Impact of acute alcohol intoxication on the severity of injury: a cause-specific analysis of non-fatal trauma

Outcomes of elevated blood alcohol concentrations in elderly patients following a ground level fall: A matched analysis from the national trauma quality program

BACKGROUND

The rising elderly population and the concomitant increase in alcohol consumption can result in a ground level fall (GLF). The purpose of this study is to evaluate the in-hospital mortality, hospital length of stay, and discharge disposition of elderly patients who sustained a ground level fall (GLF) and tested positive for an elevated blood alcohol concentration (BAC).

METHODS

The data of patients who were 65 years and older, had an injury after a GLF, and tested for BAC were accessed from the American College of Surgeon - Trauma Quality Improvement Program (ACS-TQIP) from the calendar years of 2011-2016. Patients' demography, injury, comorbidities, and outcomes were compared between the groups who tested positive (>0.08 g/dL) and negative (0 mg/dL) for BAC. Univariate, followed by matched analyses were performed. All p values are two-sided, and a p value < 0.05 is considered statistically significant.

RESULTS

Out of 20,163 patients who satisfied the inclusion criteria, 2398 patients (∼12%) tested positive for an elevated BAC. There were significant differences found between the two groups, BAC-positive vs. BAC-negative, in univariate analysis for age and sex with p values < 0.001. Propensity score matching balanced demographic characteristics; however, differences remained in certain comorbidities. Exact matching balanced patient demography, injury, and comorbidities. The paired-matched analysis showed no significant differences between the two groups for in-hospital mortality (2.1% vs. 2.1%, p = 1) and median hospital length of stay (5[4-5] vs. 5[5-5], p = 0.307). A higher proportion of patients in the BAC group suffered from alcohol withdrawal syndrome (AWS) and deep vein thrombosis (DVT) complications (9.5% vs. 1.4%, p < 0.001 and 1.5% vs. 0.5%, p = 0.018) compared to BAC-negative patients. A slightly higher percentage of patients in the BAC-positive group were discharged home without any additional services (39.6% vs. 36.9%, p = 0.009).

CONCLUSION

Of the elderly patients who sustained a GLF and tested for BAC, approximately 12% tested positive for BAC. The overall in-hospital mortality was 2.1%. The BAC-positive group suffered from higher complications of AWS and DVT, and more than 60% of patients required additional services at the time of discharge.

Effects of alcohol consumption on maxillofacial fractures in simple falls

Objectives

This study aimed to investigate the effects of alcohol consumption (AC) on maxillofacial fractures caused by falls on a level surface (simple falls).

Material and Methods

Patients with maxillofacial fractures caused by falls who visited the Oral and Maxillofacial Surgery Clinic from January 2006 to December 2016 were evaluated. Patients with simple falls were subdivided into those who fell with AC (Falls with AC) and those who fell without AC (Falls without AC).

Results

Of 180 patients with falls with maxillofacial fractures, 155 had simple falls, and 25 patients had falls from a height. Of the simple falls, 52 were Falls with AC, and 102 were Falls without AC. Falls with AC were significantly more frequent in males (p = .0005). The average number of fracture lines in the mandible was significantly higher in Falls with AC (2.13 ± 0.99 [mean ± SD]) than in Falls without AC (1.76 ± 0.91) (p = .011). The average Facial Injury Severity Scale was significantly higher in Falls with AC (3.08 ± 1.43) than in Falls without AC (2.43 ± 1.29) (p = .007).

Conclusions

Falls with AC were associated with more severe maxillofacial fractures than Falls without AC.

Effect of alcohol use on emergency department length of stay among minimally injured patients based on mechanism of injury: multicenter observational study

Objective

This study aimed to evaluate the effect of alcohol use on emergency department (ED) length of stay (LOS) among minimally injured patients by mechanism of injury.

Methods

This was a retrospective study of injury surveillance data for injured patients (except poisoning), aged over 18 years, discharged home from the ED, and treated at seven academic EDs in Korea during 2008 to 2012. Patients were divided into alcohol-related and alcohol-unrelated groups based on self-report. We used multivariable quantile regression models for the analysis and adjusted covariates including age, sex, consciousness status, severity of injury, emergency medical service use, the season, day and time of visit, and hospital. To determine if there were different effects of alcohol use across mechanism of injury, all analyses were stratified by each mechanism.

Results

Among 192,200 patients, 95,807 patients were analyzed. The number of participants in the alcohol-related group was 16,249 (17.0%). In the multivariable quantile regression model, the alcohol-related group had significantly longer ED LOS at the 10th (7 minutes; 95% confidence interval [CI], 6 to 8), 50th (21 minutes; 95% CI, 19 to 23), and 90th (81 minutes; 95% CI, 74 to 87) percentiles when compared to the alcohol-unrelated group. The effect of alcohol use on increased ED LOS was most prominent in motor vehicle injuries.

Conclusion

We found that alcohol use was associated with increased emergency ED LOS. Furthermore, if we limited our attention to the effect of alcohol use on the number of patients, the burden of alcohol use on the ED would have been underestimated.

