Toxicology Screening Results: Injury Associations Among Hospitalized Trauma Patients

Drug and alcohol intoxication in major trauma: Associations, trends and outcomes over a decade

OBJECTIVES

Drug and alcohol intoxication is common among injured patients altering trauma presentation and characteristics. However, uncertainty exists regarding the effect of intoxication on injury severity, as well as outcomes. The present study aims to provide an update on substance-use patterns and their association with traumatic presentation and outcome within a contemporary Australian context.

METHODS

All major trauma patients captured in our centre's Trauma Registry between July 2010 and June 2020 were included. Demographic, injury characteristic, outcome and substance-use data were collected. Differences in injury severity and characteristics were explored using χ2 tests, while outcomes were modelled using adjusted binomial logistic regression.

RESULTS

Among 9700 patients, 9% were drug-intoxicated prior to injury, while 9.4% were alcohol-intoxicated. Drug use almost tripled between 2010 (4.8%) and 2020 (13.3%), while alcohol intoxication fell, from 11.7% to 7.3%, over the same period. Although there were significant differences in trauma mechanism among intoxicated patients, group comparison found no difference in Injury Severity Score for any group. Regarding outcomes, all intoxication resulted in significantly greater odds (odds ratio 1.62-2.41) of ICU admission. No difference in mortality was found among individual substance-use groups; however, polysubstance-intoxicated patients had 3.52 times greater odds of dying (95% confidence interval 1.21-10.23) compared to non-intoxicated patients.

CONCLUSION

Within this contemporary Australian population, we demonstrate escalating rates of drug intoxication and declining rates of alcohol intoxication prior to trauma. Intoxication was associated with more frequent violent and non-accidental injury, and despite no difference in severity, it was associated with worse outcomes.

Trends and outcomes of trauma patients positive to marijuana and cocaine

PURPOSE

Substance misuse has long been recognized as a major predisposing risk factor for traumatic injury. However, there still exists no clear scientific consensus regarding the impact of drug use on patient outcomes. Therefore, this study aims to evaluate the demographic profile, hospital-course factors, and outcomes of trauma patients based on their toxicology.

METHODS

This is a non-concurrent cohort study of 3709 patients treated at the Puerto Rico Trauma Hospital during 2002-2018. The sample was divided into four groups according to their toxicology status. Statistical techniques used included Pearson's chi-square test, Spearman correlation, and negative binomial and logistic regressions.

RESULTS

Admission rates for marijuana (rho = 0.87) and marijuana and cocaine positive (rho = 0.68) patients increased. Positive toxicology patients underwent surgery more often than negative testing patients (marijuana: 68.7%, cocaine: 65.6%, marijuana & cocaine: 69.8%, negative: 57.0%). Among patients with non-penetrating injuries, a positive toxicology for cocaine or marijuana was linked to a 48% and 42% increased adjusted risk of complications, 37% and 27% longer TICU LOS, and 32% and 18% longer hospital LOS, respectively.

CONCLUSION

Our results show an association between positive toxicology for either marijuana, cocaine, or both with higher need for surgery. Additionally, our results show an increase in complications, TICU LOS, and hospital LOS among non-penetrating trauma patients testing positive for marijuana or cocaine. Therefore, this study provides valuable information on the clinical profile of patients with positive toxicology, suggesting they might benefit from more aggressive management.

Rates and types of urine drug screen false negative results compared with confirmatory toxicology testing in major trauma patients

BACKGROUND

Trauma centers are required to screen patients for alcohol use, and if necessary, intervene and refer to treatment (SBIRT). Similar screening for illicit drug use is recommended but not required. Urine drug screening (UDS) underestimates problematic substance use. This study aimed to estimate the types and rates of UDS false negatives (FN) compared to comprehensive testing by liquid chromatography-mass spectrometry (LC-MS) in trauma patients.

METHODS

We performed a prospective cohort study of deidentified urine samples from adult trauma and burn activation patients. Both UDS and LC-MS comprehensive testing of >200 analytes were performed by a reference laboratory on all samples. Iatrogenic medications were excluded from the FN count. Crosstab analyses were conducted for UDS versus LC-MS outcomes to establish FN types and rates. We dichotomized the results by creating an "intentionality" variable (intentional injuries by self/others versus accidental injuries). A series of crosstabs with odds ratios considered intentionality by substance class and demographics. Statistically significant variables by Chi-Square were assessed by logistic regression.

RESULTS

Psychoactive FN were detected in 56/100 urine samples analyzed; the most frequent included anticonvulsants (primarily gabapentin, N = 13), opioid agonists (N = 12), antihistamines (primarily diphenhydramine, N = 10), and phenethylamines (primarily bupropion, N = 5). Nonpsychoactive FN were detected in 70/100 samples; the most common were nicotine (N = 33), caffeine (N = 23), acetaminophen (N = 22), and antidepressants (N = 12). Of substance classes included in the UDS and also tested by LC-MS, FN occurred for opiates (3%), amphetamines (5%) and opioids (25%). Polypharmacy was associated with fall injuries in elderly patients. Cocaine (p = 0.015) and cannabinoids (p = 0.002) were significantly associated with intentionality.

CONCLUSIONS

Our results indicate that FN for potentially important psychoactive and nonpsychoactive substances are common when toxicologic testing is limited to routine UDS in trauma patients. We recommend expanding SBIRT in this patient population to include misuse of tobacco products, prescription analgesics, and over-the-counter antihistamines.

