A comparison of alcohol-positive and alcohol-negative trauma patients

Cocaine use in trauma: the vices-paradox revisited

BACKGROUND

The "vices-paradox" describes the paradoxical association between illicit substance use and decreased mortality risk in trauma patients. Cocaine's vasoconstrictive effects may decrease hemorrhage but also increase the risk of thromboembolic complications. To clarify the effects of cocaine use on trauma patients, we compared the risk of mortality and thromboembolic complications in patients screening positive for cocaine with those screening negative.

METHODS

We searched the Trauma Quality Improvement Program database to identify patients 18 years and over who had presented with a drug and alcohol screen on admission between 2017 and 2019. After excluding all patients who had tested positive for alcohol and substances other than cocaine, we then compared the clinical outcomes of patients who were positive and negative for cocaine use.

RESULTS

Of the 312,553 patients identified, 11,942 (3.82%) had tested positive for cocaine. Cocaine users were significantly more likely to present with stab (8.0% vs 3.1%) or gunshot wounds (8.0% vs 3.0%) but had lower rates of mortality (3.6% vs 4.7%), myocardial infarction (0.1% vs 0.2%,) and cerebrovascular accident (0.3% vs 0.4%,). After controlling for covariates, the risk of death, myocardial infarction, and cerebrovascular accident did not significantly differ between cocaine and non-cocaine users.

CONCLUSION

Trauma patients positive for cocaine have similar risks of death and thromboembolic complications and so have a similar prognosis to patients negative for all drugs or alcohol, indicating that the "vices-paradox" does not apply to cocaine use. However, these patients more commonly present after penetrating trauma, suggesting cocaine use in hazardous environments.

The impact of alcohol use and withdrawal on trauma outcomes: A case control study

INTRODUCTION

Many patients admitted to hospitals with acute trauma have positive serum blood alcohol levels. Published associations between alcohol use, injury patterns, and outcomes are inconsistent. We sought to further delineate the impact of alcohol use and alcohol withdrawal on hospital outcomes amongst acute trauma patients.

METHODS

We performed a retrospective analysis of adult trauma patients hospitalized at a suburban level 1 trauma center between January 2015 and September 2019 with a blood alcohol level measurement and/or classification as alcohol withdrawal syndrome (AWS). Patients were separated into three groups: BAL ≤10 mg/dL, BAL >10 mg/dL, and alcohol withdrawal syndrome (AWS).

RESULTS

Overall, 3896 patients met study criteria with 75.6% BAL ≤10, 23.2% BAL >10, and 1.2% AWS. The median age was significantly different (BAL ≤ 10: 59 years, BAL > 10: 44 years, AWS: 53.5 years). Alcohol withdrawal was experienced by patients with BAL ≤10 and BAL >10. While injury severity and mortality were similar across all 3 groups, AWS patients experienced significantly longer hospital and ICU lengths of stay, unplanned ICU admission, need for mechanical ventilation, and higher rates of complications. Patients with AWS had high rates of acute neuropsychiatric symptoms, complicating their management.

CONCLUSIONS

Except for mortality, AWS patients experienced worse outcomes. The complex nature of alcohol withdrawal cases, including the possibility of developing AWS despite a negative BAL on admission, emphasizes the need for early assessment for alcohol withdrawal risk factors and input from specialists.

Mechanisms of change in drinking following an alcohol-related injury: A qualitative examination of the sentinel event effect

Sentinel events are negative health-related events that trigger change in risky health behaviors. Despite its presumed major role in behavior change, the sentinel event effect has received little empirical attention. Through analysis of qualitative interviews, we explored how sentinel events trigger behavior change. Methods: Thematic analysis and concept mapping were used to develop a preliminary model of the sentinel event effect among a sample of 24 adult heavy drinking Mexican-origin men previously admitted to a hospital due to injury. The model was checked against cases that did versus did not report change in alcohol use following an alcohol-related negative event. Results: Findings suggest that sentinel events may arouse negative emotional reactions, encourage reflection on the negative consequences of drinking, and cause reevaluation of the severity and significance of drinking. These processes may increase motivation to change. Conclusions: Findings support the concept of the sentinel event as a natural intervention, and identifies potential social-cognitive and motivational mechanisms through which it influences change. Findings stand to inform research on mechanisms underlying brief intervention effects, and research that seeks to identify treatment targets.

