will allow for three-dimensional (3D) reconstructions of organs and vasculature with sensitivity and specificity equivalent to more traditional angiographic imaging.

This patient’s obvious injury—to zone I of the neck—will necessitate a focused assessment of the trachea, great vessels, esophagus, and bilateral pleural cavities. Traditionally, this has been accomplished by a combination of plain-film radiography, angiography, bronchoscopy, and esophagoscopy. Increasing CT speed and resolution is leading to the increased use of this test at centers with experienced radiographers and traumatologists. The sequencing of diagnostic studies will depend on the patient’s stability. In this case, he is likely to require intubation and perhaps exploratory surgery first. A noninvasive study such as contrast-enhanced CT (with angiographic reconstructions) may help to guide the surgical approach to removal of the impaling object if the patient is calm and stable enough to tolerate the test.

Zone I of the neck includes the area from the inferior aspect of the cricoid cartilage down to the thoracic outlet. Zone I injuries require the complex diagnostic workup described in the previous section, followed by a surgical approach that allows access to both the neck and chest. Partial or complete median sternotomy is often necessary to access an injured great vessel or to repair the trachea or esophagus.

Zone II of the neck includes the area from the angle of the mandible down to the cricoid cartilage. Injuries in zone II are addressed through a lateral or transverse cervical incision, with the surgeon able to achieve both proximal and distal control of the carotid or jugular vessels before exploring the wound itself.

Zone III of the neck includes the area from the angle of the mandible upward to the base of the skull. Zone III vascular injuries pose a significant operative risk because distal control of an injured vessel cannot be achieved. Injuries in zone III are therefore approached angiographically or as part of a more complex neurosurgical operation.