Alcohol level at head injury and subsequent psychotropic treatment during trauma critical care

The impact of ETOH intoxication on the development of admission coagulopathy after traumatic brain injury: a prospective evaluation

INTRODUCTION

Coagulopathy after severe traumatic brain injury (sTBI) results in a ten-fold increased risk of death. Our aim was to investigate the effect of ETOH intoxication on admission coagulopathy after sTBI.

METHODS

Patients with sTBI [Glasgow Coma Scale <9 or evidence of intracranial pathology on computed tomography (CT)] from 1/2010 to 12/2011 were prospectively enrolled. Demographics, clinical characteristics, laboratory values, head CT scan findings, physical examination, injury severity indices, and interventions were recorded. ETOH blood levels were obtained. The incidence of admission coagulopathy was compared between patients who were ETOH-positive (ETOH+) and those who were ETOH-negative (ETOH-). Logistic regression was performed to identify independent risk factors.

RESULTS

A total of 216 patients were enrolled. 20.4 % were ETOH+. Admission coagulopathy was significantly lower for ETOH+ patients (15.9 vs. 39.0 %, adjusted p = 0.020). Prothrombin time (PT) and International Normalized Ratio (INR) on admission were significantly lower for ETOH+ patients (16.7 vs. 14.3, adjusted p = 0.016 and 1.35 vs. 1.13, adjusted p = 0.040, respectively). Injury Severity Score ≥25, hypotension, and loss of gray/white differential were identified as independent risk factors for the development of admission coagulopathy. ETOH intoxication was the only protective predictor [AOR (95 % CI): 0.32 (0.12, 0.84), adjusted p = 0.021].

CONCLUSIONS

ETOH intoxication is associated with a lower incidence of admission coagulopathy in patients with sTBI. Further research is warranted.

Influence of alcohol on early Glasgow Coma Scale in head-injured patients

BACKGROUND

To assess the depressant effects of alcohol on the level of consciousness of patients admitted with head injuries, this study examined the changes that occur in the Glasgow Coma Scale (GCS) of traumatic brain injury patients over time.

METHODS

The records of 269 head trauma patients consecutively admitted to the neurosurgery intensive care unit were examined retrospectively. Eighty-one patients were excluded because of incomplete data. The remaining 188 patients were further divided into an intoxicated group (blood alcohol concentration [BAC] ≥ 0.08%, n = 100 [53%]) and a nonintoxicated group (BAC <0.08%, n = 88 [47%]). The GCS in the prehospital setting, in the emergency department, and the highest GCS achieved during the first 24 hours postinjury were compared.

RESULTS

The change between emergency department-GCS and the best day 1 GCS in the intoxicated group was greater than the nonintoxicated group and deemed clinically and statistically significant; median change (3 vs. 0) p < 0.001. To assess whether these results were directly related to the BAC%, piecewise regression using a general linear model was used to assess the intercept and slope of alcohol on the changes of GCS with cutting point at BAC% = 0.08. The analysis showed that, in the nonintoxicated range, the effect of alcohol was not significantly related to the changes of GCS. But in the intoxicated range, BAC% was significantly positively related to the changes of GCS.

CONCLUSION

This study concludes that the GCS increases significantly over time in alcohol intoxicated patients with traumatic brain injury.

Isolated severe traumatic brain injuries: association of blood alcohol levels with the severity of injuries and outcomes

BACKGROUND

Traumatic brain injury is a common cause of death after traumatic insults. Alcohol intoxication is a recognized contributor to the occurrence of these injuries. The specific effects of alcohol exposure on injury severity and subsequent outcomes, however, remain controversial. The aim of this study was to investigate the relationship between blood alcohol levels (BAL) and outcomes in patients with isolated severe traumatic brain injuries (sTBI).

METHODS

During the calendar year 2003, as part of a pilot project, the Los Angeles County Department of Health Services obtained routine BAL on all patients transported to any of its 13 trauma centers. This study analyzes the effect of BAL on outcomes in patients with isolated sTBI (head Abbreviated Injury Scale (AIS) score >or=3; extracranial AIS score <3). The Low/No ethanol (ETOH) group included patients with negative or low (<0.08 mg/dL) BAL. Patients with BAL >or=0.08 mg/dL constituted the high ETOH group. Logistic regression was performed to determine whether alcohol levels had an independent association with outcomes.