Decreased incidence of venous thromboembolism found in trauma patients with positive blood alcohol concentration on admission

BACKGROUND

The reported incidence of venous thromboembolism (VTE) disease in trauma is 1-58% and is considered a preventable cause of mortality. Positive blood alcohol concentration (BAC) is found in 8-45% of trauma admissions; however, its association with VTE is controversial.

OBJECTIVES

We hypothesized that a positive BAC on admission would be associated with a lower rate of VTE in a large national database of trauma patients.

METHODS

We queried the largest United States trauma registry, National Trauma Data Bank (2007-2015), for any patient with positive BAC on admission. The primary outcome was VTE and the secondary outcome was mortality. A multivariable logistic regression model was used for analysis.

RESULTS

From 2,725,032 patients (70.1% male, 29.9% female), 1,800,216 (66.1%) had a negative BAC while 924,816 (33.9%) had a positive BAC. A positive BAC was associated with lower rates of VTE (OR = 0.88, CI = 0.86-0.90, p < 0.001) and mortality (OR = 0.91, CI = 0.90-0.93, p < 0.001).

CONCLUSION

In a large national database, trauma patients with a positive BAC were associated with a lower rate of VTE compared to those with negative BAC. Additionally, trauma patients with positive BAC had a lower association with mortality. These findings remained after adjustment of well-known risk factors for VTE and mortality, respectively.

The impact of alcohol-related admissions on resource use in critically ill patients from 2009 to 2015: an observational study

Excessive alcohol use is associated with increased health care utilisation and increased mortality. This observational study sought to identify the proportion of patients admitted with a critical illness in which alcohol misuse contributed, and to examine the resource use for this group. We performed an observational retrospective database review of all admissions to the Alice Springs Hospital intensive care unit (ICU) between 1 January 2009 and 31 December 2015. The Alice Springs Hospital ICU is a ten-bed unit located in Central Australia, with approximately 600 admissions annually. The per capita consumption of alcohol in Central Australia is approximately 1.5 times the national average. The primary aim was to determine the proportion of admissions to intensive care in which alcohol misuse was identified as a contributing cause. Secondary aims examined resource utilisation including ICU and hospital length of stay, need for and duration of mechanical ventilation, and ICU re-admission. There were 3,768 admissions involving 2,670 individual patients. Of these admissions 947 (25%) were associated with alcohol misuse. Admissions associated with alcohol were significantly more likely to require mechanical ventilation (30% versus 20%, <i>P</i> <0.01), and had a significantly longer ICU length of stay (2.1 versus 1.9 days, <i>P</i> <0.05). The proportion of admissions in which alcohol misuse was implicated is amongst the highest in the published literature. The results of this study should drive further policy change directed at harm minimisation, and warrant more detailed epidemiological work at both a local and national level.

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.

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.

Alcohol use by urban bicyclists is associated with more severe injury, greater hospital resource use, and higher mortality