Drinking context and cause of injury: Emergency department studies from 22 countries

Background

It is estimated that up to a third of injuries requiring emergency department admission are alcohol-related. While injuries that are alcohol-related are unsurprising to emergency department staff, less is understood about the precursors to the injury event.

Methods

Using data from representative emergency department injury patients in 22 countries, we examined associations between context of injury (private or public), cause of injury (fall or trip, being stuck/cut/ or burned and violence) and alcohol use. Alcohol-related policy data were also obtained from each study locale.

Results

Injuries were similarly reported in private (54%) and public settings (46%) while cause of injury was most often due to falls (39%) or being struck/cut or burned (38%). Violence-related injuries were reported by approximately 1 in 5 patients (23%). Increased odds of drinking prior to the injury event was associated with injury due to violence in private settings but not public venues. Similarly, patients from regions with fewer restrictive alcohol policies were more likely to report drinking prior to an injury event and have elevated violence-related injuries in private settings.

Conclusion

Understanding the cause and context of injury and alcohol use are important components to evaluation and development of alcohol policies.

Falling down a flight of stairs: The impact of age and intoxication on injury pattern and severity

Background

Falling down a flight of stairs is a common injury mechanism in major trauma patients, but little research has been undertaken into the impact of age and alcohol intoxication on the injury patterns of these patients. The aim of this study was to compare the impact of age and alcohol intoxication on injury pattern and severity in patients who fell down a flight of stairs.

Methods

This was a retrospective observational study of prospectively collected trauma registry data from a major trauma centre in the United Kingdom comparing older and younger adult patients admitted to the Emergency Department following a fall down a flight of stairs between July 2012 and March 2015.

Results

Older patients were more likely to suffer injuries to all body regions and sustained more severe injuries to the spine; they were also more likely to suffer polytrauma (23.6% versus 10.6%; p < 0.001). Intoxicated patients were more likely to suffer injuries to the head and neck (42.9% versus 30.5%; p = 0.006) and were significantly younger than sober patients (53 versus 69 years; p < 0.001).

Conclusion

Older patients who fall down a flight of stairs are significantly different from their younger counterparts, with a different injury pattern and a greater likelihood of polytrauma. In addition, alcohol intoxication also affects injury pattern in people who have fallen down a flight of stairs, increasing the risk of traumatic brain injury. Both age and intoxication should be considered when managing these patients.

Ethanol, Trauma, and the Brain

Alcohol intoxication plays a significant and causal role in various fatal injuries. In comparison to sober individuals, intoxicated people have a greater generic risk for being involved in hazardous activities that may result in fatal injuries. However, it is not clear whether the biological effects of acute alcohol intoxication result in worse injuries than those sustained by sober individuals who are injured by identical mechanisms. Alcohol intoxication has a neuroprotective effect in experimental animal models of traumatic brain injury (TBI) but the evidence for a similar effect in humans is controversial. Earlier studies found such a protective effect, but more recent large epidemiological studies have not confirmed this finding; some studies also suggest a dose-related protective or exacerbating effect of alcohol intoxication on TBI. There are two apparent alcohol-associated syndromes in which an otherwise survivable blunt force impact to the head of an intoxicated individual is fatal at the scene. The first is a fatal cardiorespiratory arrest (the so-called alcohol concussion syndrome or “commotio medullaris”); the second is “traumatic basilar subarachnoid hemorrhage” (secondary to tears in the cerebral arteries, particularly the intracranial and extracranial vertebral arteries).

Resource utilization and outcomes of intoxicated drivers

Background

The high risk behavior of intoxicated drivers, impaired reaction time, lack of seat belt use, and increased incidence of head injury raises questions of whether pre-hospital use of alcohol leads to a higher injury severity score and worse clinical outcomes. We therefore compared intoxicated and non-intoxicated drivers of motor vehicle crashes with respect to outcome measurements and also describe the resources utilized to achieve those outcomes at our Level 1 trauma center.

Methods

Retrospective descriptive study (Jan 2002-June 2007) of our trauma registry and financial database comparing intoxicated drivers with blood alcohol levels (BAC) > 80 mg/dl (ETOH > 80) with drivers who had a BAC of 0 mg/dl (ETOH = 0). Drivers without a BAC drawn or who had levels ranging from 1 mg/dL to 80 mg/dL were excluded. Data was collected on demographic information (age, gender, injury severity score or ISS), outcome variables (mortality, complications, ICU and hospital LOS, ventilator days) and resource utilization (ED LOS, insurance, charges, costs, payments). Statistical analysis: p < 0.05 vs. ETOH > 80; stratified chi square.

Results

Out of 1732 drivers, the combined study group (n = 987) of 623 ETOH = 0 and 364 ETOH > 80 had a mean age of 38.8 ± 17.9, ISS of 18.0 ± 12.1, and 69.8%% male. There was no difference in ISS (p = 0.67) or complications (p = 0.38). There was a trend towards decreased mortality (p = 0.06). The ETOH = 0 group had more patients with a prolonged ICU LOS (≥ 5 days), ventilator days (≥ 8 days), and hospital LOS (> 14 days) when compared to the ETOH > 80 group (p < 0.05). The ETOH > 80 group tended to be self pay (4.9% vs. 0.7%, p < 0.5) and less likely to generate payment for hospital charges (p < 0.5). Hospital charges and costs were higher in the ETOH = 0 group (p < 0.5).

