Treatment course and outcomes following drug and alcohol-related traumatic injuries

Grill-Related Burn Injuries: A Matched Cohort Study

Barbequing can result in devastating burn injuries with unsafe practices. This study aims to characterize the demographics, injury characteristics, and outcomes of grill-related burns and identify ways of burn prevention. A retrospective review of patients admitted to a single-institution, metropolitan burn center from January 1, 2017, to July 1, 2023. Data included demographics, burn injury characteristics, and outcomes. Each Grill Cohort patient was matched to 3 nongrill controls by mBaux score and burn location. Of 2355 patients, 69 (2.9%) met Grill Cohort inclusion criteria. The Grill Cohort had 55 (79.7%) males and an average age of 41.7 ± 17.5 years old. In the Grill Cohort, 25 (36.2%) patients had positive blood alcohol, 8 (11.6%) tested positive for amphetamines, and 5 (7.2%) for cocaine at the time of admission. A total of 61 (88.4%) Grill Cohort burns involved the upper extremity, 43 (62.3%) the head/neck, 34 (49.3%) the lower extremity, and 30 (43.5%) the trunk. Compared with the Control Cohort, the Grill Cohort had smaller proportions of patients who were undomiciled (P < .01) or had a history of mental illness (P < .001). Grill-related burns had a greater proportion of flash/flame burns (P < .001). This study suggests that middle-aged, domiciled males without psychiatric comorbidities are more likely to make preventable grilling errors resulting in burn injuries. Prevention strategies targeting this demographic group should emphasize the risks of grilling while intoxicated, proper handling of propane tanks and lighter fluid, and the use of flash/flame-resistant gear protecting the upper extremities and head/neck.

Opioid-related polysubstance use and its effect on mortality and health resource utilization among trauma patients

BACKGROUND

Pre-injury opioid use is common, but the effects of opioid-related polysubstance use on mortality and health resources utilization (HRU) have not been investigated yet. The objective of this study was to investigate the effects of opioid-related polysubstance use on mortality and HRU among patients in trauma centres in the US.

METHODS

We conducted a retrospective cross-sectional study using the US National Trauma Databank from the year 2017 to 2019. Patients (≥ 18 years of age) who tested positive for opioids were included. Patients were analysed based on the number of substances used (i.e., opioids only, two substances (opioids + 1 substance), and three or more than three substances (opioids +  ≥ 2 substances)), and polysubstance by type (i.e., opioids only, opioids and alcohol, opioids and stimulants, opioids and benzodiazepine, and other combinations). Multivariate logistic regression was used to determine the association between polysubstance use, mortality and HRU (i.e., need for hospital admission, ICU, and mechanical ventilation).

RESULTS

Both polysubstance by number and type analyses showed that opioid-related polysubstance use was not significantly associated with mortality compared to opioids only. The odds of hospital admission were higher among the opioids and benzodiazepines group (OR 1.15, 95% CI 1.06-1.24, p < 0.01). The need for ICU was magnified using benzodiazepines and stimulants with opioids (OR 1.44, 95% CI 1.27-1.63, p < 0.01) when compared to the opioids only group.

CONCLUSION

Opioid-related pre-injury polysubstance use was associated with higher HRU in trauma patients. The evidence can be used by policymakers and practitioners to improve patient outcomes in trauma centers.

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.

A serial cross-sectional study of trends and predictors of prescription controlled substance-related traumatic injury

Pre-injury drug use is a key contributor to traumatic injury. However, limited research has examined trends and predictors of controlled substance-related trauma. The present study aims to provide better clarity on the specific role of prescription-controlled substances (PCS) in traumatic injury events. The data source was the American College of Surgeons National Trauma Data Bank. Trends by injury mechanism and intent for patients with PCS and no-confirmed substances were compared from 2007 to 2014. Logistic regression models were also performed to examine the association between substance use and injury mechanism and intent for data across the study period. Of 405,334 trauma patients, 328,623 (81.1%) had no-confirmed substances and 76,711 (18.9%) had PCS detected. The majority of events in the PCS and no-confirmed substance groups were classified as unintentional. Motor vehicle traffic (MVT), falls, other transport, and cut/pierce injuries accounted for approximately 80% of all injuries. From 2007 to 2014, the proportion of injuries with PCS increased for all injury mechanisms and injury intents. The injury mechanisms of fire/burn, firearm, machinery, poisoning, and other transport were significantly more likely to have PCS relative to MVT injuries. For injury intent, self-harm was more likely to have a toxicology test positive for PCS, while assault was less likely to have a toxicology test positive for PCS compared to unintentional injuries. PCS-related traumatic injuries increased significantly over time and across injury mechanisms and intents. These findings can be used to inform prescribing and understand risk factors to reduce the likelihood of PCS-related traumatic injury.