Alcohol use is a risk factor for severe injury in pedestrians struck by motor vehicles. Our objective was to investigate alcohol use by bicyclists and its effects on riding behaviors, medical management, injury severity, and mortality within a congested urban setting. A hospital-based, observational study of injured bicyclists presenting to a Level I regional trauma center in New York City was conducted. Data were collected prospectively from 2012 to 2014 by interviewing all bicyclists presenting within 24 h of injury and supplemented with medical record review. Variables included demographic characteristics, scene-related data, Glasgow Coma Scale (GCS), computed tomography (CT) scans, and clinical outcomes. Alcohol use at the time of injury was determined by history or blood alcohol level (BAL) >0.01 g/dL. Of 689 bicyclists, 585 (84.9%) were male with a mean age of 35.2. One hundred four (15.1%) bicyclists had consumed alcohol prior to injury. Alcohol use was inversely associated with helmet use (16.5% [9.9-25.1] vs. 43.2% [39.1-47.3]). Alcohol-consuming bicyclists were more likely to fall from their bicycles (42.0% [32.2-52.3] vs. 24.2% [20.8-27.9]) and less likely to be injured by collision with a motor vehicle (52.0% [41.7-62.1] vs. 67.5% [63.5-71.3]). 80% of alcohol-consuming bicyclists underwent CT imaging at presentation compared with 51.5% of non-users. Mortality was higher among injured bicyclists who had used alcohol (2.9% [0.6-8.2] vs. 0.0% [0.0-0.6]). Adjusted multivariable analysis revealed that alcohol use was independently associated with more severe injury (Adjusted Odds Ratio 2.27, p = 0.001, 95% Confidence Interval 1.40-3.68). Within a dense urban environment, alcohol use by bicyclists was associated with more severe injury, greater hospital resource use, and higher mortality. As bicycling continues to increase in popularity internationally, it is important to heighten awareness about the risks and consequences of bicycling while under the influence of alcohol.

Use of Out-of-Hospital Ethanol Administration to Improve Outcome in Mass Methanol Outbreaks

STUDY OBJECTIVE

Methanol poisoning outbreaks are a global public health issue, with delayed treatment causing poor outcomes. Out-of-hospital ethanol administration may improve outcome, but the difficulty of conducting research in outbreaks has meant that its effects have never been assessed. We study the effect of out-of-hospital ethanol in patients treated during a methanol outbreak in the Czech Republic between 2012 and 2014.

METHODS

This was an observational case-series study of 100 hospitalized patients with confirmed methanol poisoning. Out-of-hospital ethanol as a "first aid antidote" was administered by paramedic or medical staff before the confirmation of diagnosis to 30 patients; 70 patients did not receive out-of-hospital ethanol from the staff (12 patients self-administered ethanol shortly before presentation).

RESULTS

The state of consciousness at first contact with paramedic or medical staff, delay to admission, and serum methanol concentration were similar among groups. The median serum ethanol level on admission in the patients with out-of-hospital administration by paramedic or medical staff was 84.3 mg/dL (interquartile range 32.7 to 129.5 mg/dL). No patients with positive serum ethanol level on admission died compared with 21 with negative serum ethanol level (0% versus 36.2%). Patients receiving out-of-hospital ethanol survived without visual and central nervous system sequelae more often than those not receiving it (90.5% versus 19.0%). A positive association was present between out-of-hospital ethanol administration by paramedic or medical staff, serum ethanol concentration on admission, and both total survival and survival without sequelae of poisoning.

CONCLUSION

We found a positive association between out-of-hospital ethanol administration and improved clinical outcome. During mass methanol outbreaks, conscious adults with suspected poisoning should be considered for administration of out-of-hospital ethanol to reduce morbidity and mortality.

Alcohol exposure, injury, and death in trauma patients

BACKGROUND

The association of alcohol use with in-hospital trauma deaths remains unclear. This study identifies the association of blood alcohol content (BAC) with in-hospital death accounting for injury severity and mechanism.

METHODS

This study involves a historical cohort of 46,222 admissions to a statewide trauma center between January 1, 2002, and October 31, 2011. Blood alcohol was evaluated as an ordinal variable: 1 mg/dL to 100 mg/dL as moderate blood alcohol, 101 mg/dL to 230 mg/dL as high blood alcohol, and greater than 230 mg/dL as very high blood alcohol.

RESULTS

Blood alcohol was recorded in 44,502 patients (96.3%). Moderate blood alcohol was associated with an increased odds for both penetrating mechanism (odds ratio [OR], 2.22; 95% confidence interval [CI], 2.04-2.42) and severe injury (OR, 1.25; 95% CI, 1.16-1.35). Very high blood alcohol had a decreased odds for penetrating mechanism (OR, 0.75; 95% CI, 0.67-0.85) compared with the undetectable blood alcohol group. An inverse U-shaped association was shown for severe injury and penetrating mechanism by alcohol group (p < 0.001). Moderate blood alcohol had an increased odds for in-hospital death (OR, 1.50; 95% CI, 1.25-1.79), and the odds decreased for very high blood alcohol (OR, 0.69; 95% CI, 0.54-0.87). An inverse U-shaped association was also shown for in-hospital death by alcohol group (p < 0.001). Model discrimination for in-hospital death had an area under the receiver operating characteristic curve of 0.64 (95% CI, 0.63-0.65).

