Severe Injuries in E-Scooter Accidents

An Evaluation of Data From the TraumaRegister DGU

Background: The e-scooter has become an alternative mode of transport in urban areas, and this has led to a rising number of injuries. There is a lack of comprehensive, nationwide data on severe injuries due to e-scooter accidents.

Methods: From 2020 onward, e-scooter accidents have been recorded as a separate subgroup in the multicenter TraumaRegister DGU (TR-DGU) (DGU = German Trauma Society). In this study, we analyzed the data from 2020–2023 and compared them with data for bicyclists and other road users.

Results: We compared data on 538 persons who were severely injured in e-scooter accidents with data on injured bicyclists and other road users. Compared to cyclists, e-scooter accident victims were more often male (78.4% versus 72.3%), younger (44.3 versus 54.5 years) and more often under the influence of alcohol (34.9% versus 15.6%). More than half of the accidents (54%) took place at night, and 83% of the e-scooter accident victims suffered a severe injury to the head or face (Abbreviated Injury Scale [AIS] ≥ 2). The most common injuries were subarachnoid hemorrhage (20.1%), skull base fracture (16.7%), and serial rib fractures (16.5%). 83.5% of these e-scooter accident victims were treated in intensive care; the average length of hospital stay was 7 days (interquartile range, 4–12 days). 26 (4.8%) of the e-scooter accident victims died.

Conclusion: E-scooter accidents cause severe injuries to the head and face. Middle-aged men are most commonly affected. The victims are often under the influence of alcohol, need intensive care, and have an appreciable mortality. Measures should be taken urgently to educate e-scooter riders and improve safety.

Cite this as: Hartz F, Zehnder P, Resch T, Römmermann G, Schwarz M, Kirchhoff C, Biberthaler P, Lefering R, Zyskowski M: Severe injuries in e-scooter accidents: An evaluation of data from the TraumaRegister DGU. Dtsch Arztebl Int 2025; 122: 265–70. DOI: 10.3238/arztebl.m2025.0041

Commercial e-scooter hire was launched in Germany in summer 2019 (1). Today, electric-powered scooters, offered by a variety of sharing providers, have become part of the cityscape in more than 100 German towns and cities, with over 12 million users and up to 500 000 kilometers traveled per day (2, 3).

The use of e-scooters, which travel at a maximum speed of 20 km/h, has been controversial from the outset. The main points of criticism continue to include:

• Traffic obstruction caused by parked vehicles
• Unauthorized use on sidewalks
• Tandem riding
• Reckless riding.

As the use of these vehicles has increased, so too has the number of accidents, which in turn has led to a rise in the number of road traffic-related injuries (4, 5). This has contributed to e-scooters being perceived negatively in the public debate. For example, in Italy, helmet use became mandatory in December 2024, while in Paris, a referendum in September 2023 resulted in a complete ban on rental scooters (6, 7). Other European countries have tightened their regulatory frameworks or are considering a general ban on these vehicles (8).

The medical data on injuries resulting from accidents is mainly based on regional case series and single-center studies. The pattern of injury is often multifocal, with most accident victims able to be discharged with minor injuries for further outpatient treatment (9, 10, 11, 12, 13). However, there is a relevant potential for serious injury, particularly to the head and craniofacial region (14, 15, 16). The risk factors for this include (10, 12, 17):

• Failure of e-scooter rental companies provide helmets
• Lack of driving experience
• More use at nighttime and under the influence of alcohol.

The number of unreported e-scooter accidents is likely to be high, and it is possible that the potential for serious injury is underestimated (18). This study uses the TraumaRegister DGU (TR-DGU) (DGU, German Trauma Society [Deutsche Gesellschaft für Unfallchirurgie]) to investigate demographic characteristics, injury profiles, and acute medical care for e-scooter accidents and to advance the discussion on preventive measures, rental modalities, and improvements to infrastructure with regard to severely injured individuals.

Methods

This study (TR-DGU-ID 2022–001) evaluated data from patients with severe injuries following e-scooter accidents in the period from 01.01.2020 to 31.12.2023 and compared these with injury data on cyclists (with and without motorized assistance) as well as other road users (including motorcyclists, passenger vehicle occupants, and pedestrians). The core cohort of the TR-DGU formed the basis for this. The inclusion criteria consisted of a maximum Abbreviated Injury Score (MAIS) of ≥ 3 or a MAIS of 2 if accident victims were transferred to an intensive care unit or died in hospital. Accident victims who had minor injuries and were not admitted to an intensive care unit or who did not die were excluded. The MAIS grades the severest injury according to the Abbreviated Injury Scale (AIS), with the highest severity level of an injury being taken into account. The score ranges from 1 (minor injury) to 6 (unsurvivable).