Conclusions

The data suggests that intoxicated drivers may have better outcomes and a trend towards reduced mortality. They appeared to be less likely to have prolonged hospital LOS, ICU LOS, and ventilator days. We also observed that intoxicated drivers were more likely to be self-pay, less likely to have charges > $50K, and less likely to pay ≥ 90% of the charges. Further research using multivariable analysis is needed to determine if these apparent outcomes differences are driven by acute intoxication, and the tendency for endotracheal intubation and ICU admission, rather than injury severity.

Spinal injuries after falls from hunting tree stands

BACKGROUND CONTEXT

Spinal injuries are common sequelae of falls from hunting tree stands. Significant neurological injury is not uncommon and can result in significant morbidity as well as enormous expenditure of health care dollars. Recent literature on the subject is limited.

PURPOSE

The purpose of this study was to identify precipitating causes, characterize the spectrum of spinal injury, and determine potential interventional safety and prevention recommendations.

STUDY DESIGN

A retrospective study.

METHODS

Medical record review of 22 patients admitted either directly or via referral to a level I spinal cord injury referral center over a 10-year period (1995-2005) after a fall from a hunting tree stand.

RESULTS

All patients were men with a mean age of 46 years (range, 27-80 years). Initial acute care hospitalization averaged 10 days (range, 2-28 days). The average height of fall was 18 feet (range, 10-30 feet). Four of 19 falls (21%) occurred during the morning hours, 2 of 19 falls occurred during the afternoon, and 13 of 19 falls (68%) occurred during the evening hours. Time lapse from injury to presentation to an emergency department ranged from 30 minutes to 14 hours. Alcohol use was a factor in 2 of 20 falls (10%). Hypothermia complicated 3 of 21 cases (14%). Associated injuries were present in 12 of 21 patients (57%) and included fractures to the axial and appendicular skeleton, pneumothoraces, a retroperitoneal bleed, and a brachial plexopathy. Eight of 22 patients (37%) sustained injury to the cervical spine. Five of these 8 patients (63%) had neurological deficits (3 complete and 2 incomplete spinal cord injuries). Thirteen of 22 (59%) patients sustained injury to the thoracic or lumbar spine. Ten of these 13 (77%) had neurologic deficits (3 complete and 7 incomplete). Nine of 22 (41%) patients were treated nonoperatively; the remaining 13 (59%) underwent operative intervention.

CONCLUSIONS

Falls from hunting tree stands remain a significant cause of spinal injury and subsequent disability. The best intervention for these injuries is prevention. There is a continued need for hunter safety education to reduce the incidence of these injuries with emphasis on safety harness usage, proper installation and annual inspection of tree stands, hunting in groups with periodic contact, the use of communication devices, and abstinence from alcohol consumption while hunting.

Causes, types and severity of injury among army soldiers hospitalized with alcohol comorbidity

AIM

To examine the relationship between alcohol use and the cause, type and severity of hospitalized injuries.

DESIGN/SETTING

We used the Total Army Injury and Health Outcomes Database (TAIHOD) to conduct cross-sectional analyses of the association between alcohol comorbidity and the cause, type and severity of soldiers' non-combat injuries requiring hospitalization.

PARTICIPANTS

Subjects were active-duty US army soldiers (n = 211 790) hospitalized with a primary diagnosis of injury between 1980 and 2002.

FINDINGS

Alcohol comorbidity was positively associated with hospitalized injuries resulting from fights and falls and negatively associated with sports injuries; positively associated with hospitalized cases of head injury, open wounds and poisonings and negatively associated with musculoskeletal injury; and, overall, associated with shorter length of stay. Controlling for demographic factors did not moderate the association between alcohol and cause, type or severity of injury.

CONCLUSION

Alcohol comorbidity is specifically associated with injuries related to impairment and antisocial behavior.

Injury severity: role of alcohol, substance use and risk-taking

OBJECTIVE

The objective of the present study was to quantify the relationship between acute alcohol consumption and injury severity.

METHODS

A cross-sectional study was conducted at the Gold Coast Hospital, Gold Coast, Queensland, Australia between October 2000 and October 2001. Data were collected from a systematic sample of patients greater than 15 years of age who presented to the ED for treatment of an injury sustained less than 24 h prior to presentation. Study participants were interviewed face to face on-site. Information obtained included: demographics details; situational variables relative to time of injury (i.e. location, activity and companions at time of injury); self-reported alcohol consumption in the 6 and 24 h prior to time of injury; usual alcohol consumption patterns; self-reported substance use in the 6 and 24 h prior to time of injury; and risk-taking behaviour. Injury severity was coded from patient medical records using the New Injury Severity Score.

RESULTS

Of 789 eligible patients presenting during the study periods, 593 were interviewed (75.2%). Patients who reported drinking above low-risk levels (odds ratio [OR] = 3.35; 95% confidence interval [CI] 1.2-9.6) or who drank beer (OR = 3.54; 95% CI 1.1-11.1) in 6 h prior to injury were significantly more likely to sustain serious than minor injury. Drinking setting and usual drinking patterns were not significantly associated with injury severity, either in crude analyses, or after adjusting for relevant variables.

