Alcohol and Trauma

Clinician assessment of blood alcohol levels among emergency department patients

INTRODUCTION

Alcohol intoxication is a significant public health concern and is commonly seen among emergency department (ED) patients. This study was undertaken to identify the accuracy of clinician assessment of blood alcohol levels among emergency department patients.

METHODS

This prospective survey study was conducted at a Level 1 Trauma Center. Eligible study participants included physicians, nurses, and medical students involved in the care of patients who had BAC. Clinicians estimated the BAC prior to results availability.

RESULTS

Among 243 clinicians, the mean difference between the estimated BAC and actual BAC was 17.4 (95% CI: 4.7 to 30.1). Providers tended to overestimate the actual BAC level. The accuracy between roles (attendings, residents, RNs, students) was not significant (ANOVA p-value 0.90). Accuracy was not correlated with age of the patient (Pearson correlation 0.04, p-value 0.54). Accuracy was not associated with the patient's gender (Student's t-test two-tailed p-value 0.90), ethnicity (White versus all others, t-test p-value 0.31), nor insurance (government versus not government, t-test p-value 0.81). The average accuracy value was associated with mode of arrival (t-test p-value 0.003). The average accuracy for walk-in subjects was -14.9 (CI: -32.8 to 3.1) compared to ambulance arrivals 28.3 (CI: 12.7 to 44.0). Providers underestimated BAC for walk-ins and overestimated BAC for ambulance arrivals. Among 107 patients with a BAC of 0, clinician estimates ranged from 0 to 350. Clinicians estimated non-zero BAC levels in 17% of patients with BAC of 0 (N = 18).

CONCLUSIONS

Clinicians' estimates of BAC were often inaccurate, and often overestimated the BAC.

The cost of alcohol-attributable injuries and poisonings in Canada, 1992

Alcohol-related injuries and poisonings are estimated to have caused 1.7% (3,359) of all deaths, 4.0% (123,119) of all corresponding potential years of life lost, 1.1% (38,687) of all hospitalizations, and 1.3% (533,895) of hospital days in Canada in 1992. The cost of these injuries is estimated to have been $3.9 billion, using a societal point of view and the human capital method of valuing forgone productivity. Leading causes of these human and economic costs are motor vehicle accidents, falls, self-inflicted injury and assault. Injuries and poisonings comprise a large portion of alcohol-related mortality (50% of deaths; 66% of potential years of life lost), morbidity (45% of hospitalizations) and economic costs (51%). Policy implications of these results are discussed.

Acute alcohol intoxication

Acute alcohol intoxication is a clinically harmful condition that usually follows the ingestion of a large amount of alcohol. Clinical manifestations are heterogeneous and involve different organs and apparatuses, with behavioral, cardiac, gastrointestinal, pulmonary, neurological, and metabolic effects. The management of an intoxicated patient occurs mainly in the emergency department and is aimed at stabilizing the clinical condition of the patient, depending on his/her clinical presentation. One specific drug that is useful in the treatment of acute alcohol intoxication is metadoxine, which is able to accelerate ethanol excretion. In patients presenting an acute alcohol intoxication, alcohol-related disorders should be detected so that the patient can be directed to an alcohol treatment unit, where a personalized, specific treatment can be established.

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 injury in adolescents

OBJECTIVE

To determine the frequency of alcohol ingestion in adolescent victims of major trauma and determine whether alcohol ingestion is associated with increased injury severity or death.

METHODS

Subjects were all patients between 12-25 years of age treated at Pennsylvania trauma centers in 1996 who were reported to the state trauma database. Data on age, mechanism of injury (E-code), blood alcohol concentration (BAC), Injury Severity Score (ISS), and survival were obtained from the state database. BAC positive and negative patients within three groups: ages 12-17, 18-20, and 21-25, were compared to determine any difference in death rate, injury severity or type of injury.

RESULTS

4309 patients aged 12-25 were reported to the state in 1996. 2724 (63.2%) underwent testing for BAC, with 884 (32.5%) of those tested being positive. Testing positive were: 93/726 (12.8%) between 12-17 years old, 249/844 (29.5%) between 18-20 years old, and 542/1154 (47.0%) between 21-25 years old. 567/884 (64.1%) of those testing positive had BAC > or = 100 mg/dl. There were no statistically significant differences in mean ISS or death rate between BAC negative and BAC positive patients in either of the age groups. Regression analysis also showed no relationship between mortality and either the presence of alcohol or the actual level of BAC. Other regression analysis demonstrated a slight downward trend for ISS with increasing intoxication, which was statistically significant at P < 0.01.