CONCLUSION

Injury severity and mechanism are strong intermediate outcomes between alcohol and death. Severe injury itself carried the greatest odds for death, and with the moderate BAC group at greatest odds for severe injury and the very high BAC group at the lowest odds for severe injury. The result was a similar inverse-U shaped curve for odds for in-hospital death. Clear associations between blood alcohol and in-hospital death cannot be analyzed without consideration for the different injuries by blood alcohol groups.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Complications associated with blood alcohol concentration following injury

Alcohol increases the risk of injuring oneself and others. However, following an injury there appears to be a benefit to alcohol in mediating the body's response to a traumatic injury and reducing mortality. The physiological mechanism underlying this reported association is poorly understood. One approach to explaining the pathways by which alcohol affects acute mortality following a traumatic injury is to identify differential prevalence of medical complications associated with increased mortality. The goal of this study was to evaluate the association between blood alcohol concentration and complications subsequent to a traumatic injury that are associated with increased in-hospital mortality. This study involved a retrospective analysis of traumatic injuries occurring between 2000 and 2009 as reported by all level I and II trauma units in the state of Illinois. The study includes all patients with blood alcohol toxicological examination levels ranging from zero to 500 mg/dL and meeting additional inclusion criteria (n = 84,974). A reduction in complications of cardiac and renal function by 23.5% and 30.0%, respectively, was attributable to blood alcohol concentration. In addition, blood alcohol concentration was associated with fewer cases of pneumothorax and convulsions. However, blood alcohol concentration continued to be positively associated with aspiration pneumonitis and acute pancreatitis in the final models. The net impact of alcohol following an injury is protective, largely attributable to a reduction in complications relating to cardiac and renal function. This study helps to explain the observed protective effect from blood alcohol concentrations in reducing in-hospital mortality after an injury, as reported in many studies.

Injury-related consequences of alcohol misuse among injured patients who received screening and brief intervention for alcohol: a latent class analysis

BACKGROUND

Screening and brief alcohol intervention has demonstrated efficacy in improving drinking and other risk behaviors for some patient populations. However, it is not clear that brief interventions are helpful to all injured patients who drink at risk levels. This paper identifies latent classes of intervention recipients based on injury-related consequences and risks of alcohol misuse and then determines which profiles experienced the greatest improvements in drinking.

METHODS

A secondary analysis was conducted using data from injured patients (N = 737) who reported heavy drinking and received a brief alcohol intervention in a Level I trauma center. Latent class analysis was used to determine patient profiles, and 7 indicators commonly associated with alcohol-related injury from the Short Inventory of Problems+6 were used to determine the latent class measurement model. Covariates were regressed onto the model to assess factors related to class membership, and drinking outcomes were analyzed to examine improvements in drinking.

RESULTS

Five classes emerged from the data. The classes that reported the greatest improvements in drinking following discharge were those characterized by multiple alcohol-related risks and those characterized by a history of alcohol-related accidents and injuries. Attributing the current injury to drinking was a significant predictor of class membership among those classes that reported higher levels of improvement.

CONCLUSIONS

This study provides tentative evidence that subclasses exist among heavy drinking injured patients who received a brief intervention in a Level I trauma center, and some subclasses experience greater drinking improvements than others. Further research is required to substantiate the findings of this secondary analysis.

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.

Alcohol and trauma--in every age group

BACKGROUND

The purpose was to determine the proportion of alcohol-positive (AlcPos) trauma patients in different age groups and any association with mortality using the National Trauma Data Bank.

METHODS

Several variables were extracted from the National Trauma Data Bank (version 6.2) using MS Access 2007: age, alcohol presence, Injury Severity Score (ISS), and discharge status (alive vs dead). Age groups for logistic regression were arbitrarily defined as follows: 0 to 10, 11 to 20, 21 to 39, 40 to 64, and older than 64 years.