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.

Cocaethylene: When Cocaine and Alcohol Are Taken Together

Cocaine is taken frequently together with ethanol and this combination produces a psychoactive metabolite called cocaethylene which has similar properties to the parent drug and may be more cardiotoxic. Cocaethylene has a longer half-life than cocaine, so that people who combine cocaine and ethanol may experience a longer-lasting, as well as more intense, psychoactive effect. Cocaethylene is the only known instance where a new psychoactive substance is formed entirely within the body. Although known to science for decades, cocaethylene has not been extensively studied and even its metabolic pathways are not entirely elucidated. Like its parent drug, cocaethylene blocks the reuptake of dopamine and increases post-synaptic neuronal activity; the parent drug may also block reuptake of serotonin as well. Cocaethylene has been studied in animal models in terms of its pharmacology and its potential neurological effects. Since the combination of cocaine and alcohol is commonly used, it is important for clinicians to be aware of cocaethylene, its role in prolonging or intensifying cocaine intoxication, and how it may exacerbate cocaine-induced cardiovascular disorders. Most cardiac-related risk assessment tools do not ask about cocaine use, which can prevent clinicians from making optimal therapeutic choices. Greater awareness of cocaethylene is needed for clinicians, and those who use cocaine should also be aware of the potential for polysubstance use of cocaine and ethanol to produce a potentially potent and long-lasting psychoactive metabolite.

Vices-paradox in trauma: Positive alcohol and drug screens associated with decreased mortality

BACKGROUND

Improved survival in trauma patients with acute alcohol intoxication has been previously reported. The effect of illegal and controlled substances on mortality is less clear. We hypothesized that alcohol, illegal and controlled substances are each independently associated with lower odds of mortality in adult trauma patients.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients screening positive for alcohol, illegal or controlled substances on admission. A multivariate logistic regression analysis was used to determine odds of mortality. A similar analysis was used after stratification by injury severity scale (ISS).

RESULTS

From 1,299,705 adult patients, 660,135 were screened for substance use. Of these patients, 497,872 were male, 227,995 (34.5 %) screened positive for alcohol, 155,437 (23.5 %) for illegal substances and 90,259 (13.7 %) for controlled substances. Mortality rate was 6.2 % with alcohol, 5.1 % with illegal substances, and 5.7 % with controlled substances compared to 8.0 % with no substance use (p < 0.001). After controlling for covariates, all groups had lower odds of mortality: alcohol (OR = 0.88, CI = 0.84-0.92, p < 0.001), illegal substances (OR = 0.83, CI = 0.77-0.90, p < 0.001), controlled substances (OR = 0.72, CI = 0.67-0.79, p < 0.001). When stratified by ISS, alcohol and illegal substances continued to be associated with decreased mortality until ISS 50. Controlled substances were associated with decreased mortality when ISS > 16.

CONCLUSION

Patients positive for alcohol, illegal or controlled substances have 12 %, 17 %, and 28 % decreased odds of mortality, respectively. This paradoxical association should be confirmed with future clinical studies and merits basic science research to identify biochemical or physiological components conferring a protective effect on survival in trauma patients.

Drug use in Canadian patients with trauma after cannabis legalization

Background:

The federal Cannabis Act came into force on Oct. 17, 2018, in Canada, making Canada only the second country in the world to legalize the cultivation, acquisition, possession and consumption of cannabis and its by-products. This provided a unique opportunity to evaluate the impact of this legislation on drug-related trauma.