CONCLUSIONS

Alcohol ingestion is found even in early adolescent trauma patients and is seen to increase throughout the teenage years, occurring in over one-quarter of patients 18 to 20 years of age. Suspicion must be high that ingestion of alcohol has occurred in adolescent trauma. Further efforts should be made to improve the rate of testing in late adolescents, to ensure adequate identification of all alcohol-exposed patients and enable educational interventions. No significant differences in mortality were seen between alcohol positive and negative patients, but there was a trend to decreased injury severity with the presence of alcohol.

Withdrawal syndromes

The pathophysiology of substance withdrawal is elucidated by a review of classic and cutting-edge research. The manifestation and evaluation of the associated withdrawal syndromes from ethanol, sedative-hypnotics, opioids, and baclofen, are compared. The general management of and pharmacotherapy for these patients are discussed.

Acute ethanol intoxication in a model of traumatic brain injury with hemorrhagic shock: effects on early physiological response

OBJECT

Traumatic brain injury (TBI) is exacerbated by hypotension and hypoventilation. Because previous studies have shown a potentiating effect of ethanol (EtOH) on TBI and hemorrhagic shock (HS), the authors investigated the effects of EtOH on the early physiological response to TBI with and without HS.

METHODS

Anesthetized swine, weighing approximately 20 kg each, underwent fluid-percussion TBI of 3 atm with or without 30 ml/kg hemorrhage for a period of 30 minutes. The mean arterial blood pressure, intracranial pressure, cerebral perfusion pressure (CPP), cardiac output, cerebral venous oxygen saturation, and metabolic parameters were monitored for 3 hours postinjury. Ventilation and the response to hypercapnia were also measured. Regional cerebral blood flow and renal blood flow were measured using dye-labeled microspheres. Five groups were studied: control, TBI, TBI/EtOH, TBI/HS, and TBI/HS/EtOH. The EtOH (3.5 g) was given intragastrically 100 minutes preinjury. The TBI/HS/EtOH group demonstrated a 3-hour mortality rate of 56% and postinjury apnea requiring ventilation in 44% of animals compared with 0% in all other groups. Minute ventilation and the hypercapnic ventilatory response were significantly reduced in the postinjury period in the TBI/HS/EtOH group. The animals in this group had significantly lower CPP and cardiac output in the first 60 minutes postinjury, as well as lower renal and cerebral blood flow. Postinjury cerebral venous lactate levels were higher, and cerebral venous pH was lower in the TBI/HS/EtOH group.

CONCLUSIONS

In this model of TBI, acute EtOH intoxication in the presence of HS potentiates the physiological and metabolic alterations that may contribute to secondary brain injury.

Effects of ethanol in an experimental model of combined traumatic brain injury and hemorrhagic shock

OBJECTIVES

Given that clinical and laboratory studies suggest that ethanol and hemorrhagic shock (HS) potentiate traumatic brain injury (TBI), the authors studied the effects of ethanol in a model of combined TBI and HS.

METHODS

A controlled porcine model of combined TBI and HS was evaluated for the effect of ethanol on survival time, hemodynamic function, and cerebral tissue perfusion. Anesthetized swine (17-24 kg) were instrumented, splenectomized, and subjected to fluid percussion TBI with concurrent 25-mL/kg graded hemorrhage over 30 minutes. Two groups were studied: control (n = 11) and ethanol (n = 11). Ethanol, 3.5 g/kg intragastric, was given 100 minutes prior to TBI/HS. Systemic and cerebral physiologic and metabolic parameters were monitored for 2 hours without resuscitation. Regional cerebral blood flow (rCBF) and renal blood flow were measured with dye-labeled microspheres. Data were analyzed with 2-sample t-test and repeated-measures ANOVA.

RESULTS

Ethanol levels at the time of injury were 162 +/- 68 mg/dL. Average TBI was 2.65 +/- 0.35 atm. Survival time was significantly shorter in the ethanol group (60 +/- 27 min vs 94 +/- 28 min, p = 0.011). The ethanol group had significantly lower mean arterial pressure, cerebral perfusion pressure, and cerebral venous O2 saturation in the postinjury period. Cerebral O2 extraction ratios and cerebral venous lactate levels were significantly higher in the ethanol group. A trend toward lower postinjury rCBF in all brain regions was observed in the ethanol group.