RESULTS

Approximately 47% of all trauma survivors were tested for alcohol (621,174 of a total of 1,311,137), and 28% of those were AlcPos (176,107/621,174). The proportion of AlcPos patients gradually increased to maximum at 22 years, when 46% (6797/14,732) tested were AlcPos. The proportion AlcPos gradually declined to 35% by age 50 years, then to 15% (2516/16,244) by age 66 to 70 years. The ISSs were significantly higher in AlcPos patients in all age groups (P < .01). Mortality rates were higher in AlcPos children (up to age 20 years) and in adults older than 40 years. The AlcPos patients who were 21 to 39 years old had lower mortality compared with alcohol-negative patients. Logistic regression analysis (controlling for ISSs) revealed that being AlcPos did not play a role in mortality until age 21 to 39 years (AlcPos lower mortality) and in age 40 to 64 years and older than 65 years (AlcPos higher mortality).

CONCLUSIONS

Trauma patients of all ages may be AlcPos. Being AlcPos is a marker for greater injury in all age groups. After controlling for ISSs, trauma patients 40 years and older who were AlcPos have increased mortality. This study suggests a role for alcohol testing in all age groups.

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.

Dose-response relationship between in-hospital mortality and alcohol following acute injury

Although the relationship between alcohol and injury incidence is well researched, there continues to be dispute about the relationship between alcohol and mortality following an injury. Findings from past studies have varied primarily because of methodological issues and have failed to characterize the dose-response relationship. The main objective of this study was to evaluate the dose response relationship of in-hospital mortality and blood alcohol concentration (BAC). This study was a retrospective analysis of traumatic injuries occurring between 1995 and 2009 as reported by all level 1 and 2 trauma units in the State of Illinois. The study includes all patients with blood alcohol toxicological examination levels ranging from zero to 500 mg/dl (N = 190,612). The Illinois trauma registry includes all patients sustaining traumatic injuries and admitted to a trauma center for ≥12 h. A total of 6733 patients meeting the inclusion criteria died following admission. Patients that were dead on arrival and those that died during the initial assessment within the emergency room were excluded. In the adjusted multivariable model, a decrease in in-hospital mortality was strongly associated with an increase in blood alcohol concentration (adjusted OR = 0.83 per 100 mg/dl units change in BAC; CI 95%: 0.80, 0.85; p < 0.001). The direction of the dose response relationship was consistent across the stratified models, with the exception of patients suffering burns. The largest reduction of in-hospital case fatality rates by blood alcohol concentration was observed among patients suffering penetrating or severe injuries (Injury Severity Score ≥ 16). In the clinical setting, it is important to understand not only how to recognize intoxicated patients, but also how alcohol may affect the course of treatment. The consistency of the findings across the multivariable models indicates that blood alcohol concentration is strongly associated with lower in-hospital mortality among those that survive long enough to receive treatment in specialized trauma units.

Alcohol intoxication in road traffic accidents leads to higher impact speed difference, higher ISS and MAIS, and higher preclinical mortality

Alcohol is one of the most important personal risk factors for serious and fatal injuries, contributing to approximately one third of all deaths from accidents. It is also described that alcohol intoxication leads to a higher mortality in the clinical course. In this study, we hypothesized that alcohol intoxication leads to different accident kinematics, a higher ISS (Injury Severity Score), and higher preclinical mortality compared to sober patients. A technical and medical investigation of alcohol intoxicated road users was performed on the scene of the crash and at the primary admitting hospital. Alcohol testing was performed with either breath alcohol tests or measurement of blood alcohol concentration (BAC) in a standard laboratory test. Between 1999 and 2010, 37,635 road traffic accidents were evaluated by the Accident Research Unit. Overall 20,741 patients were injured, 2.3% of the patients were killed. Among the injured patients, 2.2% with negative BAC were killed, compared to 4.6% fatal injuries in patients with a positive BAC (p < 0.0001). Of the patients with a positive BAC, 8.0% were severely injured, compared to 3.6% in the BAC negative group (p < 0.0001). Regarding the relative speed at impact (Δv for motorized drivers, vehicle collision speed for pedestrians and bikers), there was a significant higher difference for BAC positive patients (30 ± 20) compared to the BAC negative patients (25 ± 19, p < 0.0001). Alcohol intoxication in trauma patients leads to higher preclinical mortality, higher impact speed difference, and higher injury severity. The subgroup analysis for different alcohol concentrations shows no difference in ISS, MAIS, and relative speed, but a correlation of increasing age of patients with higher alcohol concentrations.