Methods:

We performed a prospective observational study on the use of cannabis and other illicit drugs in the trauma population at a lead Canadian trauma centre in London, Ontario, in the 3 months before (July 1 to Sept. 30, 2018) and 3 months after (Nov. 1, 2018, to Jan. 31, 2019) the legalization of cannabis in Canada. We defined cannabis use as a positive cannabinoid screen result at the time of assessment by the trauma team. We also screened for opioids, amphetamines and cocaine.

Results:

A total of 210 patients were assessed by our trauma service between July 1 and Sept. 30, 2018, and 141 patients were assessed between Nov. 1, 2018, and Jan. 31, 2019. Motor vehicle collisions were the most common cause of trauma both before (101 [48.1%]) and after (67 [47.5%]) legalization. The mean Injury Severity Score was 17.6 (standard deviation [SD] 13.0) and 19.7 (SD 14.8), respectively. Drug screens were done in 88 patients (41.9%) assessed before legalization and 99 patients (70.2%) assessed after legalization. There was no difference in the rate of positive cannabinoid screen results before and after legalization (22 [25%] v. 22 [22%]). There was a trend toward higher rates of positive cannabinoid screen results (2/10 [20%] v. 5/8 [62%]) and positive toxicology screen results (5/10 [50%] v. 6/8 [75%]) after legalization among patients with penetrating trauma, but our sample was too small to achieve statistical significance.

Conclusion:

We found no difference in the rates of positive cannabinoid screen results among patients assessed at our trauma centre in the 3 months before and the 3 months after legalization of cannabis; however, there was a trend toward an increase in the rates of positive results of toxicology screens and cannabinoid screens among those with penetrating trauma. These preliminary single-centre data showing no increased rates of cannabis use in patients with trauma after legalization are reassuring.

The Effect of Illegal Drug Screening Results and Chronic Drug Use on Perioperative Complications in Trauma

Context:

Illegal drug use and need for surgery are common in trauma. This allows examination of the effects of perioperative drug use.

Aim:

The aim was to study the effects of illegal drug use on perioperative complications in trauma.

Setting and Design:

Propensity-matched analysis of perioperative complications between drug screen-positive (DSP) and drug screen-negative (DSN) patients from the National Trauma Data Bank (NTDB).

Methods:

The NTDB reports drug screening as a composite. We compared complications for DSP, DSN, and specific chronic drug disorders. Time to first procedure was analyzed to determine whether delay to surgery was associated with reduced complications.

Statistics:

Logistic regression with 11 predictor variables was used to calculate propensity scores. Categorical and continuous variables were compared using Chi-square and Student’s t-test, respectively.

Results:

752,343 patients (21.9%) were tested for illegal drugs. DSP was protective for mortality-relative risk (RR) 0.84 (P < 0.001) and arrhythmia RR 0.87 (P = 0.02). All complications (AC) were higher for DSP with a RR of 1.08 (P < 0.001). Cocaine, cannabis, and opioids were associated with reduced mortality. Cocaine was associated with increased myocardial infarction (MI). All four chronic drug disorders were associated with markedly higher arrhythmia. All except cannabis were associated with higher AC. Mortality was significantly lower for DSP for every time interval until first procedure. Continuous-time until procedure was associated with increased MI and arrhythmia.

Conclusions:

DSP was protective of mortality and cardiac complications. Drug disorders were protective for mortality but increased arrhythmia and AC. Delay until the surgery does not diminish cardiac or overall risk.

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.

Current illicit drug use profile of orthopaedic trauma patients and its effect on hospital length of stay

INTRODUCTION

The purpose of this study was to investigate the prevalence of illicit drug use among patients admitted with traumatic orthopaedic injuries and to determine its effect on hospital length of stay (LOS). We hypothesized that patients with pre-injury drug use would have a longer hospital LOS compared to those who do not use drugs.

METHODS

We conducted a retrospective cohort study at our level 1 urban trauma center of patients admitted with traumatic orthopaedic injuries between 2013 and 2015 with urine toxicology screening. We collected demographic and hospital LOS data from chart review.

RESULTS

Of 611 patients, over half (55%) had a positive drug screen: marijuana (41%), amphetamine (19%), cocaine (7%), and/or PCP (2%). The highest incidence of drug use was in males under 19 years of age (81%). Patients with any drug use had a longer hospital LOS compared to those who did not use drugs (8.3 vs. 6.3 days; p = 0.03). Patients who used amphetamines had a longer hospital LOS than those patients who did not (9.5 vs. 6.9 days; p = 0.01).