Penetrating trauma: Relationships to recreational drug and alcohol use

INTRODUCTION

The incidence of alcohol and recreational drug use is increasing. The impact on penetrating trauma is unknown. This study was undertaken to identify the incidence of alcohol and recreational drug use prior to penetrating trauma, and to identify ISS and outcomes among patients with penetrating trauma.

METHODS

In this retrospective study, eligible subjects included trauma patients age 18 and older, with major trauma (admitted or evaluated by the Trauma Team) from 2017 to 2021. A chart review was conducted to identify data including mechanism of injury, ISS, alcohol level, toxicologic testing, length of stay, and final disposition.

RESULTS

Among 1270 adult subjects with penetrating trauma during 2017 through 2020, the majority were male (N = 1071; 84%), and African American (N = 679; 54.3%) or White (N = 537; 42.9%). Mechanisms of injury included gunshot wound (GSW) (N = 973; 76.6%) or stab wound (N = 297; 23.4%). Injury severity score (ISS) ranged from 1 to 75. Among 426 subjects (33.5%) tested for recreational drugs, 395 (93%) were positive for at least one substance. The most common recreational drugs identified included marijuana (N = 280; 65.7%), benzodiazepine ((N = 131;30.8%), alcohol ((N = 248; 25.3%), opiate ((N = 116; 27.2%), cocaine (N = 87; 20.4%), and amphetamine ((N = 84; 19.7%). Subjects with an ISS of 9 to 15 had higher odds of testing positive for opiates compared to subjects with an ISS of 1 to 3 (OR 2.3). Most patients were ultimately discharged home ((N = 912;71.8%) and a minority expired (N = 142; 11.2%).

CONCLUSIONS

Positive screens for alcohol and recreational drugs were common among penetrating trauma patients in this setting. The most common identified recreational drugs included marijuana, benzodiazepine, opiates, alcohol, cocaine, and amphetamine.

Implications of positive urine toxicology screening in trauma patients

BACKGROUND

Pain management in trauma patients can be difficult due to their varied injuries and presence or absence of illicit substances in their systems. Additionally, trauma patients have variable lengths of stay. Limiting length of stay to what is medically necessary and preventing long-term dependence on narcotic medications are important in trauma patient care.

METHODS

We performed a retrospective review of 385 consecutive trauma activations at a Level II trauma center with urine toxicology screens from 2015. Main outcome measures recorded were urine toxicology results, average daily morphine milligram equivalents (MME), length of stay (LOS), injury severity score (ISS). We also recorded patient demographic information. Statistical analysis compared outcomes and demographics between trauma patients with positive urine toxicology screens to those with negative screens. Significance was set at p < 0.05.

RESULTS

Positive urine toxicology screens were present in 230/385 (59.7%) patients. The median (interquartile range (IQR)) daily MME usage in the positive urine toxicology group was 25.2 (12.0-48.6) versus 12.4 (2.5-27.5) for those with a negative drug screen (p < 0.001). Median LOS was 3 (1-6) days versus 2 (1-4) days for the positive and negative groups, respectively (p = 0.004). There were no differences in age, gender distribution, or ISS between the two groups. Subgroup analysis showed urine toxicology positive for opiates, benzodiazepines, and tetrahydrocannabinol (THC) were associated with increased daily MME. Benzodiazepines and amphetamines were associated with increased LOS.

CONCLUSION

This study identifies a positive toxicology screening as a risk factor for increased narcotic demands and longer length of stay in trauma patients. These findings may assist in developing treatment plans and setting expectations in this population. This information can also lead to proactive interventions aimed at minimizing narcotic use and shortening LOS in this population.

Does Level of Blood Alcohol Content Affect Clinical Outcomes After Trauma in Older Adult Patients?

INTRODUCTION

Preinjury alcohol use and older age have independently been associated with poor outcomes. This study examined whether higher levels of blood alcohol concentration (BAC) correlated with an increased likelihood of poor outcomes in older trauma patients.

METHODS

This was a retrospective cohort study of injured patients ≥65 years with BAC testing presenting to a Level 1 trauma center between 2015 and 2018. Patients were stratified by BAC at 4 thresholds of intoxication: BAC ≧10 mg/dL, BAC ≧80 mg/dL, BAC ≧150 mg/dL, and BAC ≧200 mg/dL. Propensity score matching using inverse probability of treatment weighting was used to estimate outcomes. Logistic and Poisson regression models were performed for each threshold of the BAC level with the matched cohort to assess clinical outcomes.

RESULTS

Of all older patients (n = 3112), 32.5% (n = 1012) had BAC testing. In the matched cohort of 883 patients (76.7 ± 8.2 years; 48.1% female), 111 (12.5%) had BAC ≧10 mg/dL, 83 (74.8%) had BAC ≧80 mg/dL, 60 (54.1%) had BAC ≧150 mg/dL, and 37 (33.3%) had BAC ≧200 mg/dL. Falls (60.5%) and motor vehicle crashes (28.9%) were the most common mechanisms of injury. Median (IQR) of Injury Severity Score (ISS) was 5 (1-10). The risk of severe injury (ISS ≧15) was similar between alcohol-positive and alcohol-negative patients (9.9% vs 15.0%, P = .151). BAC ≧10 g/dL was not associated with length of stay, intensive care unit admission, or in-hospital complication, nor was any of the other 3 analyzed BAC thresholds.