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.

Alcohol and the head-injured patient

Alcohol intoxication is a major predisposing factor for trauma in general and head injury in particular. The management of the head-injured patient is highly contingent on the accurate assessment of this patient’s consciousness, which is invariably impaired if the patient is intoxicated. This complicates the decision-making process and impedes the promptness needed in management when the head injury is severe. Furthermore, the prognosis of the head injury can depend on the patient’s degree and pattern of intoxication. This article presents some of the latest epidemiological data about the association of alcohol and head injury. It also highlights some of the challenges posed by alcohol intoxication in the management of head-injured patients, and examines the importance of documenting intoxication in head-injured patients.

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

Background

Alcohol and drug use is known to be a major factor affecting the incidence of traumatic injury. However, the ways in which immediate pre-injury substance use affects patients' clinical care and outcomes remains unclear. The goal of the present study is to determine the associations between pre-injury use of alcohol or drugs and patient injury severity, hospital course, and clinical outcome.

Materials and methods

This study used more than 200,000 records from the National Trauma Data Bank (NTDB), which is the largest trauma registry in the United States. Incidents in the NTDB were placed into one of four classes: alcohol related, drug related, alcohol-and-drug related, and substance negative. Logistic regression models were used to determine comorbid conditions or treatment complications that were significantly associated with pre-injury substance use. Hospital charges were associated with the presence or absence of drugs and alcohol, and patient outcomes were assessed using discharge disposition as delimited by the NTDB.

Results

The rates of complications arising during treatment were 8.3, 10.9, 9.9 and 8.6 per one hundred incidents in the alcohol related, drug related, alcohol-and-drug related, and substance-negative classes, respectively. Regression models suggested that pre-injury alcohol use is associated with a 15% higher risk of infection, whereas pre-injury drug use is associated with a 30% higher risk of infection. Pre-injury substance use did not appear to significantly impact clinical outcomes following treatment for traumatic injury, however.

Conclusion

This study suggests that pre-injury drug use is associated with a significantly higher complication rate. In particular, infection during hospitalization is a significant risk for both alcohol and drug related trauma visits, and drug-related trauma incidents are associated with increased risk for additional circulatory complications. Although drug and alcohol related trauma incidents are not associated with appreciably worse clinical outcomes, patients experiencing such complications are associated with significantly greater length of stay and higher hospitalization costs. Therefore significant benefits to trauma patients could be gained with enhanced surveillance for pre-injury substance use upon admission to the ED, and closer monitoring for infection or circulatory complications during their period of hospitalization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Alcohol-use disorders in the critically ill patient

Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs. This review discusses the development and progression of critical illness in patients with AUDs. In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies. In particular, surgical patients with AUDs experience higher rates of postoperative hemorrhage, cardiac complications, sepsis, and need for repeat surgery. Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes. AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis. The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome. The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs. Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.

Elevated Blood Alcohol Level May be Protective of Trauma Patient Mortality

To determine whether a positive blood alcohol level (BAL) affects morbidity and mortality at a Level I trauma center, a retrospective review of trauma patients 18 years of age and older was performed. There were 7985 trauma patients and 8 per cent (645) had a positive BAL. BAL(+) patients had lower Injury Severity Score (ISS) (8 vs 11, P < 0.01), lower rate of penetrating injury (9 vs 25%, P < 0.01), and were older (38 vs 32 years, P = 0.01). Overall there were 559 deaths (7%); (1% mortality in BAL(+) patients and 7% in BAL(-) patients; P < 0.0001). There were 352 (4.4%) complications with similar rates among BAL(-) and (+) patients. On univariate analysis, a positive BAL was inversely associated with death (OR, 0.17) as was blunt trauma (OR, 0.29), whereas older age (OR 1.009) and increased ISS (OR 1.13) were associated with death. On multivariable analysis, after adjusting for age, ISS, and mechanism of injury, a positive BAL remained protective against death (OR 0.35) as did blunt trauma (OR 0.2). Age (OR 1.04) and increased ISS (OR 1.19) were associated with mortality. In conclusion, a positive BAL was associated with a decreased mortality risk in trauma patients, which persisted after adjusting for multiple confounding variables.