CONCLUSION

Compared to the orthopaedic trauma population two decades ago, the current population using illicit drugs is younger (<30 years) with an increased preference for amphetamine and marijuana and a decreased preference for cocaine. Pre-injury drug use was associated with a longer hospital LOS in patients with a traumatic orthopaedic injury. Knowledge of the current trends in illicit drug use amongst orthopaedic trauma patients could facilitate medical decision-making regarding clinical care and optimizing resource utilization in this complex population of individuals.

Efficacy of Dronabinol for Acute Pain Management in Adults with Traumatic Injury: Study Protocol of A Randomized Controlled Trial

Delta-9-tetrahydrocannabinol (Δ⁹-THC) and other cannabinoids present in cannabis (marijuana) have been shown to affect the normal inhibitory pathways that influence nociception in humans. The potential benefits of cannabinoids as an analgesic are likely greatest in hyperalgesic and inflammatory states, suggesting a role as a therapeutic agent for treating acute pain following injury. Dronabinol is a licensed form of Δ⁹-THC. The primary objective of this single center randomized controlled trial is to evaluate the efficacy of adjunctive dronabinol versus control (systemic analgesics only, no dronabinol) for reducing opioid consumption in adults with traumatic injury. Study inclusion is based on high baseline utilization of opioids ≥50 morphine equivalents (mg) within 24 h of admission for adults aged 18-65 years with traumatic injury. There is a 48-hour screening period followed by a 48-hour treatment period after randomization. A total of 122 patients will be randomized 1:1 across 2 study arms: adjunctive dronabinol versus control (standard of care using systemic analgesics, no adjunctive dronabinol). Patients randomized to the dronabinol arm should receive their first dose within 12 h of randomization, with a dose range of 5 mg up to 30 mg daily in divided doses, in addition to systemic analgesics as needed for pain. The primary efficacy endpoint is a change in opioid consumption (morphine equivalents), assessed post-randomization (48 h after randomization) minus pre-randomization (24 h prior to randomization). This is the first randomized trial to investigate whether adjunctive dronabinol is effective in reducing opioid consumption in acute pain management of traumatic injury. Trial Registration: ClinicalTrials.gov Identifier: NCT03928015.

Trends and Disparities in Inpatient Costs for Eye Trauma in the United States (2001-2014)

PURPOSE

To determine the trends and disparities in inpatient costs for eye trauma in the United States from 2001 through 2014.

DESIGN

Retrospective population-based cross-sectional study.

METHODS

National Inpatient Sample, a representative sample of U.S. hospital discharges, was used to determine costs of eye trauma hospitalizations. Linear regression was used to estimate changes in mean inflation-adjusted cost per admission. Multivariable logistic regression was used to evaluate factors associated with a cost in the highest quartile (>$13 000) including age, sex, race, income quartile, primary payer, hospital location, size, and type. The model was adjusted for year of admission, length of stay, type of trauma, comorbidities, and the type and number of procedures performed.

RESULTS

The inpatient costs for eye trauma from 2001 through 2014 totaled $1.72 billion. The mean cost (95% confidence interval [CI]) per stay remained relatively constant: $12 000 ($11 000-13 000) in 2001 to $11 000 ($10 000-12 000) in 2014 (P = .643). A cost in the highest quartile was more likely in African Americans compared to whites (adjusted odds ratio, 1.3; 95% CI, 1.2-1.5), patients in the highest income quartile compared to those in the lowest (1.3; 1.2-1.5), uninsured patients compared to publicly insured patients (1.2; 1.1-1.4), teaching hospitals compared to non-teaching ones (1.5; 1.2-1.8), and the West compared to the South (2.4; 2.0-2.8).

CONCLUSIONS

Inpatient costs of eye trauma have remained steady and can be potentially reduced by addressing associated disparities. Further research including outpatient costs and eye trauma in vulnerable populations will be key to optimizing care and advancing healthcare equity.

Patient-Reported Outcome Measures and Patient Activation: What Are Their Roles in Orthopedic Trauma?