CONCLUSION

Overall, any detectable BAC along and increasing thresholds of BAC was not associated with poor in-hospital outcomes of older patients after trauma. Alcohol screening was low in this population, and intoxication may bias injury assessment, leading to mistriage of older trauma patients.

A mixed psychiatric and somatic care unit for trauma patients: 10 years of experience in an urban level I trauma center in the Netherlands

BACKGROUND

A medical-psychiatric unit (MPU) is a special ward where staff is trained in caring for patients with psychiatric or behavioural problems that need hospitalisation for physical health problems. It is well known that these patients are at higher risk of complications and have a longer length of stay resulting in higher costs than patients without psychiatric comorbidity. The objective of this study was to analyse the trauma patient population of the first 10 years of existence of the MPU in a level I trauma center.

PATIENTS AND METHODS

A retrospective analysis was performed in 2-year cohorts from 2006 to 2016. All trauma patients admitted to the MPU were compared with the overall trauma patient population in VUmc. Data (psychiatric diagnosis, substance abuse, trauma scores, surgical interventions, complications, mortality) were extracted from individual patient notes and the Regional Trauma Registry.

RESULTS

258 patients were identified. 36% of all patients had a history of previous psychiatric admission and 30% had attempted suicide at least once in their lifetime. Substance abuse was the most common psychiatric diagnosis (39%), with psychotic disorder (28%) in second place. The median hospital stay was 21 days. Median MPU length of stay was 10 days (range 1-160). Injuries were self-inflicted in 57%. The most common mechanism of injury was fall from height with intentional jumping in second place. Penetrating injury rate was 24% and 33% had an ISS ≥ 16, compared to 5% and 15%, respectively, in the overall trauma patient population. The most common injuries were those of the head and neck. Complication rate was 49%.

CONCLUSION

Trauma patients that were admitted to the MPU of an urban level I trauma center had serious psychiatric comorbidity as well as high injury severity. Penetrating injury was much more common than in the overall trauma patient population. A high complication rate was noted. The high psychiatric comorbidity and the complicated care warrants combined psychiatric and somatic (nursing) care for this subpopulation of trauma patients. This should be taken into account in the prehospital triage to a trauma center. The institution of a MPU in level I trauma centers is recommended.

Psychoactive substances and violent offences: A retrospective analysis of presentations to an urban emergency department in Switzerland

BACKGROUND

Psychoactive substances are often regarded as causal factors contributing to violent injuries, sexual abuse and homicides. While these effects have been demonstrated for some substances (e.g. cocaine), current available data for others are more controversial (e.g. cannabis) or very limited (e.g. ecstasy).

AIMS OF THE STUDY

To collect data on the type and frequency of psychoactive substance use in cases of emergency department (ED) presentations related to interpersonal violence.

METHODS

Retrospective study at the University Hospital of Bern, Switzerland, between May 2012 and June 2016. The study covered cases of violent crime associated with psychoactive substances. Cases of isolated ethanol intoxication, suicide attempts, and substance use for medical purposes were excluded.

RESULTS

The study included 103 cases among the 164,846 ED attendances. In the majority of the cases, the type of violence was bodily force (52%) related to urban violence (83%). The mean patient age was 29 years and 79% were male. 63% of the patients reported use of more than one drug; alcohol co-use was reported in 60% of the cases. Besides alcohol, the substances most often reported were cannabis (50%) and cocaine (21%). Alcohol and cannabis was also the most commonly reported substance combination (36% of the total cases). Urine drug screening was performed in 34% of the cases and cannabis and cocaine were the most commonly detected substances (46% and 19%, respectively). There were no cases of novel substances. 23% of the patients were admitted to a hospital ward, 10% to a psychiatric clinic.

CONCLUSION

Cannabis and cocaine were, besides alcohol, the substances most often reported in ED presentations related to offences of violence. Because of the high prevalence of alcohol co-use, no final conclusions can be drawn on the contribution of single substances.

A comparison of alcohol positive and alcohol negative trauma patients requiring an emergency laparotomy

BACKGROUND

The effect of alcohol exposure on patients undergoing a laparotomy for trauma is unknown. The purpose of this study was to compare outcomes of morbidity and mortality between alcohol positive and alcohol negative trauma patients who required emergent laparotomies using the National Trauma Data Bank (NTDB).

METHODS

A retrospective database analysis was performed using 28,354 NTDB incident trauma cases, from 2007 through 2012, who had been tested for alcohol and who required abdominal operations (using ICD-9-CM procedure codes) within 24h of presentation. Variables used: age, gender, admission year, alcohol presence, ISS, GCS, injury type & mechanism, discharge status, hospital LOS, ICU stay, ventilator use, and hospital complications.

RESULTS

In adjusted analyses, there were no statistically significant differences between the alcohol positive and alcohol negative cohorts when evaluating in-hospital mortality (OR, 0.93; 95% CI: 0.84-1.03), likelihood of earlier hospital discharge (HR, 1.02; 95% CI: 0.99-1.05), and the all-inclusive category of in-hospital complications (OR, 1.04; 95% CI: 0.97-1.12).

