Subway-related trauma at an urban level I trauma center.

INTRODUCTION: Subway-related trauma is an understudied category of urban injury. Prior work has focused on high-acuity train-contact events, with less attention to more common mechanisms and the roles of psychiatric illness and substance use. We analyzed a large contemporary cohort to define epidemiology, injury patterns, and outcome predictors across the full spectrum of subway trauma.

METHODS: We performed a retrospective cohort study of adults presenting with subway-related injury to a Level I trauma center (2018-2024). Registry data and manual chart review captured demographics, mechanisms, comorbidities, intoxication, injury severity, and outcomes. Injuries were categorized using validated natural language processing. Multivariable logistic regression identified predictors of train-contact mechanism, major trauma (ISS ≥ 15), TBI, and assault.

RESULTS: Among 809 patients, median age was 50 years and 81.2% were male. Falls were most common (57.2%), followed by train contact (16.8%) and assault (16.7%). Median ISS was 9, with 25.0% sustaining major trauma. TBI occurred in 40.5% and did not differ by mechanism. Train contact was the most severe mechanism and the only independent predictor of major trauma (aOR 5.08). Psychiatric diagnosis (aOR 1.59) and acute intoxication (aOR 1.69) independently predicted train contact, while intoxication predicted TBI (aOR 1.66). Psychiatric illness and substance use disorder were associated with longer hospitalization independent of injury severity. Assault exposure varied by race/ethnicity.

CONCLUSION: Most subway injuries result from falls rather than intentional mechanisms. Train contact drives severity, while intoxication increases TBI risk. Psychiatric and substance use comorbidities prolong hospitalization, supporting routine behavioral health screening and targeted prevention strategies.