CONCLUSION

The results of the present study support the conclusion that among injured patients who presented for treatment at a large metropolitan ED, although acute alcohol consumption does not appear to be associated with minor or moderate injury, there is some evidence to suggest that acute alcohol consumption is associated with serious injury.

A 6-months assessment of the alcohol-related clinical burden at emergency rooms (ERs) in 11 acute care hospitals of an urban area in Germany

Background

The purpose of the study was to identify and to profile alcohol-related attendances to emergency rooms (ERs) of 11 hospitals of various medical specialties covering a large urban population, to assess risk factors associated with short-stay cases, repeat attendances and higher degree of alcohol consumption and to estimate their impact on the alcohol-related burden at ERs.

Methods

A 6-months study was carried out to obtain clinical and administrative data on single and multiple attendances at ERs in 11 governmental acute hospitals in a large city in Germany. All alcohol-related attendances at ERs of study hospitals were eligible. A broad definition of alcohol-related attendances independently from alcohol diagnosis and various demographic, clinical and administrative measures were used. Odds ratios for the associations of these measures with duration of stay, repeat attendances and higher degrees of alcohol consumption were derived from multivariate binomial and multinomial logistic regression models.

Results

1,748 patients with symptoms of alcohol consumption or withdrawal (inclusion rate 83.8%) yielded 2,372 attendances (3% of all medical admissions), and resulted in 12,629 inpatient-days. These patients accounted for 10.7 cases per 1,000 inhabitants. The average duration of inpatient stay was 10 days. 1,451 of all patients (83%) presented once, whereas the median of repeat attendances was three for the remaining 297 patients. Short-stay cases (<24 hours) were significantly linked with male gender, alcohol misuse, trauma (or suspicion of a trauma) and medical specialties. Increased levels of alcohol consumption at first attendance were significantly associated with repeat attendances in due course. In a multinomial logistic regression model higher degrees of alcohol consumption were significantly associated with male gender, trauma, short-stays, attendance outside regular working time, and with repeat attendances and self-discharge.

Conclusion

Apart from demographic factors, the alcohol-related clinical burden is largely determined by short-stay cases, repeat attendances and cases with higher levels of alcohol consumption at first attendance varying across medical specialties. These findings could be relevant for the planning of anti-alcoholic interventions at ERs.

Alcohol related falls: an interesting pattern of injuries

OBJECTIVE

To discover if there is a significant difference in the pattern and severity of injury sustained during falls in patients who have consumed alcohol and those who have not. To determine how pattern and severity of injury correlates with blood alcohol concentration.

METHOD

A prospective quasi-randomised controlled study between November 2001 and July 2002. All healthy adults between 16 and 60 years who had fallen from standing height were included. A systematic history and examination permitted calculation of injury severity scores as per abbreviated injury scale update 1998. Blood alcohol concentrations were obtained from intoxicated patients with consent.

RESULTS

351 healthy adult patients were included in the study, there were 238 in the no alcohol group, 113 had consumed alcohol and blood alcohol intake were obtained for 47. The alcohol group had a higher incidence of head injuries (46 (48%) versus 22 (9%)) with a lower incidence of limb injuries (39 (39%) versus 183 (76%)) than the no alcohol group. There was a significant difference in the pattern of injury between the alcohol and no alcohol groups (chi(2), p<0.001) and there was a significant difference in the injury severity scores (p<0.001, Z = -2.5). In the alcohol group severity and pattern correlated with alcohol concentration at the time of injury. Patients with an alcohol concentration<2 g/l had mostly soft tissue limb injuries (58%), 2-2.5 mostly significant limb fractures (55%), and >2.5 mostly significant head injuries (90%).

CONCLUSIONS

Alcohol related falls are more often associated with severe craniofacial injury. The severity of both limb and head injury is greater and correlates directly with blood alcohol concentration.

Aggression involving alcohol: relationship to drinking patterns and social context

AIMS

The present study examines the relationships between: (1) alcohol involvement/perceived intoxication level of participants and aggression severity; (2) respondent drinking patterns and involvement in alcohol-related aggression; and (3) social context and alcohol-related aggression.

DESIGN

Random digit dialing (RDD) with computer assisted telephone interviewing (CATI) was used to obtain a random sample of Ontario adults aged 18-60 (response rate of 67%).

PARTICIPANTS

Respondents who reported that they had been involved personally in physical aggression in the past 12 months were the focus of the present study.

MEASUREMENTS

Questions were asked regarding the most recent incident of physical aggression, including whether the respondent and opponent drank alcohol prior to aggression, perceived intoxication levels at the time, number of participants, relationship to opponent, social context of aggression, time of day and day of week. Three items were used to assess aggression severity: injury to respondent, use of threats by respondent or opponent and police involvement.