The data come from the TR-DGU. Since 1 July 2020, e-scooter accidents have been recorded separately. The TR-DGU documents data on severely injured patients in standardized and pseudonymized form in a multicenter database. Prospective data were collected on the following four phases:

• Prehospital phase
• Trauma bay and subsequent surgical phase
• Stay on an intensive care unit
• Hospital discharge.

Around 90% of participating centers—with over 38 000 cases from nearly 700 centers—are located in Germany. The TR-DGU data entry sheet is available in two versions:

• The standard sheet (approximately 100 parameters)
• The quality management (QM) sheet (approximately 40 parameters, for the TraumaNetzwerk DGU [DGU trauma network]).

Both versions were used for this study, with only the standard sheet recording blood alcohol content (ethanol in plasma). Of the 538 e-scooter accidents, the standard form was available for 370 (68.8%) of accident victims and the QM form for 168 (31.2%).

Statistical analysis

Data analysis was performed using SPSS (version 29.0. IBM Corp. Armonk NY, USA). For the descriptive analysis, either the mean and standard deviation or the median and interquartile range (IQR), as well as absolute numbers and percentages relative to the study population, were calculated. The 95% confidence interval was also calculated for e-scooter drivers.

Results

Comparison of e-scooter accident victims with other road users

Between January 2020 and December 2023, 538 e-scooter accident victims fulfilled the inclusion criteria of the TR-DGU core cohort, corresponding to 1.2% of the total 45 242 traffic accident victims in that period (Table 1).

Table 1

E-scooter accident victims compared with other road users (bicycle, motorbike, car, pedestrian)

E-scooter drivers were on average younger and more often male compared to cyclists, car drivers, and pedestrians. Only among motorcyclists was an even lower average age and a higher proportion of males observed. The mean Injury Severity Score (ISS) in e-scooter riders was slightly lower compared to other road users. However, the proportion of head injuries with an AIS ≥ 2 was comparatively higher among e-scooter drivers. The mortality rate was roughly equivalent to that of cyclists and motorcycle riders (Table 1).

Time and season of accidents

Most e-scooter accidents (38%) took place during the summer months. The number of accidents declined significantly during the winter months (11%). Half of the accidents took place at the weekend, often between 6:00 pm and 6:00 am (54%; Figure 1).

Figure 1

Time of accident

Comparison of e-scooters with bicycles (including electric bikes)

During the same period, 11 430 bicycle accidents were registered, of which 1384 (12.1%) involved bicycles with electric motor assistance (Table 2). E-scooter accident victims were on average 10 years younger compared to cyclists, and the proportion of older accident victims was lower among e-scooter users.

Table 2

Prehospital data, trauma bay management, and hospital treatment of e-scooter accident victims compared with bicycle riders (including electric bikes)

Approximately 13% of e-scooter accidents were recorded as accidents on the way to or from work, and 90.3% of victims were transported to hospital by road (Table 2).

Prehospital phase

In 16% of e-scooter accident victims, a prehospital Glasgow Coma Scale (GCS) score of ≤ 8 was observed, and 4.9% had a systolic blood pressure (SBP) of ≤ 90 mm Hg (Table 2). Endotracheal intubation was performed in 17.6%, chest compressions in 1.4%, and tranexamic acid administration in 9.5% of e-scooter accident victims. This group were more frequently transported directly to a level-I hospital compared to bicycle accident victims (61.7% versus 55.9%; Table 2).

Trauma bay and subsequent surgical phase

In the trauma bay, FAST ultrasound (FAST, focused assessment with sonography for trauma) was performed in 84.5% of e-scooter accident victims. Selective cranial computed tomography (cCT) was performed more frequently in e-scooter accident victims (19.5% versus 15.8%), whereas whole-body CT was used less often (72.7 versus 75.9%; Table 2). In all, 20 (3.7%) of the e-scooter accident victims received packed red blood cells in the trauma bay, and 84 (15.6%) were transferred to the operating room (OR) for further treatment immediately following trauma bay treatment (Table 2).

Blood alcohol levels were recorded in 232 e-scooter accident victims. Blood alcohol was detected in 143 (62%) e-scooter users, and the blood alcohol level was above the legal limit of 0.5‰ in around one-third (34.9%) of these. In comparison, this was the case in only 15.6% of bicycle accident victims (Table 2).