CONCLUSIONS

After adjusting for age, gender, admission year, ISS, GCS, and injury mechanism, there were no major differences between the alcohol positive and alcohol negative cohorts when it came to in-hospital mortality, likelihood of earlier hospital discharge, and most of the in-hospital complications measured among adult trauma patients requiring emergency laparotomies.

Demographic and socioeconomic factors influencing disparities in prevalence of alcohol-related injury among underserved trauma patients in a safety-net hospital

BACKGROUND

Alcohol-related trauma remains high among underserved patients despite ongoing preventive measures. Geographic variability in prevalence of alcohol-related injury has prompted reexamination of this burden across different regions. We sought to elucidate demographic and socioeconomic factors influencing the prevalence of alcohol-related trauma among underserved patients and determine alcohol effects on selected outcomes.

METHODS

A retrospective analysis examined whether patients admitted to a suburban trauma center differed according to their blood alcohol concentration (BAC) on admission. Patients were stratified based on their BAC into four categories (undetectable BAC, BAC 1-99mg/dL, BAC 100-199mg/dL, and BAC ≥ 200mg/dL). T-tests and X2 tests were used to detect differences between BAC categories in terms of patient demographics and clinical outcomes. Multivariate linear and logistic regressions were used to investigate the association between patient variables and selected outcomes while controlling for confounders.

RESULTS

One third of 738 patients analyzed were BAC-positive, mean (SD) BAC was 211.4 (118.9) mg/dL, 80% of BAC-positive patients had levels ≥ 100mg/dL. After risk adjustments, the following patient characteristics were predictive of having highly elevated BAC (≥200mg/dL) upon admission to the Trauma Center; Hispanic patients (adjusted odds ratio (OR)=1.91, 95% confidence interval (CI): 1.14-3.21), unemployment (OR=1.74, 95% CI: 1.09-2.78), Medicaid beneficiaries (OR=3.59, 95% CI: 1.96-6.59), and uninsured patients (OR=2.86, 95% CI: 1.60-5.13). Patients with BAC of 100-199mg/dL were likely to be more severely injured (P=0.016) compared to undetectable-BAC patients. There was no association between being intoxicated, and being ICU-admitted or having differences in length of ICU or hospital stay.

CONCLUSION

Demographic and socioeconomic factors underlie disparities in the prevalence of alcohol-related trauma among underserved patients. These findings may guide targeted interventions toward specific populations to help reduce the burden of alcohol-related injury.

A Ten year review of alcohol use and major trauma in a Canadian province: still a major problem

Background

Alcohol plays a significant role in major traumatic injuries. While the role of alcohol in motor vehicle trauma (MVT) is well described, its role and approaches to prevention in other injury mechanisms is less defined.

Methods

A 10 year retrospective examination of Alberta Trauma Registry (ATR) data was conducted on all major trauma patients (age ≥ 9 and ISS ≥ 12) from 2001–2010. The role and prevalence of alcohol is examined.

Results

Of 22,457 patients included in our study, only 60 %(n = 13,552) were screened for alcohol use. Of those screened, 38 %(n = 5,170) tested positive for alcohol with a mean blood alcohol concentration (BAC) of 39.4 ± 21.1 mmol/L. Of the positive screening tests, 82.3 % had BAC levels greater than the common legal driving limit of 17.4 mmol/L (0.08 %). Testing positive was associated with male gender (p < 0.001) and younger age (p < 0.001). The rate of positive alcohol use in major trauma increased from 20.3 % in 2001 to 24.3 % in 2010, corresponding with a screening rate increase from 51.3 % to 61.2 % over the same period. Railway incidents have the highest rate of alcohol involvement (65 %), followed by undetermined-if-accidental/self-inflicted (53.5 %) and assault (49 %); motor vehicle traffic (MVT) incidents had a frequency of 25.4 %.

Conclusions

The prevalence of alcohol use in major trauma appears to be increasing in Alberta but the true extent is still underappreciated. Furthermore, the role of alcohol in non-MVT injuries is significant and deserves further attention. The vast majority of patients involved in alcohol-related trauma are legally intoxicated. Alcohol use continues to be a substantial contributor to major trauma in Alberta, and represents an important opportunity to reduce preventable injuries.

Alcohol consumption and interpersonal injury in a pediatric oral and maxillofacial trauma population: a retrospective review of 1,192 trauma patients

The social, financial, and health implications of adult alcohol-related oral and maxillofacial trauma have been recognized for several years. Affordability and widespread accessibility of alcohol and issues of misuse in the pediatric trauma population have fostered concerns alcohol may be similarly implicated in young patients with orofacial trauma. The aim of this study was to review data of pediatric facial injuries at a regional maxillofacial unit, assess the prevalence of alcohol use, and review data of patients sustaining injury secondary to interpersonal violence. This study is a retrospective, 3-year review of a Regional Maxillofacial Unit (RMU) trauma database. Inclusion criterion was consecutive facial trauma patients under 16 years of age, referred to RMU for further assessment and/or management. Alcohol use and injuries sustained were reviewed. Of 1,192 pediatric facial trauma patients, 35 (2.9%) were associated with alcohol intake. A total of 145 (12.2%) alleged assault as the mechanism of injury, with older (12-15 years) (n = 129; 88.9%), male (n = 124; 85.5%) (p < 0.001) patients commonly involved and alcohol use implicated in 26 (17.9%) presentations. A proportion of vulnerable adolescents misuse alcohol to the risk of traumatic facial injury, and prospective research to accurately determine any role of alcohol in the pediatric trauma population is essential.