FINDINGS

(1) Injury to respondent and threats by respondent were not associated with alcohol involvement per se, but were significantly related to perceived level of alcohol intoxication; (2) drinking pattern of respondent was significantly associated with alcohol-related aggression but unrelated to aggression that did not involve alcohol; and (3) a number of contextual factors (e.g. gender, number of participants, time of day) were found to be associated with alcohol involvement in aggression.

CONCLUSIONS

The results suggest that both drinking pattern and contextual factors are important in distinguishing between alcohol-related aggression and non-alcohol-related aggression. As well, alcohol intoxication may be an important predictor of aggression severity.

Factors affecting injury severity to rear-seated occupants in rural motor vehicle crashes

Injury to rear-seat occupants (RSOs) has received little systematic study in the literature. Past studies have focused on patterns of injury presented to the emergency department, various aspects of restraint usage and injury, or specific populations of RSOs. This is the first systematic analysis of injury severity to RSOs. RSOs involved in motor vehicle crashes (MVCs) sustain injuries of equal severity as do front-seated occupants (FSOs) involved in the same crash. The setting was a rural North Carolina emergency department where patients were evaluated at the sole hospital for the county. The design was a 2-year retrospective review of all MVCs with RSOs occurring in Pitt County North Carolina in calendar years 1988 and 1989. The Wilcoxon Rank-Sum Test and Logistic Regression Analysis with Injury Severity Score (ISS) as the dependent variable were performed. Three hundred forty-six crashes involving 367 vehicles with RSOs and 1,273 occupants that sent 222 patients to the hospital. ISS was higher for unrestrained occupants (1.87 versus 0.51), occupants of vehicles driven by legally intoxicated drivers (4.04 versus 0.73), occupants between the ages of 30 and 59 years (1.06 versus 0.65) and FSOs (1.04 versus 0.85) (Wilcoxon Rank-Sum test P <.0002). Logistic regression analysis confirmed these findings with the exception of more severe injuries for the 30 to 59 age range and impact speed. The analysis failed in these 2 cases. Restraint usage offered the greatest protective effect (OR 0.37). Lesser protective effects were noted with rear seat occupancy (OR 0.43) and age < 13 years (OR 0.77). More severe injuries were predicted by driver intoxication (OR 2.5), and age > 60 years (OR 1.25). In our rural population, RSOs sustain less severe injuries than FSOs. Restraint usage and sober drivers provide a greater protective effect however. Seat location does not replace restraint usage or sobriety.

Alcohol consumption in victims of violence: a trend study for the period 1970-1998

This 29-yr. retrospective study is about alcohol consumption by victims of violence intentionally injured (N = 13,048) and general patients unintentionally injured (N = 296,544) who were treated for their injuries at the Trauma Center of the University Hospital Groningen (The Netherlands) during the period 1970-1998. The incidence rate for general patients with alcohol consumption was statistically significantly greater than the incidence rate of victims of violence with alcohol consumption. A long-term significant linear trend was observed for both types of patients during the 29-yr. period. However, the increase in incidence rate among the general patients with alcohol consumption was four times greater than the increase in incidence rate for the victims of violence with alcohol consumption. Males predominated in both types of patients (with and without alcohol consumption). The statistically significant highest incidence rates (and male predominance) were found in the age group 20-24 years for both categories of patients.

Alcohol and violence-related injuries in the emergency room

This chapter reviews data on estimated blood alcohol concentration (BAC), self-reported consumption, and drinking patterns and problems from emergency room (ER) studies of alcohol and violence-related injury. These studies used probability samples of all injured patients that were representative of the population served by the ER where the data were collected. Those with violence-related injuries were more likely to be admitted to the ER with a positive BAC, to report drinking prior to the event, and to report more frequent heavy drinking and alcohol-related problems than those admitted to the same ER during the same time period with injuries from other causes. Limitations to these ER studies, including representativeness of samples, alcohol's presence and role in violence perpetration compared to violence victimization, the presence of other psychoactive substances, and the actual risk at which alcohol places the individual for injuries resulting from violence are discussed.

The relationship of alcohol to injury in assault cases

Little is known about the precise role of alcohol in the escalation of interactions from threats into physical violence or its contribution to the risk of injury. Experimental studies indicate that intoxicated subjects (allegedly) give markedly higher electric shocks than sober subjects and are less sensitive to their cries of pain. However, few studies in a naturalistic setting have examined whether aggressive acts become more serious and result in higher injury rates when the assailants have been drinking than when they are sober. This chapter reviews the two bodies of research on the effects of alcohol on interpersonal aggression and violence; presents new data on the escalation of threatening interactions to assaults and the likelihood of victim injury given an assault, using data from the National Crime Victimization Survey for the years 1992 and 1993; and suggests future directions for research based on our findings that alcohol's impact on both escalation and injury differed according to the victim-assailant relationship.