Hospital stay and discharge

Of the 548 e-scooter accident victims, 83.8% received intensive care. The median length of stay on the intensive care unit was 2 days (IQR 1–3), while the total hospital stay lasted a median of 7 days (IQR 4–12) (Table 2). A total of 26 (4.8%) patients died in hospital, compared to 680 (5.9%) cyclists. E-scooter accident victims were more likely to be discharged directly home and were less likely to require rehabilitation or transfer to another hospital (Table 2).

Injury pattern, severity, and frequency

The average ISS score among e-scooter accident victims was 16.4, with almost 50% of e-scooter riders having an ISS ≥ 16. Severe head injuries (AIS ≥ 3) were diagnosed in 47.8% of e-scooter accident victims, which corresponds to a higher frequency compared to cyclists (40.8%; Table 2). In total, 60% of e-scooter accident victims suffered head injuries with an AIS score ≥ 2, 32% suffered chest injuries, and 23% facial injuries (Figure 2).

Figure 2

Injury pattern according to body region

The most common injuries were subarachnoid hemorrhage (20.1%), skull base fracture (16.7%), and serial rib fractures (16.5%, Table 3). Of the 10 most common injuries, eight involved the head or face.

Table 3

List of the 10 most commonly documented injuries in e-scooter accident victims

Discussion

This study investigated, for the first time, accident victims with severe injuries following e-scooter accidents in German-speaking countries and is currently the largest analysis regarding this means of transport. Between 2020 and 2023, 538 e-scooter riders were included and compared with 11 430 bicycle accident victims and 44 704 other road users involved in accidents.

As in previous studies (56–85%), the majority of e-scooter accident victims in this study were male (78%) (9, 12, 19, 20, 21, 22, 23). The average age was 44.3 years and approximately 10 years lower compared to cyclists, but around 10 years higher compared to e-scooter riders in the abovementioned comparative studies on e-scooter accidents (26–35 years). Since this study included only accident victims with severe injuries, the high proportion of older e-scooter riders (21.2% ≥ 60 years) may point to an increased risk of severe injuries in this age group. Of the 538 e-scooter accident victims, 43 (8%) were under the age of 18 years. While the use of e-scooters on public roads in Germany is permitted from the age of 14, the largest commercial rental companies require users to be at least 18 years old. Since this study does not allow for a distinction between privately owned and rental e-scooters, it remains unclear to what extent minors access rental scooters privately or by getting around age checks.

The average distance traveled by rental vehicles was approximately 1.74 km (24), according to the evaluation report by the German Federal Highway Research Institute (Bundesanstalt für Straßenwesen), indicating that they are predominantly used for short distances during leisure time. Accordingly, a large proportion of the accidents investigated in this study occurred at the weekend (50%) and at nighttime (54%). In the majority of cases, victims were transported to hospital by road (90.3%), which is due to the mainly inner-city use of e-scooters.

E-scooter accident victims were more likely to be under the influence of alcohol than were cyclists. Approximately two-thirds of e-scooter riders tested had a positive blood alcohol level, with the level being above the legal limit of 0.5‰ in around one-third (n = 81, 35%) of these. Previous studies also documented a high proportion of alcohol-related accidents, which represents a significant safety risk associated with e-scooter use (10, 11, 17, 20, 25, 26, 27, 28). In response to these findings, cities such as Oslo implemented a nighttime (11:00 pm to 05:00 am) ban on the use of rental mopeds. In Helsinki, the maximum permitted speed for e-scooters on weekend nights has been reduced from 25 km/h to 15 km/h (8). The efficacy of these measures remains to be seen.

In addition, the (partial) legalization of cannabis in Germany from 1 April 2024 could pose a further challenge (29). There are no scientific data available as yet on the
effect of cannabis use on fitness to drive among e-scooter users.

The pattern of injury in e-scooter accident victims in this study is characterized in particular by the very high frequency of severe head and facial injuries. Of the 538 accident victims, 47.8% suffered a head injury with an AIS of 3 or higher. If one also takes into account head and facial injuries with an AIS of 2 or higher, the proportion rises to 83% of cases. Head injuries were more frequently diagnosed in e-scooter riders than in cyclists and the other road users included in the comparison. Of the 10 most common injuries, eight involved the head or face, with subarachnoid hemorrhage (SAH) occurring in one in five and skull base fracture in one in six accident victims. Severe head injuries were more frequently seen than in earlier studies that looked at smaller case numbers and included patients with minor injuries (9–45%) (10, 12, 14, 17, 19, 21, 23). In many cases, severe head injuries are likely to have been the reason for trauma bay activation, the more common initial presentation to level-I trauma centers (62%) with neurosurgical capabilities, and the use of selective cCT as part of trauma bay care.