RESULTS

There were 815 patients with isolated severe head injuries. Overall, 468 patients (57%) constituted the Low/No ETOH group, and 347 (43%) the high ETOH group. Alcohol levels were not significantly associated with severity of injury, hypotension at admission, Glasgow Coma Scale score, incidence of major complications, and intensive care unit or hospital length of stay. However, adjusted mortality was significantly lower in the high ETOH group when compared with the Low/No ETOH (8.9% vs. 17.1%; adjusted odds ratio: 0.60, 95% confidence interval: 0.37-0.96, p = 0.037). In the subgroup of patients with Injury Severity Score >15 the relative risk for mortality in the high ETOH group was significantly lower than in patients with Low/No ETOH. There was also an increased survival with high ETOH in patients with Injury Severity Score >25, but this was not statistically significant.

CONCLUSIONS

Among patients with isolated sTBI, BAL do not seem to be associated with overall injury severity, head injury severity, or the occurrence of major morbidities. Similarly, hospital and intensive care unit lengths are not affected by high admission BAL level. The adjusted overall in-hospital mortality, however, is significantly lower in patients presenting with the high BAL (>or=0.08 g/dL) after isolated sTBI.

Serum ethanol levels: predictor of survival after severe traumatic brain injury

BACKGROUND

Recent studies have suggested that moderate doses of ethanol (ETOH) before traumatic brain injury (TBI) may have a neuroprotective role.

OBJECTIVE

: The objective of this study is to investigate the effects of serum ETOH levels on outcomes after TBI. Our hypothesis was that ETOH exposure is associated with improved survival in severe TBI patients and that the serum ETOH levels on admission correlate with survival.

METHODS

All patients sustaining severe TBI (head abbreviated injury score >or=3) admitted to the Surgical Intensive Care Unit at the Los Angeles County + University of Southern California Medical Center from January 2000 to December 2005 who had a serum ETOH level measured on admission were analyzed. Patients were classified into ETOH-positive and ETOH-negative groups, according to the serum ETOH levels and compared for differences in outcomes using logistic regression to adjust for clinically and statistically relevant confounding factors.

RESULTS

During the 5-year study period, 482 severe TBI patients admitted to the Surgical Intensive Care Unit at Los Angeles County + University of Southern California Medical Center had a serum ETOH level measured on admission. A total of 47% of severe TBI patients were tested for ETOH. ETOH levels were positive in 37% (179) and negative in 63% (303) of the TBI patients. The ETOH-positive group had a higher percentage of males (91% vs. 79%, p = 0.001), lower percentage of penetrating injuries (9% vs. 20%, p = 0.002), and lower injury severity score (25.7 +/- 11.5 vs. 28.4 +/- 14.1, p = 0.05). Overall mortality was significantly lower in the ETOH-positive group at 27% versus 40% (odds ratio = 0.55, 95% confidence interval: 0.37-0.82; p = 0.004). This survival benefit remained significant after multivariable analysis (adjusted odds ratio = 0.54, 95% confidence interval: 0.31-0.92; adjusted p = 0.02). The mean serum ETOH level was significantly higher for survivors than for nonsurvivors (0.11 +/- 0.21 vs. 0.05 +/- 0.10, p < 0.001). The serum ETOH levels significantly correlated with the probability of survival (r = 0.21, p < 0.001), but this correlation was not strong as shown by the low r value.

CONCLUSION

The results of this study suggest that elevated ETOH serum levels are independently associated with higher survival in patients with severe traumatic brain injuries. Additional research is required to further investigate the mechanism and potential therapeutic implications of this association.

Traumatic brain injury in intoxicated patients

BACKGROUND

We sought to evaluate the effect alcohol intoxication may have had in nonsurgically treated patients with severe traumatic brain injury.

METHODS

The Montreal General Hospital Traumatic Brain Injury Registry was used to identify all adult patients with a Glasgow Coma Scale score < or =8 at admission, within a 15-month period. All charts were retrospectively reviewed.

RESULTS

Twenty-three patients had toxic blood alcohol levels (BAL > or =21.7 mmol/L), 24 were alcohol negative (BAL <3 mmol/L), and 10 were alcohol-influenced or had unknown BAL. Patients were more likely to have intracranial pressure monitoring if they had multiple intracranial hemorrhages, sustained multiple injuries, or had a post-resuscitative Glasgow Coma Scale score < or =8. Intoxicated patients had a mean delay of 151 minutes more in the insertion time of an intracranial pressure monitoring device, compared with alcohol-negative patients.

CONCLUSIONS

Alcohol was a confounding factor in the treatment of some of our patients.