Outcome after traumatic brain injury in the U.S. military medical system

Personality and behavioral change after traumatic brain injury (TBI) are often the most significant concerns for the families of TBI patients. This report examines discharge from military service after TBI for medical and behavioral criteria. When compared with the total discharge population (n = 1,879,724), the relative risk for behavioral discharge was 1.8 times greater for those with mild TBI (n = 1,778), and no difference for those with moderate (n = 174) or severe TBI (n = 274). Discharge for alcoholism or drug use was 2.6 times for mild TBI, 5.4 times for moderate TBI, and no difference for severe TBI compared with the total discharge population. Discharge for criminal conviction was 2.7 times for those with mild head injury, and no difference for those with moderate or severe TBI when compared with the total discharge population. Discharge for medical disability ranged from 7.5 times to 40.4 times, and mortality ranged from 11.6 to 142.4 times the total discharge population. Total sick days defined as the time from admission to return to duty or separation from service increased with head injury severity. Mean Injury Severity Score for mild TBI was 5.5, and 20.9 for severe TBI. Patients who sustain TBI should be monitored after injury for development of behavioral problems. The most effective way to reduce the cost of TBI is primary prevention of these injuries and examining military practices to reduce exposure to risk of TBI. Secondary and tertiary prevention measures such as evaluation and rehabilitation, where indicated, should be undertaken on a routine basis after TBI.

The frequency of unsuspected minor illness or injury in intoxicated patients

OBJECTIVE

To determine the frequency of unsuspected minor illness or injury in a group of patients frequently seen in the ED for acute intoxication.

METHODS

The medical records of the 20 patients seen most frequently in the ED for acute intoxication in 1993 were reviewed for the number of ED visits for intoxication, the number of associated documented episodes of minor trauma or illness, the extent of ED workup of discovered illness or injury, and patient disposition from the ED.

RESULTS

The 20 study patients were evaluated in the ED 1,858 times in 1993 for acute intoxication, a mean of 92.5 visits/patient (+/- 26.6). The most frequent injury was minor trauma above the neck, occurring a mean of 9 times (+/- 3.6) in each of the study patients during 1993. Evaluation included repeated neurologic examinations and frequent radiography of the cervical spine (n = 80), skull (n = 5), facial bones (n = 6), and mandible (n = 5). A limited number of head CT scans also were done (n = 8). The most frequent minor illnesses were gastritis (n = 7), managed with hydration, and mild hypothermia (n = 6), managed with passive rewarming.

CONCLUSIONS

The incidence of unsuspected minor illness or injury in this patient group was substantial. While most unsuspected medical problems had little clinical significance, some were potentially dangerous, and some necessitated hospitalization (e.g., hypothermia, hematemesis, and respiratory depression).

Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients

The association of alcohol and injury might be expected to vary by the specific cause of injury, but few studies have examined such associations across all causes of injury coming from the same population, largely because of the lack of a sufficient number of cases. This study examines the association of drinking patterns and problems and drinking-in-the-injury-event for six mutually exclusive causes of injury (falls, penetrating trauma, motor vehicle accidents, fires, violence, and other causes) in a merged sample of 3109 patients from four emergency room/trauma center studies that used identical study methodology. The predictive value of drinking and demographic variables are examined separately for each cause of injury, and variables predictive of reporting drinking before the event, feeling drunk at the time of injury, and attributing a causal association of drinking and the injury. Injuries sustained from violence and falls had the greatest association with drinking variables, with those with positive breathalyzer readings, and those who reported drinking before injury, frequent heavy drinking, and frequent drunkenness overrepresented in these two causes. Those who reported a larger number of drinks consumed before injury and those who reported feeling drunk at the time were also overrepresented among those with injuries related to violence and falls. A larger proportion than expected of those who attributed a causal association of drinking with the event sustained injuries related to violence, whereas a smaller proportion sustained injuries from falls. Demographic characteristics were more predictive than drinking characteristics of each cause of injury, whereas drinking characteristics, particularly positive breathalyzer readings, were more predictive of drinking before specific causes of injury. These data provide information that may be useful in developing brief interventions for the prevention of alcohol-related injuries in the emergency room or trauma center setting.

Alcohol in fatal and nonfatal injuries: a comparison of coroner and emergency room data from the same county

Although alcohol is thought to be associated with severity of injury, relatively little data are available that compares alcohol's involvement in injury cases treated in the emergency room (ER) with coroner cases of injury fatality, both coming from the same county. Data from a probability sample of casualty patients 18 years and older treated at the University of Mississippi Medical Center ER in Jackson during a 6-month period (n = 275) are compared with data from coroner reports of all fatalities from unnatural causes among those 18 and older in the same county during a 1-year period surrounding the 6 months of data collection in the ER (n = 222). The two samples are compared on demographic characteristics, cause of injury, place of injury, and alcohol use before the event. A significantly larger proportion of the coroner sample was positive for alcohol (57%) and intoxicated (36%), compared with the proportion of those in the ER sample breathalyzed within 6 hr of injury, and reporting no drinking after the event who were positive (15%) and intoxicated (6%). Differences were most pronounced for motor vehicle accidents and fires. Violence-related injuries were more likely in the coroner sample (32%) than in the ER sample (16%), and they were more likely to involve alcohol at levels of intoxication. Those in the coroner sample were also more likely to be alcohol-positive for injuries occurring in all places except the home of another and the workplace. Using logistic regression, gender (male) and site (coroner) were predictive of a positive blood alcohol across all causes of injury combined. Gender (female), being alcohol-positive and site (coroner) were significantly predictive of motor vehicle accidents. Alcohol was not found to be a significant predictor for falls, other accidents, or injuries resulting from violence. Data suggest that alcohol's association with severity of injury varies by cause of injury.