The rise of patient-reported outcome (PRO) measurement across medicine has been swift and now extends to the world of orthopedic trauma. However, PRO measures (PROMs) applied to trauma patients pose special considerations; measuring "episodes of care" is less straightforward, injuries are heterogeneous in their severity, and the patient's initial visit is "postinjury." Obtaining baseline scores and assessing the impact of a traumatic event on mental health are key considerations. Currently, few, if any, trauma registries include PROs; though general and condition-specific PROMs plus the patient empowerment measure of Patient Activation represent meaningful inputs for the clinical decision-making process. To be useful in trauma care, PROMs should be psychometrically sound and validated, be used for capturing function, screen for mental state and substance use, and give the clinician a sense of the patient's "activation" (engagement in their own health). Although the implementation of routine PRO collection can seem daunting, clinicians can use a multitude of electronic resources to access validated measures and simplify the implementation process. Computer-adaptive testing has evolved to help minimize patient burden, and PROM collection must maximize efficiency. Once established as part of your practice, PROs become an important tool to track recovery, identify mental health issues, engage in the prevention of future injury, and enable care of the whole patient.

Examining the influence of blood alcohol level on the incidence of pneumonia & sepsis complications following traumatic injury

BACKGROUND

The purpose of this study was to examine the impact of blood alcohol concentration (BAC) on the occurrence of pneumonia and sepsis among traumatic injury victims.

METHODS

Retrospective study data were retrieved from the 2007-2010 National Trauma Data Bank and included all patients ≥14 years of age, with a "blunt" or "penetrating" injury, who were taken to a level 1 or level 2 trauma center, had complete systolic blood pressure and heart rate records, and had a confirmed blood alcohol test at the time of hospital arrival. Patients' characteristics and outcome information were compared between two groups (those with a BAC above the legal limit [>0.08 g/dL] and those with a negative BAC result), followed by propensity score matching and a follow-up paired analysis.

RESULTS

Of 279,460 patients, 92,960 tested positive for alcohol with a BAC above the legal limit. There were clear demographic differences between the groups (p < 0.001). Therefore, propensity score matching was performed to better balance the groups and the resulting standardized mean differences of less than 10% indicated successful matching. When comparing the occurrence of both pneumonia and sepsis between the matched pairs, there was a statistically significantly higher rate of pneumonia in the alcohol positive patients, 8.0% vs. 7.3%, (p = 0.03), but no significant clinical difference. Additionally, no significant difference was observed for the rate of sepsis across the groups (p = 0.62).

CONCLUSION

Patients who tested positive for alcohol following a traumatic injury showed a statistically higher incidence of pneumonia, but there was no clinically significant difference. Additionally, there was no significant difference identified in the incidence of sepsis between the BAC groups.

The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury

Background

Widespread legislative efforts to legalize marijuana have increased the prevalence of marijuana use and abuse. The effects of marijuana on pain tolerance and analgesic pain management in the acute pain setting have not been reported. Although marijuana has been shown to have antinociceptive effects and is approved for medical use to treat chronic pain, anecdotal evidence suggests marijuana users admitted with traumatic injuries experience poorer pain control than patients who do not use marijuana. We hypothesized that marijuana users would report higher pain scores and require more opioid analgesia following traumatic injury.

Methods

This retrospective pilot study included all patients involved in motor vehicle crashes, consecutively admitted to four trauma centers from 1/1/2016–4/30/2016. Marijuana status was examined as non-use and use, and was further categorized as chronic and episodic use. We performed a repeated measures mixed model to examine the association between marijuana use and a) average daily opioid consumption and b) average daily pain scores (scale 0–10). Opioid analgesics were converted to be equianalgesic to 1 mg IV hydromorphone.

Results

Marijuana use was reported in 21% (54/261), of which 30% reported chronic use (16/54). Marijuana use was reported more frequently in Colorado hospitals (23–29%) compared to the hospital in Texas (6%). Drug use with other prescription/street drugs was reported in 9% of patients. Other drug use was a significant effect modifier and results were presented after stratification by drug use. After adjustment, marijuana users who did not use other drugs consumed significantly more opioids (7.6 mg vs. 5.6 mg, p <  0.001) and reported higher pain scores (4.9 vs. 4.2, p <  0.001) than non-marijuana users. Conversely, in patients who used other drugs, there were no differences in opioid consumption (5.6 mg vs. 6.1 mg, p = 0.70) or pain scores (5.3 vs. 6.0, p = 0.07) with marijuana use compared to non-use, after adjustment. Chronic marijuana use was associated with significantly higher opioid consumption compared to episodic marijuana use in concomitant drug users (11.3 mg vs. 4.4 mg, p = 0.008) but was similar in non-drug users (p = 0.41).