The prevalence of positive drug and alcohol screens in elderly trauma patients

BACKGROUND

Alcohol and drug abuse are recognized to be significantly prevalent in trauma patients, and are frequent harbingers of injury. The incidence of substance abuse in elderly trauma patients has, however, been limitedly examined. The authors sought to identify the spectrum of positive alcohol and drug toxicology screens in patients ≥65 years admitted to a Level I trauma center.

METHODS

Patients ≥65 years old admitted to an American College of Surgeons (ACS) Level I trauma center over a 60--month period were identified from the trauma registry. Demographic data, blood alcohol content (BAC), and urine drug screen (UDS) results at admission were obtained and analyzed. The positive results were compared with individuals below 65 years in different substance categories using Fisher's exact test.

RESULTS

In the 5-year period studied, of the 4139 patients ≥65 years, 1302 (31.5%) underwent toxicological substance screening. A positive BAC was present in 11.1% of these patients and a positive UDS in 48.3%. The mean BAC level in those tested was 163 mg/dL and 69% of patients had a level >80 mg/dL.

CONCLUSIONS

These data show that alcohol and drug abuse are an issue in patients ≥65 years in our institution, though not as pervasive a problem as in younger populations. Admission toxicology screens, however, are important as an aid to identify geriatric individuals who may require intervention.

Incongruence between trauma center social workers' beliefs about substance use interventions and intentions to intervene

This study explored trauma centers social workers' beliefs regarding four evidence-based interventions for patients presenting with substance abuse issues. Previous research has indicated that health care providers' beliefs have prevented them from implementing non-abstinence based interventions. Study results indicated that the majority of social workers believed in the 12-step approach and were least comfortable with the harm reduction approach. However, results showed that in some cases, social workers may have negative personal beliefs regarding non-abstinence based interventions, but do not let their personal beliefs get in the way of utilizing these interventions if they are viewed as appropriate for the client's situation.

Violence-related injury and gender: the role of alcohol and alcohol combined with illicit drugs

INTRODUCTION AND AIMS

The positive relationship between alcohol use, gender and violence-related injury is well established. However, less is known about injuries when alcohol is used in combination with other drugs.

DESIGN AND METHODS

Self-report information was collected on alcohol and illicit drug use in the 6 h before a violence-related injury in probability samples of patients presenting to emergency departments (n=9686).

RESULTS

Patients with violence-related injuries reported the highest rates of alcohol use (49% of men; 23% of women) and alcohol use combined with illicit drugs (8% of men; 4% of women) whereas non-violent injury patients reported lower rates of alcohol use (17% of men; 8% of women) and alcohol use combined with drugs (2% for men; 1% for women). Marijuana/hashish was the most commonly reported drug. The odds of a violent injury were increased when alcohol was used [men: odds ratio (OR)=5.4, 95% confidence interval (CI) 4.6-6.3; women: OR=4.0, 95% CI 3.0-5.5] or when alcohol was combined with illicit drug use before the injury (men: OR=6.6, 95% CI 4.7-9.3; women: OR=5.7, 95% CI=2.7-12.2) compared with non-users. No significant change in the odds of a violent injury was observed for men or women when alcohol users were compared with alcohol and drug users.

DISCUSSION AND CONCLUSIONS

The positive association between alcohol and violent injury does not appear to be altered by the added use of drugs. Additional work is needed to understand the interpersonal, contextual and cultural factors related to substance use to identify best prevention practices and develop appropriate policies.

Studying psychoactive substance use in injured patients: does exclusion of late arriving patients bias the results?

BACKGROUND

Most studies of the prevalence of psychoactive substances in injured emergency department patients have excluded those who arrive more than 6h after injury. This may cause a selection bias. The aim of this study was: (1) to describe the characteristics of patients who arrive more than 6h after injury, compared to patients who arrive sooner (2) to examine whether self-report can add to the assessment of alcohol use when the patient is assessed more than 6h after injury.

METHODS

Blood sample analysis and self-report data were used to assess the prevalence of psychoactive substances in injured patients admitted to an emergency department within 48 h of injury (n=1611). Discriminant function analysis was used to assess group differences.

RESULTS

The patients who arrived more than 6h after injury differed significantly from those who arrived earlier in several respects. They more often screened positive for hypnotics; they were older, they were more likely to have had a fall and they were more often injured at home and at night. Self reported use of alcohol showed good consistency with blood sample screening within 6h of injury and could therefore be used to assess alcohol use more than 6h after injury.

CONCLUSIONS

Patients who arrive more than 6h after injury differ significantly from those who arrive earlier. Future studies on the prevalence of psychoactive substances in emergency departments could expand the inclusion window.

Trauma activation patients: evidence for routine alcohol and illicit drug screening

Background

Statistics from the National Trauma Data Bank imply that discretionary blood alcohol and urine drug testing is common. However, there is little evidence to determine which patients are appropriate for routine testing, based on information available at trauma center arrival. In 2002, Langdorf reported alcohol and illicit drug rates in Trauma Activation Patients.