Identification of hazardous/harmful drinking among subcritically injured patients

OBJECTIVES

To examine the relationship between a saliva alcohol test (SAT) and hazardous/harmful drinking, as measured by the Alcohol Use Disorders Identification Test (AUDIT), among a sample of subcritically injured patients.

METHODS

Patients (n = 78) seeking treatment for a subcritical injury were saliva-tested for alcohol and interviewed regarding their drinking behaviors and related difficulties. Associations of SAT values with AUDIT results were determined.

RESULTS

SAT results and hazardous/harmful drinking were not independent events (p < 0.001). Estimates of sensitivity and specificity (using a dichotomous SAT result [> or = 4 mmol/L] to identify positive AUDIT patients) were 65.2% and 83.6%, respectively. SAT-positive people had significantly higher AUDIT scores than did SAT-negative individuals (p < 0.0001). Patients experiencing assault-type injuries were much more likely to be SAT-positive than were patients incurring other types of injury. Discriminant function analysis suggests that AUDIT scores can successfully identify SAT-positive and SAT-negative patients; the analysis accounted for 42.5% of the variance and correctly classified 84.6% of the sample.

CONCLUSIONS

The use of an easy-to-administer, noninvasive, routine SAT, among patients presenting for a subcritical injury in a hospital ED, provides a mechanism for the identification of individuals with a history of hazardous/harmful drinking. However, since discrimination of hazardous/harmful drinking is imperfect, some caution is warranted when conducting such screening activities.

Dose-related effect of alcohol on mismatch negativity and reaction time performance

In a recent study, the mismatch negativity (MMN) component of auditory event-related potential, elicited by occasional frequency changes in a repetitive tone, was strongly attenuated by a low dosage of alcohol. We investigated the phenomenon in nine subjects with two different dosages of ethanol (0.35 and 0.55 g/kg), and with two magnitudes of frequency changes (5% and 10%), in a single-blind, placebo-controlled paradigm. Ethanol had no observable effect on the N1 and P2 deflections, nor on the reaction time to frequency changes measured in a separate session. However, the MMN was attenuated after administration of the larger dosage of alcohol, suggesting impaired preconscious processing of stimulus features outside the scope of attention. The results support the view according to which the automatic functions of human information processing are more sensitive than the controlled functions to the detrimental effects of alcohol. The fact that the MMN suppression was stronger when stimulus deviation was smaller indicates that at relatively low blood alcohol concentrations the detection of small deviations is especially hampered.

Alcohol and non-fatal injury in the U.S. general population: a risk function analysis

This paper reports a risk function analysis of average daily volume of alcohol consumed and the frequency of consuming 5 or more drinks during a single day with reporting an injury in a probability sample of the U.S. adult household population living in the 48 contiguous states. The data are from the 1990 National Alcohol Survey on a weighted sample of 1150 respondents, 748 of whom were current drinkers. Risk of injury was found to increase with an average daily volume of 1 drink for both males and females and for those 30 and younger and those over 30, and to increase with a frequency of consuming 5 or more drinks on one day more often than twice a year. These data suggest that risk for injury may be increased at relatively low levels of consumption and, if so, that preventive efforts aimed at more moderate drinkers may have a greater impact on the reduction of alcohol-related accidents than efforts focused on heavier drinkers who are fewer in number.

Low dose of ethanol suppresses mismatch negativity of auditory event-related potentials

The acute effect of a low dose of ethanol (0.5 g/kg) on attention and auditory event-related potentials (ERPs) was investigated in 10 social drinkers using a single-blind, placebo-controlled cross-over design. A dichotic listening task, in which the subjects were instructed to attend selectively to stimuli to one ear while ignoring stimuli to the other, was used. The amplitudes of N1, P2, and the mismatch negativity (MMN) were significantly diminished by alcohol. The latencies of the MMN and N2b were also significantly increased after alcohol ingestion. The novel finding of the significant (> 60% reduction in amplitude) suppression of the MMN can be interpreted as indicating disturbed preconscious detection of acoustic changes outside the scope of attention. Because this is a prerequisite to an attentional shift, the MMN suppression may be related to increased risk for accidents after alcohol ingestion. The same dose of alcohol that suppressed the MMN left intact selective attention and conscious "target" detection, as reflected by the processing negativity and P3 deflections, thus suggesting that the automatic functions of human information processing are more sensitive to alcohol than the controlled, attentional functions.

The incidence of stairway injuries in Austria

Stairs are among the most hazardous features of the everyday environment, yet stairway falls have received little research attention. A stratified random sample of Austrian residents was surveyed in person in 1989. Of over 55,000 respondents, 147 reported a stairway injury in the previous year that limited activity for at least one day. Thirty-seven percent of these injuries resulted in hospitalization. Extrapolating to the entire country of 8 million people, each year some 20,000 Austrians sustain serious stairway injuries resulting in over 7,500 hospitalizations. The incidence of stairway injury increases monotonically with age, and females are more at risk than males. The stereotypical stairway injury victim is an elderly woman, not highly educated, who is unmarried and living alone.