Conclusion

These preliminary data suggest that marijuana use, especially chronic use, may affect pain response to injury by requiring greater use of opioid analgesia. These results were less pronounced in patients who used other drugs.

Preexisting psychiatric illness worsens acute care outcomes after orthopaedic trauma in obese patients

PURPOSE

Pre-existing psychiatric illness, illicit drug use, and alcohol abuse adversely impact patients with orthopaedic trauma injuries. Obesity is an independent factor associated with poorer clinical outcomes and discharge disposition, and higher hospital resource use. It is not known whether interactions exist between pre-existing illness, illicit drug use and obesity on acute trauma care outcomes.

PATIENTS AND METHODS

This cohort study is from orthopaedic trauma patients prospectively measured over 10 years (N = 6353). Psychiatric illness, illicit drug use and alcohol were classified by presence or absence. Body mass index (BMI) was analyzed as both a continuous and categorical measure (<30 kg/m² [non-obese], 30-39.9 kg/m² [obese] and ≥40 kg/m² [morbidly obese]). Main outcomes were the number of acute care services provided, length of stay (LOS), discharge home, hospital readmissions, and mortality in the hospital.

RESULTS

Statistically significant BMI by pre-existing condition (psychiatric illness, illicit drug use) interactions existed for LOS and number of acute care services provided (β values 0.012-0.098; all p < 0.05). The interaction between BMI and psychiatric illness was statistically significant for discharge to locations other than home (β = 0.023; p = 0.001).

DISCUSSION

Obese patients with orthopaedic trauma, particularly with preexisting mental health conditions, will require more hospital resources and longer care than patients without psychiatric illness. Early identification of these patients through screening for psychiatric illness and history of illicit drug use at admission is imperative to mobilize the resources and provide psychosocial support to facilitate the recovery trajectory of affected obese patients.

Outcomes after traumatic injury in patients with preexisting psychiatric illness

BACKGROUND

Patients with psychiatric illness have been shown to experience higher rates of traumatic injury. Injury patterns, treatment decisions, and outcomes have not been well characterized in patients with psychiatric illness after injury, in particular those who undergo acute surgical intervention. The purpose of this analysis was to determine mortality, complications, and surgical intervention rates in patients with psychiatric illness after traumatic injury.

METHODS

This is a retrospective study of trauma patients ≥18 years old admitted to LAC + USC Medical Center between January 2008 and March 2015. Patients with psychiatric diagnoses were identified using ICD-9 diagnosis codes. Multivariate logistic regression analyses taking into account demographic and injury characteristics were used to identify associations between psychiatric comorbidity, injury mechanism, surgical interventions, and outcomes in patients after injury.

RESULTS

A total of 26,502 patients were analyzed. Of these, 3,040 (11.5%) had a documented psychiatric comorbidity (2.0% depressive disorder, 0.8% bipolar disorder, 1.3% schizophrenia, 0.5% anxiety disorder, 3.2% substance use disorder). Patients with psychiatric illness were significantly older (49.6 years vs. 42.0 years, p < 0.001), had a lower proportion of penetrating injuries (13.8% vs. 18.1%, p < 0.001), and had a higher incidence of self-inflicted injuries (11.6% vs. 0.72%, p < 0.001). No difference in gender distribution was observed (74.2% men vs. 74.4% men, p = 0.80). Overall mortality was similar in both groups (adjusted odds ratio [aOR], 0.73; p = 0.07). Patients with psychiatric illness were significantly less likely to undergo acute surgical intervention within 6 hours of emergency department admission (aOR, 0.64; p < 0.001). Time from ED arrival to consent for acute surgical intervention was similar in both groups (94.8 min vs. 93.0 min, p = 0.84). No significant difference in mortality after acute surgical intervention was observed (aOR, 0.26; p = 0.10). Psychiatric illness was associated with a significantly higher likelihood of developing complications (aOR, 1.90; p < 0.001) and longer hospital lengths of stay (10.6 days vs. 6.2 days, p < 0.001).