CONCLUSION

In this TBI/HS model, ethanol administration decreased survival time, impaired the hemodynamic response, and worsened measures of cerebral tissue perfusion.

Alcohol abuse/dependence in motor vehicle crash victims presenting to the emergency department

OBJECTIVE

1) To determine the prevalence of current alcohol abuse/alcohol dependence (AA/AD) among the full injury range of ED motor vehicle crash (MVC) patients; and 2) compare AA/AD and non-AA/AD patient characteristics.

METHODS

This was a prospective cohort study using a stratified random sample of MVC patients aged > or = 18 years presenting to a university hospital and university-affiliated community hospital ED from May 1, 1992, to August 30, 1994. A diagnosis of current AA/AD was based on the alcohol section of the Diagnostic Interview Survey (DIS). Other measurements included the presence of blood alcohol (BAC+), Injury Severity Score (ISS-85), occupant status (driver/passenger), age, gender, seat belt use, culpability for crash, and ED disposition (admitted vs released). A weighted prevalence was determined; subgroups were compared using t-tests, chi 2, 2-factor analysis, and logistic regression modeling; alpha = 0.05.

RESULTS

1,161 patients were studied. The weighted prevalence of current AA/AD was 22.5%; 53% of these patients were released from the ED. Almost 45% of the patients with current AA/AD were BAC-. When controlling for BAC and AA/AD, greater injury severity and culpability were associated with a BAC+, but not with current AA/AD.

CONCLUSION

Almost 23% of ED MVC patients have current AA/AD; BAC testing does not accurately identify these patients. Intervention strategies must be directed to both admitted and released patients.

Alcohol use among injured patients aged 12 to 18 years

OBJECTIVE

To examine the scope of alcohol use among a population of injured adolescents.

METHODS

A convenience sample of injured patients aged 12-18 years seen at a pediatric ED was tested for the presence of alcohol. Injured patients seen within 6 hours of their injuries were asked to submit urine samples for testing using reagent strips. Data were collected from the patient, out-of-hospital emergency care personnel, and parents regarding the circumstances of the injury.

RESULTS

Of the 243 injured patients who were tested during an 8-month period, 231 were included in the final analysis. Ninety patients (39%) were alcohol-positive. The mean age of the alcohol-positive group was 16.0 +/- 1.64 years, compared with 15.3 +/- 1.8 years for the alcohol-negative group (p < 0.003). There was no significant difference between the 2 groups based on race, gender, or injury characteristics. A positive urine alcohol test was found for 18 (33%) of motor vehicle crash victims, 9 (38%) of the motor vehicle drivers, 10 (37%) of the patients who attempted suicide, and 49 (44%) of the assault victims.

CONCLUSIONS

A substantial percentage of injured adolescent patients were alcohol-positive. The authors recommend the use of alcohol screening when treating injured adolescents.

Effects of ethanol on respiratory function in traumatic brain injury

It has been observed that traumatic brain injury (TBI) increases the susceptibility of the brain to subsequent hypoxia, and prolonged apnea occurs in ethanol (EtOH)-treated animals following brain injury. This investigation tests the hypothesis that EtOH suppresses ventilation and hypercapnic respiratory drive following TBI. Immature pigs were anesthetized with halothane and received a 2 to 3 atm fluid-percussion brain injury. Respiratory parameters, including tidal volume, frequency, ventilation (VE), and arterial blood gases were measured on 100% O2 and on 5% to 6% inspired CO2 in O2 prior to and at 10, 60, 120, and 180 minutes after TBI. Hypercapnic response sensitivity (S) was measured as the change in VE per mm Hg increase in PaCO2. Intracranial pressure, mean arterial blood pressure, heart rate, brain temperature, glucose, and EtOH levels were also monitored. Three groups were studied: the first group of six received EtOH (3.5 gm/kg, intragastrically) without brain injury; the second group of six received TBI without EtOH; the third group of eight received EtOH and TBI. Ethanol levels were 121 +/- 13 (standard error of the mean) mg/dl in the EtOH/TBI group (136 +/- 25 in the EtOH group) at the time of injury, and 175 +/- 12 mg/dl in the EtOH/TBI group (200 +/- 20 mg/dl in the EtOH group) at 120 minutes after injury. The EtOH/TBI animals had significantly lower VE and S, and higher PaCO2 following brain injury (p < 0.05, repeated-measures analysis of variance). No significant differences were identified between groups for pH, PaCO2, intracranial pressure, heart rate, brain temperature, or glucose levels. Ethanol intoxication leads to significant impairment of respiratory control following traumatic brain injury and may contribute to brain injury in intoxicated trauma victims.