Cause of casualty and drinking patterns: an emergency room study of unintentional injuries

A probability sample of 1494 adult casualty patients sampled in four hospitals in a single Californian county were breathalyzed and interviewed regarding the cause of injury, drinking prior to the injury, quantity and frequency of usual drinking, frequency of drunkenness and prior alcohol-related accidents. In the total sample, 9% were positive on the breathalyzer (4% were at or above 0.10), 17% reported drinking within 6 h prior to the injury, and 29% reported heavy drinking during the last year. Overall, 15% reported a prior alcohol-related accident and this was significantly greater among heavy drinkers than other drinkers. Cause of casualty (fall, cutting/piercing, motor vehicle accident, other collision, fire, other cause) in relation to alcohol consumption variables was analyzed separately in gender- and age-specific categories. Few significant associations were found between drinking variables and individual causes of injury. While these findings may be due to the relatively small number of cases for some causes, as well as to other variables not examined here including severity and type of injury, such baseline exploratory data are important in furthering our understanding of alcohol's involvement in casualty occurrence and point to the need for additional research on alcohol and causes of injury.

Alcohol consumption and injury in the general population: from a national sample

The association of alcohol consumption with injuries is well documented in the literature. The majority of data for non-fatal injuries has come from emergency room (ER) studies, however, and little is known of how representative ER samples are of injuries in the general population or of the actual risk at which drinking places the individual for accidental injury. Data were collected (1990) from a national probability household sample (N = 2058; weighted N = 1150) on: the respondent's most recent injury; whether treatment was obtained for that injury, and where; drinking prior to injury; quantity and frequency (Q-F) of usual drinking; frequency of drunkenness; experiences associated with alcohol dependence; and social consequences related to drinking--all during the last year. Injury for the last year was categorized as follows: without injury, untreated injury, injury treated in the ER, other treated injury. Males treated in the ER were significantly more likely to be heavy drinkers and were more likely to report alcohol dependence experiences and social consequences related to drinking than those without injuries, while females treated in the ER were more likely to report social consequences related to drinking compared to those without injuries. Age (OR = 0.87) and Q-F (OR = 1.31) were found to be predictive of reporting an injury during the last year. Among injured none of these variables were predictive of reporting treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol and injuries: a review of international emergency room studies

This paper reviews emergency room (ER) studies from a number of countries which have focused on the association of alcohol and casualties. The review emphasizes studies which used probability sample of patients to represent the population of the emergency facility where the data were collected, and which separated injured patients from patients with medical conditions not due to injuries (the 'non-injured'). Reviewed here are studies concerned with: (1) estimated prevalence of positive blood alcohol at the time of the ER visit; (2) self-reported alcohol consumption prior to the event resulting in a need for ER treatment; (3) patients' descriptions of their usual drinking patterns and alcohol-related problems; (4) predictions of casualties and of alcohol-related casualties. Comparisons of findings from several countries are also presented. Comments on limitations of ER studies as well as other issues pertaining to the usefulness and interpretation of such data, and future directions for research in emergency room populations are discussed.

Alcohol and non-traffic unintended injuries

In a review of the English language literature on alcohol and unintentional injury we identified 21 studies on falls, 36 on drownings and 32 on burns from 1947-1986. The proportion of fatal and non-fatal fall victims who had been drinking ranged from 21-77%, and 18-53% respectively. In three more recent studies, 35-63% of persons fatally injured in falls had been drinking. In five other studies 13-37% of persons injured in non fatal falls had been drinking. In our earlier review of drowning studies with complete ascertainment and duration of submergence specified, 27-47% of those who drowned had positive BAC's. In eight subsequent studies, alcohol was identified in 21-47% of drowning deaths. In our earlier review alcohol was involved in 9-86% of burn deaths. In five more recent US studies, alcohol was found in 12-61% of fatally injured burn victims. Case control studies are needed to establish whether alcohol increases the risk of trauma. Studies are also needed of interventions to reduce the proportion of these injuries where alcohol is involved.

Alcohol in home and leisure injuries

The part that alcohol plays in non-motor vehicle unintentional injuries is not well known. Injuries at home and during leisure form a very heterogeneous group. Alcohol involvement varies considerably from one subgroup to another: for example, all cases of alcohol poisoning involve alcohol by definition, whereas alcohol involvement is very infrequent in sports injuries. One-third of falls, half of drownings and fire deaths and two-thirds of hypothermia deaths involve alcohol. Young and middle-aged males form a risk group of alcohol-related trauma. Alcohol involvement varies also from country to country: deaths from alcohol poisoning are several times as common in Finland as in other Western countries. In contrast to experience in Western countries, in Dar es Salaam, Tanzania, wealthier injured Africans were found to have alcohol involvement more often than poor Africans. Alcohols seems to increase the risk of falling, bicycle and motor vehicle injuries largely to the same extent. The relative importance of the two main components of alcohol-related risk--risk-taking and impaired psychomotor functions--requires further exploration in each main external cause category of home and leisure injuries.