Methodology/Principal Findings

This is a retrospective investigation of alcohol and illicit drug rates in consecutive St. Elizabeth Health Center (SEHC) trauma patients. SEHC Trauma Activation Patients are compared with the Langdorf Activation Patients and with the SEHC Trauma Nonactivation Patients. Minimum Rates are positive tests divided by total patients (tested and not tested). Activation patients: The minimum alcohol rates were: SEHC 23.1%, Langdorf 28.2%, combined 24.8%. The minimum illicit drug rates were: SEHC 15.7%, Langdorf 23.5, combined 18.3%. The minimum alcohol and/or illicit drug rates were: SEHC 33.4%, Langdorf 41.8%, combined 36.2%. Nonactivation patients: The SEHC minimum alcohol rate was 4.7% and the minimum illicit drug rate was 6.0%.

Conclusions

Alcohol and illicit drug rates were significantly greater for Trauma Activation Patients, when compared to Nonactivation Patients. At minimum, Trauma Activation Patients are likely to have a 1-in-3 positive test for alcohol and/or an illicit drug. This substantial rate suggests that Trauma Activation Patients, a readily discernible group at trauma center arrival, are appropriate for routine alcohol and illicit drug testing. However, discretionary testing is more reasonable for Trauma Nonactivation Patients, because minimum rates are low.

Prevalence of alcohol and other substances of abuse among injured patients in a Norwegian emergency department

BACKGROUND

Studies have found a high prevalence of both alcohol and other impairing psychoactive drugs in injured patient populations. The aim of this study was to assess the prevalence of potentially impairing psychoactive substances in all patients admitted to a hospital emergency department with injuries from accidents, assault or deliberate self harm.

METHODS

A total of 1272 patients over 18 years of age, admitted to the hospital within 12h of injury, were included. Presence of alcohol was determined by an enzymatic method and other drugs by liquid chromatography-mass spectrometry (LC-MS) or gas chromatography-mass spectrometry (GC-MS), both highly specific analytical methods for determining recent intake.

RESULTS

There were 510 (40%) women in the sample. Of the patients, 38% of the women and 48% of the men had a positive blood sample for psychoactive substances on admission. The most prevalent psychoactive substance was alcohol (27%) with an average concentration of 1.5 g/kg. A further 21% of patients tested showed use of medicinal drugs, and 9% showed use of illicit substances. Cannabis was the most prevalent illicit drug (6.2%). Diazepam (7.4%) and zopiclone (5.3%) were the most prevalent medicinal drugs. In road traffic accidents, 25% of the car drivers had positive findings, about half of them for alcohol.

CONCLUSION

Psychoactive substances were found in nearly half the patients admitted with injuries. The most common substance was alcohol. Alcohol was particularly related to violence, whereas medicinal drugs were most prevalent in accidents at home.

Beliefs and practices of pediatric emergency physicians and nurses regarding counseling alcohol-using adolescents: can counseling practice be predicted?

OBJECTIVES

The objectives of the study were to investigate the attitudes and practices of pediatric emergency department (PED) physicians (MDs), MD extenders (MD's assistants [PAs], nurse practitioners [NPs]), and nurses (RNs) regarding their counseling of alcohol-using adolescent PED patients and to determine which, if any, PED clinician characteristics predict current counseling practice.

METHODS

An Internet-based survey of PED clinicians (MDs, PAs, NPs, and RNs) from 11 academic US PEDs was conducted. Respondents were asked about their counseling training, current counseling practices, confidence in their counseling skills, importance of counseling, attitudes and beliefs about counseling, and demographic information. Univariate and multivariate analyses were performed to determine the relationship between clinician characteristics and counseling practice.

RESULTS

Counseling practice was strongly associated with one's profession; PED MDs/PAs/NPs reported significantly higher rates of counseling alcohol-using adolescents than PED RNs. These 2 groups differed significantly in terms of counseling training and experience. Counseling training and experience remained significant predictors of counseling practice, even after controlling for profession and other covariates. Both groups had similar views on the importance of counseling, confidence in their ability to counsel, and counseling substance-using adolescent PED patients.

CONCLUSIONS

Pediatric ED MDs/PAs/NPs differ significantly from PED RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

Alcohol-related injury visits: do we know the true prevalence in U.S. trauma centres?

INTRODUCTION

Alcohol consumption is a significant risk factor for injuries. Further, level I trauma centres are mandated to screen and provide a brief intervention for identified problem drinkers. However, a valid population-based estimate of the magnitude of the problem is unknown. Therefore, the goal of this study is to evaluate the extent to which the present literature provides a valid estimate of the prevalence of alcohol-related visits to U.S. trauma centres.

METHODS

A Medline search for all articles from 1966 to 2007 that might provide prevalence estimates of alcohol-related visits to U.S. trauma centres yielded 836 articles in English language journals. This review included only papers whose main or secondary goal was to estimate the prevalence of positive blood alcohol concentration (BAC) or acute intoxication. Both a crude aggregate estimate and sample size adjusted estimate were calculated from the included papers and the coverage and comparability of methods were evaluated.

RESULTS

Of the 15 studies that met inclusion criteria, incidence estimates of alcohol-related visits ranged from 26.2% to 62.5% and yielded an aggregate, weighted estimate of 32.5%. Target population, capture rate, and threshold for a positive screening result varied considerably across studies. No study provided a comprehensive estimate, i.e., of all trauma patients hospitalised, treated and released, or who died.