Waiting for the patient to "sober up": Effect of alcohol intoxication on glasgow coma scale score of brain injured patients

BACKGROUND

Between 35% to 50% of traumatic brain injury (TBI) patients are under the influence of alcohol. Alcohol intoxication may limit the ability of the Glasgow Coma Scale (GCS) to accurately assess severity of TBI. We hypothesized that alcohol intoxication significantly depresses GCS scores of TBI patients.

METHODS

A 10-year, retrospective analysis of a Level I trauma center registry was undertaken. The study population consisted of all blunt injured TBI patients tested for blood alcohol concentration (BAC, n = 1,075). Patients were divided into two groups; intoxicated (mean BAC 202 +/- 77 mg/dL, n = 504) and nonintoxicated (BAC = 0, n = 571). TBI was classified using ICD-9 codes as concussion alone (ICD-9 850, n = 90) and intracranial injury (ICI, ICD-9 851-854, n = 985). Severity was further classified using the Abbreviated Injury Score (AIS). Mean GCS score was compared between the two groups. Patients who were either intubated or hypotensive upon arrival were analyzed separately to rule out confounding effects on GCS score. Severely intoxicated patients (BAC >250 mg/dL, [mean +/- SD] 309 +/- 54 SD, n = 118) were similarly compared. Finally, multivariate linear regression analysis was undertaken to determine whether BAC level was an independent predictor of GCS score while controlling for confounding factors.

RESULTS

Intoxicated and nonintoxicated TBI patients were clinically similar. Alcohol intoxication had little effect on GCS score, with less than a single point difference in all types of TBI, except the most severely injured (AIS 5 injuries, GCS score difference 1.4 points). These results were not altered by endotracheal intubation, systemic hypotension, or severe intoxication. Similarly, BAC was not a significant independent predictor of GCS score in a multivariate model.

CONCLUSION

Alcohol intoxication does not result in clinically significant changes in GCS score for patients with blunt TBI. Hence, alterations in GCS score after TBI should not be attributed to alcohol intoxication, as doing so might result in inappropriate delays in monitoring and therapeutic interventions.

Traumatic brain injury and substance misuse: a systematic review of prevalence and outcomes research (1994-2004)

A systematic review of the evidence on substance misuse prevalence in patients with traumatic brain injury (TBI) and outcomes associated with this population is presented. Building upon an earlier review of the area by Corigan (1995), this review is limited to research published between 1994 and 2004. Psycinfo and Medline abstract databases were searched for English-language publications citing research from Western countries on the epidemiology and outcomes of adult TBI patients (aged 15 years or older). The majority of reviewed studies were undertaken in the USA and the investigation foci and methods used were multifarious, constraining the generalisation of the review findings. Prevalence for alcohol intoxication at time of injury in the review was found to be almost identical to that in Corrigan's review: 37-51% and 36-51%, respectively. Pre-TBI history of alcohol misuse was found to be less prevalent in the present as opposed to Corrigan's review: 37-51% and 55-66%, respectively. Outcome findings were mixed (also found by Corrigan), but mainly in the expected direction of poorer outcomes (neurological, medical, neuropsychological, and functional) in patients with pre-TBI substance misuse. Further research and implications for services are outlined.

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.

The Effects of Admission Alcohol Level on Cerebral Blood Flow and Outcomes after Severe Traumatic Brain Injury

This study examined the relationship between admission serum alcohol level (ETOH) and cerebral blood flow (CBF) and outcomes in the adult traumatic brain injured (TBI) population. We hypothesized that individuals with ETOH > 100 mg/dL will have decreased blood flow on admission and poorer outcomes. Eighty subjects, age 16-65, with severe TBI (Glasgow Coma Score [GCS] </= 8) were entered into the study. Correlational analysis assessed the relationship between ETOH and admission severity of injury scores as measured by Marshall and APACHE III scores, CBF, and outcomes. Comparison of CBF and outcomes between groups based on admission serum ETOH level was conducted with analysis of variance and post hoc Scheffé analyses as well as regression analysis. There was a significant relationship between serum ETOH level and GCS (p = 0.02), but not APACHE III scores (p = 0.12) or Marshall scores (p = 0.27). There was a significant correlation between global CBF and serum ETOH level (p = 0.02). There was no statistically significant association between serum ETOH level and GOS at 3 (p = 0.97), 6 (p= 0.56), or 12 (p = 0.73) months after injury. The data indicated that serum ETOH levels > 100 mg/dL at the time of admission after a TBI were associated with a decrease in global CBF. Elevated serum ETOH level at time of injury did not, however, impact outcomes.