CONCLUSIONS

Trauma patients with comorbid psychiatric illness were observed to have lower rates of acute surgical interventions, higher complication rates, and longer hospital lengths of stay. Further studies are needed to better characterize the causative factors underlying these associations.

LEVEL OF EVIDENCE

Epidemiological, level III.

Outcomes for older trauma patients in the emergency department screening positive for alcohol, cocaine, or marijuana use

BACKGROUND

Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients.

OBJECTIVES

To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older.

METHODS

This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80 mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens.

RESULTS

21 320 patients were included in the alcohol analysis and 17 077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p < 0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative.

CONCLUSION

Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.

Alcohol-related road traffic injuries in Al-Ain City, United Arab Emirates

OBJECTIVE

We aimed to prospectively study the demography, severity of injury and outcome of alcohol-related road traffic collision (RTC) injuries in the United Arab Emirates.

METHODS

Data of RTC Registry of Al-Ain City were prospectively collected from Al-Ain and Tawam hospitals during the period of April 2006 to October 2007. It included all RTC trauma patients who were admitted or those who died after arrival to these hospitals. Car occupants with complete data on alcohol use were included in the study. Patients were divided into two groups, those who reported using alcohol and those who did not.

RESULTS

Out of the 771 car occupants, sixteen (16) used alcohol (2.1%), 15 (94%) of them were males. The median (range) age of the alcohol group was significantly higher than those without alcohol (35 (15-53) years compared with 26 (1-78) years, p = 0.02). The UAE nationals were significantly more (P = 0.01) and the revised trauma score was significantly less in the alcohol group (P = 0.03). Head/face was the most commonly injured region in the alcohol group (94%).

CONCLUSION

Self reported alcohol-related car collisions in Al-Ain City had a low incidence. It affected older Emirati male nationals and was associated with lower revised trauma score, mainly due to head injury. There is a need for a national registry with data on alcohol abuse so as to assess its effects and strategies for its prevention.

Age and gender differences in substance screening may underestimate injury severity: a study of 9793 patients at level 1 trauma center from 2006 to 2010

BACKGROUND

Although the relationship between psychoactive substance use and injury is known, evidence remains conflicting on the impact of substance use on clinical outcomes after injury. We hypothesized that preinjury substance use would negatively impact clinical outcomes.

METHODS

National Trauma Registry American College of Surgeons identified patients (n = 9793) presenting to Duke Hospital from 2006 to 2010. Logistic regression models assessed potential predictors of receiving substance screening, mortality, length of stay, ventilator requirement, intensive care admission, or emergency department disposition.

RESULTS

Forty-seven percent (4607/9793) of patients received blood alcohol screen (BAS) and 31% (3017/9793) received urine drug screen (UDS). Men were more likely to receive both BASs (P < 0.001) and UDSs (P = 0.001) than women after controlling for potential confounders. There was no significant difference between men and women over the legal limit for alcohol (OLLA; 27.2%, 95% confidence interval [CI]: 25.7%-28.8% versus 24.8%, 95% CI: 22.3%-27.5%). Similarly, younger patients more likely received both BASs (P < 0.001) and UDSs (P < 0.001) compared with older patients. The proportion of patients aged ≤45 y OLLA (26.5 %, 95% CI: 24.9%-28.2%) was similar to those aged >45 y OLLA (26.8%, 95% CI: 24.5%-29.3%). After controlling for potential confounders neither alcohol, nor tetrahydrocannabinol, nor cocaine was predictive of mortality, ventilator requirement, length of stay, or emergency department disposition, but a higher alcohol level (P = 0.0174) predicted intensive care admission.

CONCLUSIONS

Females and those aged >45 y are less likely to receive BASs and UDSs. Differential screening that is biased may place patients at risk for receiving inadequate care.

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.

Penetrating trauma in urban women: patterns of injury and violence

BACKGROUND

Penetrating trauma is known to occur with less frequency in women than in men, and this difference has resulted in a lack of characterization of penetrating injury patterns involving women. We hypothesized that the nature of penetrating injury differs significantly by gender and that these injuries in women are associated with important psychosocial and environmental factors.