CONCLUSIONS

Although the incidence of alcohol-related visits to U.S. trauma centres appears very high perhaps higher than any other medical setting, the validity of our aggregate estimate is threatened by crucial methodological considerations. The lack of a methodologically valid prevalence estimate hinders efforts to devise appropriate policies for trauma centres and across medical settings.

The impact of child safety promotion on different social strata in a WHO Safe Community

Background:

The objective of the current study was to evaluate outcomes of a program to prevent severe and less severe unintentional child injuries among the different social strata under WHO Safe Community program. Specifically, the aim was to study effectiveness of Safe Community program for reducing child injury.

Methods:

A quasi-experimental design was used, with pre- and post-implementation registrations covering the children (0 -15 years) in the program implementation area (population 41,000) and in a neighboring control municipality (population 26,000) in Östergötland County, Sweden.

Results:

Boys from not vocationally active households displayed the highest pre-intervention injury rate in both the control and intervention areas. Also in households in which the vocationally significant member was employed, boys showed higher injury rates than girls. Households in which the vocationally significant member was self-employed, girls exhibited higher injury rates than boys in the intervention area. After 6 years of program activity, the injury rates for boys and girls in employed category and injury rates for girls in self-employed category displayed a decreasing trend in the intervention area. However, in the control area injury rate decreased only for boys of employed families.

Conclusions:

The study indicated that almost no changes in injury rates in the control area suggested that the reduction of child injuries in the intervention area between 1983 and 1989 was likely to be attributable to the safety promotion program. Therefore, the current study indicates that Safe Community program seems to be successful for reducing child injuries.

Substance use among non-fatally injured patients attended at emergency departments in Spain

AIMS

To describe the prevalence of recent use of alcohol, medication, and illegal drugs among patients who attended emergency departments (EDs) as a result of suffering an injury due to any external mechanism and to identify factors associated with alcohol and drug use.

METHODS

A cross-sectional study was conducted in eight university hospitals in Spain. Participants were adult patients admitted to a trauma ED. Oral fluid was used to test for psychoactive substances analyzed by gas chromatography-mass spectrometry. Socio-demographic data and information on circumstances of the injury were collected through interviews.

RESULTS

The analysis included 1579 patients admitted to the EDs (56.4% men). Among young people (< 40 years), 21.4% of men and 8.5% of women were positive for any illegal substance, primarily cannabinoids or cocaine; 24.7% of men and 14.8% of women were positive for alcohol. Among patients > or = 40 years, 7.4% of men and 1.6% of women were positive for any illegal substance, and 16.3% and 11.0% respectively for alcohol. Prevalence of substance detected varied across mechanism of injury, gender and age group. Night-time injury was associated with substance use.

CONCLUSIONS

A high proportion of injured patients who were treated in an EDs tested positive for psychoactive drugs. Routine testing at trauma departments would maximize the identification of patients who may benefit from referral to specialized addiction treatment centers, or brief interventions.

Alcohol, drugs and trauma: consequences, screening and intervention in 2009

Alcohol use is a preventable cause of injury as it doubles the risk of re-injury and increases mortality. For this reason, the American College of Surgeons, Committee on Trauma had mandated a screening and subsequent intervention strategy for all Level I centres, and there is good evidence to support the efficacy of such programmes. Clinicians can play a key role in reducing injury related to alcohol use through their participation in these programmes. Although validated screening tools and evidence to support brief interventions for alcohol use exist, the benefit of these experiences for other recreational drugs awaits further research in this area. In the meantime, the implementation of alcohol screening and brief intervention programmes across all trauma programmes and emergency departments should become a global healthcare priority.

Incidence and impact of undisclosed cocaine use in emergency department chest pain and trauma patients

Background

One of the highest rates of illicit cocaine consumption in Europe is in Spain. Our objective was to study the incidence and impact of undisclosed cocaine consumption in patients attending the emergency department (ED) for trauma or chest pain.

Methods

We analysed urine samples from consecutive patients attending the ED for trauma or chest pain to determine the presence of cocaine, cannabis, amphetamine/metaamphetamine and opioids by semiquantative tests with fluorescence polarization immunoassay (FPIA).

Results

Thirty percent of eligible patients participated. Of 75 cases, 61.3% had trauma and 38.7% chest pain; 25% presented a positive test for drugs. Cocaine was present in 13.3% and cannabis in the same proportion. No differences were found regarding positive cocaine test and chief complaint, ED or hospital stay, or additional tests. Cocaine-positive patients were significantly younger.

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.

A controlled trial of brief intervention versus brief advice for at-risk drinking trauma center patients

BACKGROUND

Numerous reports document that preinjury alcohol use is associated with all modes of injury requiring treatment in a trauma center, with 25% to 50% or more of patients testing positive for alcohol at the time of admission. There is evidence that in trauma patients unaddressed alcohol use problems result in recurrent injury requiring readmission to a trauma center and/or death.

METHODS

A randomized clinical trial was conducted to assess the effectiveness of two types of brief interventions to reduce drinking and the consequences of drinking. Trauma patients defined as at-risk alcohol users (n=497) were randomized into two treatment options: a brief personalized motivational intervention (PMI), or brief information and advice (BIA). After a brief assessment, PMI subjects received a motivational session, feedback letter, and two postdischarge telephone contacts, whereas the BIA group received a brochure and one postdischarge telephone contact. Both groups were reassessed at 6 and 12 months postinjury.