A biomechanical crash study conducted by the Fraunhofer Institute for High-Speed Dynamics (Fraunhofer-Institut für Kurzzeitdynamik) showed that, due to its inertia, the e-scooter acts like a lever on the rider in the event of an impact—such as against a curb—and catapults them into the air. Depending on speed, the rider may be thrown a distance of 2–5 meters. In simulation-based tests, wearing a bicycle helmet reduced the maximum translational acceleration acting on the head by 51–72%. However, the predicted head impact speeds exceeded the impact speed of approximately 5.4 m/s (30) stipulated in the German DIN EN 1078 for bicycle helmets, thereby casting doubt on whether conventional helmets provide a sufficient protective effect in typical e-scooter accident dynamics.

In general, the rate of helmet use in Germany (0–2.2%) is extremely low in an international comparison based on the hitherto available clinical studies (14, 18, 19, 20). Even though surveys showed higher numbers for private vehicle users (28.8%) and rental vehicle users (10.4%), the low rate of helmet use may be due to the lack of availability of helmets as a result of the inability to store them on rental e-scooters (24). Although the use of helmets is a general recommendation in Germany, countries like the United Kingdom achieve better helmet use rates (34–66%) (9, 15). In Australia, helmet use is compulsory in many places, and a rental system with helmets has achieved helmet wearing rates of 61.4–95.5% (31). A follow-up study conducted by Mitchell et al. in Australia showed a fall in the incidence of head injuries following the introduction of compulsory helmet use for e-scooter users. The authors concluded that wearing a helmet could make an effective contribution to reducing injury severity in e-scooter accidents (32). In Italy, the introduction of compulsory helmet use for e-scooter riders raised concerns among providers regarding their business model (33). In Germany, on the other hand, not only providers but also the authorities leave the decision on helmet use in the hands of users.

The vast majority (83.8%) of e-scooter accident victims in this study required treatment in intensive care. The length of stay in intensive care and in hospital, as well as the mortality rate, did not show any significant differences compared to bicycle accident victims. Although the absolute number of deaths due to bicycle accidents was higher, Gebhardt et al. calculated that the accident risk per kilometer for e-scooter riders is around four times higher than for cyclists (3). Given the high number of severe head injuries in our study, it can be assumed that there is a significant potential for injury among e-scooter riders. Preventive measures should include not only targeted education on the risk of serious head injuries but also regulatory controls on the availability and speed of rental e-scooters during high-risk periods (weekends and at nighttime), especially for male riders. In addition, helmet use should be actively encouraged, and the possibility of providers offering rental helmets should be examined. As additional measures, digital hurdles in the rental process as well as stricter enforcement of traffic checks could reduce the rate of riding under the influence of alcohol.

Summary

Within a 4-year period, 538 individuals were seriously injured in e-scooter accidents in the area covered by the participating TR-DGU centers, with 26 dying while in hospital. The majority of accident victims were middle-aged men. A large proportion of the accidents took place at nighttime and during the weekend, often under the influence of alcohol. Severe head injuries, in particular SAB and skull base fractures, were common. Preventive measures should take into consideration the specific injury pattern, the timing of accidents, as well as the demographic characteristics of those involved.

Limitations

Limitations of this study include the partially incomplete documentation of individual variables such as blood alcohol level, which is not recorded in the QM sheet and is not a mandatory field in the standard sheet. Information on helmet use and the precise circumstances of accidents are lacking. Moreover, it is not clear from the available data whether accident victims were using a privately owned or a rental e-scooter, which could affect the rate of helmet use.

Since the TR-DGU covers only its core cohort, it is not possible to make a statement regarding the proportion of serious injuries relative to all e-scooter injuries. Approximately 95% of severe injuries were treated at centers participating in the TR-DGU. However, around 20–25% of cases are missing from the register due to a lack of consent, meaning that the actual number of cases is likely to be higher. Differences in frequency of use and distances traveled with different means of transport could not be taken into account due to a lack of data.

Conflict of interest statement

RL received financial support from the German Academy of Trauma Surgery (Akademie der Unfallchirurgie [AUC] GmbH). There is an ongoing Service Agreement between the Akademie der Unfallchirurgie [AUC] GmbH and the University of Witten/Herdecke.
This includes scientific support in the evaluation of data in the TraumaRegister DGU.

The remaining authors declare that no conflict of interest exists.

Manuscript submitted on 8 October 2024, revised version accepted on 24 February 2025.

Translated from the original German by Christine Rye.

Corresponding author
Dr. med. Frederik Hartz

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