Mandatory toxicology testing and chemical dependence consultation follow-up in a level-one trauma center

OBJECTIVE

There is a growing body of evidence indicating an association between intoxication and major trauma. This study assessed the prevalence of alcohol or drug intoxication in major trauma admissions to an urban trauma center.

DESIGN

Sequential case series.

METHODS

Toxicology testing and structural clinical interview assessment.

MAIN RESULTS

Seventy-eight percent of patients tested had positive toxicology results. Chemical dependence assessments performed on patients who tested positive revealed that 94% met the criteria for a substance dependence or abuse disorder.

CONCLUSIONS

The implications of this data for admission toxicology testing policies and chemical dependence consultation support services to trauma units are discussed.

Alcohol-related seizures, Part I: Pathophysiology, differential diagnosis, and evaluation

Alcoholism may be society's most devastating problem short of war and malnutrition. Perhaps the most complex and perplexing medical complication of alcoholism is alcohol-related seizures. This article is a collective review designed to provide emergency physicians with an overview of the topic that is pertinent to their clinical practice. Part 1 addresses the pathophysiology, differential diagnosis, and evaluation of alcohol-related seizures. Part 2 will concentrate on the clinical presentation, management, and disposition. In addition, a classification of alcohol-related seizures will be proposed.

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.

Effects of ethanol in traumatic brain injury

The effects of ethanol intoxication on brain injury and cerebral blood flow (CBF) were investigated in a porcine fluid-percussion model of traumatic brain injury (TBI). Immature swine, under halothane anesthesia (1%), had a TBI delivered with a fluid-percussion device. The experimental group (n = 10) received ethanol (3.5 gm/kg) via gastric tube followed in 1 h by TBI. Two groups of control animals received normal saline and TBI (n = 10) or ethanol and no TBI (n = 5). Mean arterial blood pressure (MAP), intracranial pressure (ICP), arterial blood gases, and serum lactate were monitored for 3 h after the injury. CBF was measured with radiolabelled 15-micron diameter microspheres. Neuropathologic changes were evaluated and graded after formalin perfusion and brain removal at 3 h postinjury. The ethanol level 60 min post-head injury was 198 +/- 70 (SD) mg/dL in the ethanol+TBI group. At 90 min postinjury and thereafter, ethanol+TBI animals compared with TBI only animals had significantly lower MAP (63 +/- 26 mmHg vs 91 +/- 15 mmHg) and lower cerebral perfusion pressure (50 +/- 25 mmHg vs 78 +/- 15), and at 180 min postinjury, lower CBF (87 +/- 37% vs 62 +/- 79% of preinjury levels). Ethanol+TBI animals had higher blood lactates (28 +/- 11 mg/dL vs 13 +/- 6 mg/dL) than TBI only animals. Ethanol+TBI animals also had significantly longer postinjury apneas (11 +/- 8 min vs 0.6 +/- 0.4 min), with three of ten ethanol-treated animals never recovering spontaneous respiration. Ethanol intoxication produced hemodynamic and respiratory changes, which may have a deleterious effect on outcome and mortality after brain injury.

Rheumatic complications of alcohol abuse

The purpose of this report is to review rheumatic complications associated with alcoholism. Data were collected by an English-language literature search using MEDLINE (1966 to December 1991) and references from identified articles. Studies in humans, including case reports of joint disease and allied disorders associated with alcoholism, were reviewed. According to the data identified, alcoholism is associated with many rheumatic problems, including neuropathic arthropathy, hyperuricemia with gouty arthritis, septic arthritis, and joint hypermobility. Osteoporosis, osteonecrosis, and myopathy also are common. Several other rare musculoskeletal complication have been described. Early recognition of these problems is important for management. Further studies are needed to examine the effect of alcohol on connective tissue components in joints.