RESULTS

Both the PMI and BIA groups had statistically significant reductions in drinking, binge episodes, and consequences related to drinking that persisted from the 6- to the 12-month follow-up. However, although not statistically significant, for those classified as lower-level drinkers (<or=1 drink per day), there was a consistent pattern of maintaining reductions for the PMI group at 12 months compared with the BIA group.

CONCLUSION

Our results suggest that brief interventions (PMI and BIA) that link alcohol consumption with trauma injury and consequences of drinking can be effective in reducing drinking and consequences related to drinking in a significant portion of at-risk nondependent drinkers.

Substance use among emergency room patients: Is self-report preferable to biochemical markers?

AIM OF STUDY

To explore the validity of self-reported substance use among emergency room populations and the processes of sample selection bias, to establish their influence on the prevalence rates found.

METHODS

Self-reported alcohol and illicit drug use of patients in the emergency room is compared with results from an alcohol breath analyser and urine toxicology.

RESULTS

Variations in reported substance use occur when comparing self-report measures with alcohol breath analyser results and urine toxicology. Self-reported alcohol use was found among 7.5% of the patients compared with 4.7% based on alcohol breath analysers. Illicit drug use was reported by 9.0% of the patients whereas urine toxicology resulted in 30% patients positive for illicit drug use. Patients that voluntarily participate in the study differ from those that do not participate. Patients who refuse an alcohol breath analyser report slightly more alcohol use prior to the injury (difference not significant), and patients who provide a urine sample report more illicit drug use prior to the injury compared to those that refuse.

DISCUSSION

Differences in prevalence rates can be explained partly by the measurements used and partly by sample selection bias. Self-reported alcohol use and self-reported illicit drug use are preferable to the "gold standard" when used among emergency room patients, because both measures provide more accurate information on the actual use. Sample selection bias also influences the prevalence rates.

Alcohol and illicit drug use among emergency room patients in the Netherlands

AIMS

To clarify alcohol and illicit drug use within the emergency room population in three different regions in The Netherlands, focusing on whether interventions for these substances should be region specific.

METHODS

Alcohol and illicit drug use were assessed using a self-report questionnaire filled in by the patients, and by combining self-report with staff judgement on alcohol and illicit drug use.

RESULTS

Data on alcohol use (self-reported and staff judgement combined) resulted in prevalence rates of 4.9-18.2%. Patients positive for alcohol are more likely to be male, aged 48-58 years, more likely to be a frequent excessive drinker, and to have injuries as a result of violence. Patients positive for illicit drugs are more likely to be male, aged 28-38 years, unemployed, and frequent excessive drinkers. Among men aged 18-35 years with a Dutch cultural background, some differences emerge regarding alcohol consumption between the various hospitals, but most variation exists in the case of illicit drug use.

CONCLUSIONS

This paper confirms that the emergency room seems to provide an opportunity to initiate interventions regarding alcohol use and seems to suggest that this is independent of the region concerned. However, in the case of illicit drug use interventions seem to be more region specific.

The impact of home safety promotion on different social strata in a WHO safe community

OBJECTIVES

Few studies have investigated the impact of home safety promotion programmes on different social strata. The aim of this study was to investigate the distribution of effects of a community-based home safety programme on home injury rates among families with different connections to the labour market.

METHODS

A quasi-experimental design was used, with pre- and post-implementation registrations covering the total populations below 65 years of age in the programme implementation area (population 41,000) and in a neighbouring comparison municipality (population 26,000) in Ostergötland County, Sweden.

RESULTS

In the intervention and comparison areas, households in which the adults were not vocationally active displayed the highest rates of home injury. After 6 years of programme activity, the home injury rates for males and females in all social status categories displayed a decreasing trend in the intervention area. The opposite was true for the comparison area, i.e. the incidence of injury increased, with the exception of females in non-vocationally active households. The decline in injury rates in the intervention area was statistically significant for males and females in the employed category and for males in the non-vocationally active category. Changes in injury rates in the comparison area were not statistically significant.

CONCLUSION

The programme was partially successful in that it reduced the injury rate in non-vocationally active households, but it did not influence the injury rate in the employed households. The study design did not allow for conclusions regarding why the post-intervention injury rates remained higher in non-vocationally active households. Further research on the association between the incidence of home injury and socio-economic factors is warranted.

Illicit drug use and injuries: A review of emergency room studies

The reviewed emergency room studies (n = 11) show overall prevalence rates of illicit drug use of 35-40% in studies using blood and urine toxicology and 1-5% in self-report studies. Cannabis and cocaine are the substances most prevalent in these studies, with a higher prevalence of cocaine in emergency rooms in the USA than in other countries where cannabis is the most common substance. Illicit drugs and alcohol are often used in combination. No relationship was found between injury severity and illicit drug use. Less clear associations emerged concerning patient and injury characteristics and illicit drug use. However, illicit drug use seems to be more common in men aged 20-40 years and is strongly associated with violence-related injuries. Variations in the prevalence rates and patient characteristics can partly be explained by locale and/or country of research. Moreover, because methodological differences influence the study outcomes, methodological aspects of emergency room studies should be taken into consideration when interpreting the results.