MATERIALS AND METHODS

A level 1 urban trauma center registry was queried for all patients with penetrating injuries from 2002-2010. Patient and injury variables (demographics and mechanism of injury) were abstracted and compared between genders; additional social and psychiatric histories and perpetrator information were collected from the records of admitted female patients.

RESULTS

Injured women were more likely to be Caucasian, suffer stab wounds instead of gunshot wounds, and present with a higher blood alcohol level than men. Compared with women with gunshot wounds, those with stab wounds were three times more likely to report a psychiatric or intimate partner violence history. Women with self-inflicted injuries had a significantly greater incidence of prior penetrating injury and psychiatric and criminal history. Male perpetrators outnumbered female perpetrators; patients frequently not only knew their perpetrator but also were their intimate partners. Intimate partner violence and random cross-fire incidents each accounted for about a quarter of injuries observed.

CONCLUSIONS

Penetrating injuries in women represent a nonnegligible subset of injuries seen in urban trauma centers. Psychiatric and social risk factors for violence play important roles in these cases, particularly when self-infliction is suspected. Resources allocated for urban violence prevention should proportionately reflect the particular patterns of violence observed in injured women.

Brief intervention and social work: a primer for practice and policy

Most individuals in need of help for alcohol use disorders do not receive care. Screening and brief intervention (SBI) is an evidence-based practice for reducing at-risk drinking and alcohol-related risk behaviors. Health care reform sets the stage for a large expansion of SBI to individuals in the United States. Social workers have the opportunity to play an important role in helping establish SBI nationally, but they must become more involved in its delivery, educating new social workers with respect to SBI practice, and taking part in research to expand the field's knowledge of this service.

The impact of alcohol in pedestrian trauma

Across the globe, alcohol plays a major role in traffic-related injuries. It impairs the motor and cognitive coordination of drivers leading to motor vehicle collisions, which severely or fatally injure individuals across cultures and socioeconomic spectra. Although most public health initiatives have focused on driver intoxication, there is a high prevalence of alcohol use among pedestrians who are struck by motor vehicles, especially in collisions involving pedestrian fatalities. Alcohol use by pedestrians impairs judgment and coordination leading to risky street-crossing behaviors. Intoxication influences medical management by disrupting the reliability of the physical examination often necessitating expensive imaging modalities to rule out injuries. Alcohol abuse continues to impede traffic safety injury prevention efforts. This article reviews alcohol’s notorious role in traffic safety and pedestrian trauma.

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.

Acute ethanol gavage attenuates hemorrhage/resuscitation-induced hepatic oxidative stress in rats

Acute ethanol intoxication increases the production of reactive oxygen species (ROS). Hemorrhagic shock with subsequent resuscitation (H/R) also induces ROS resulting in cellular and hepatic damage in vivo. We examined the role of acute ethanol intoxication upon oxidative stress and subsequent hepatic cell death after H/R. 14 h before H/R, rats were gavaged with single dose of ethanol or saline (5 g/kg, EtOH and ctrl; H/R_EtOH or H/R_ctrl, resp.). Then, rats were hemorrhaged to a mean arterial blood pressure of 30 ± 2 mmHg for 60 min and resuscitated. Two control groups underwent surgical procedures without H/R (sham_ctrl and sham_EtOH, resp.). Liver tissues were harvested at 2, 24, and 72 h after resuscitation. EtOH-gavage induced histological picture of acute fatty liver. Hepatic oxidative (4-hydroxynonenal, 4-HNE) and nitrosative (3-nitrotyrosine, 3-NT) stress were significantly reduced in EtOH-gavaged rats compared to controls after H/R. Proapoptotic caspase-8 and Bax expressions were markedly diminished in EtOH-gavaged animals compared with controls 2 h after resuscitation. EtOH-gavage increased antiapoptotic Bcl-2 gene expression compared with controls 2 h after resuscitation. iNOS protein expression increased following H/R but was attenuated in EtOH-gavaged animals after H/R. Taken together, the data suggest that acute EtOH-gavage may attenuate H/R-induced oxidative stress thereby reducing cellular injury in rat liver.