The implications of alcohol intoxication and the Uniform Policy Provision Law on trauma centers; a national trauma data bank analysis of minimally injured patients

BACKGROUND

Alcohol intoxication may confound the initial assessment of trauma patients, resulting in increased use of diagnostic and therapeutic procedures, thereby increasing hospital costs. The Uniform Policy Provision Law (UPPL) exists in many states and allows insurance companies to deny payment for medical treatment for alcohol-related injuries. If intoxication increases resource utilization, these denials compound the financial burden of alcohol use on trauma centers. We hypothesized that patients injured while under the influence of alcohol require more diagnostic tests, procedures, and hospital admissions, leading to higher hospital charges.

METHODS

The National Trauma Databank (2000-2004) was analyzed to identify adult trauma patients (age > or = 16 years) who were discharged alive, had a length of stay < or = 1 day and minor injuries (Injury Severity Score < 9), and were tested for blood alcohol. The study was confined to minimally injured patients to facilitate identification of unexpected resource use most likely attributable to alcohol use. Resource utilization was compared among patients who tested positive or negative for alcohol use. Results are presented as odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

Sixty-eight thousand eight patients met study criteria, of which 31,020 were positive for alcohol. Despite similar baseline characteristics, alcohol-positive patients required significantly more invasive procedures, including intubation (OR 4.16, 95% CI = 3.56-4.85) and Foley catheter insertion (OR 1.52, 95% CI = 1.39-1.67) as well as diagnostic tests (CT scan OR 1.16, 95% CI = 1.12-1.20). They were also less likely to be discharged from the emergency department (OR 0.61, 95% CI = 0.58-0.64), and more frequently required hospital (OR 1.64, 95% CI = 1.57-1.73) or intensive care unit admission (OR 1.82, 95% CI = 1.71-1.94). Mean hospital charges were $1,833 greater ($10,405 +/- 225 vs. 8,572 +/- 68).

CONCLUSIONS

A significant amount of trauma center costs are primarily attributable to alcohol use rather than injury severity or outcome. The financial costs associated with alcohol use and UPPL-related cost-shifting to trauma centers is a significant burden to trauma centers. UPPL laws that penalize trauma centers for identifying intoxicated patients should be repealed in states where they exist.

Characterizing the teachable moment: is an emergency department visit a teachable moment for intervention among assault-injured youth and their parents?

OBJECTIVES

Injury interventions often invoke the teachable moment (TM); however, there is scant empirical research examining this construct with violent injuries. We sought to operationalize the TM construct and to determine whether an emergency department (ED) visit was a TM for intervention among assault-injured adolescents and their parents.

SETTING AND PARTICIPANTS

One hundred sixty-eight youth (age, 10-15 years) and their parents presenting to the ED with interpersonal assault injuries at 2 urban medical centers.

METHODS AND ANALYSIS

Data were collected using ED record abstraction and interviews. Interview questions assessed perceived injury severity, perceived susceptibility, and preventability/ability to avoid future conflict. Data were examined by age, sex, weapon involvement, and time elapsed between injury and interview. Factor analysis was used to identify the components of the TM construct, and a TM index was created for youth and parents.

RESULTS

Youth and parents found their trip to the ED moderately stressful, although parents perceived more stress than youth. Older youth (13-15 years old) and the parents of younger youth (10-12 years old) were most likely to see their injuries as preventable. The parent TM index was positively correlated with parent-reported aggression (r = 0.16, P < 0.03); the youth's TM index scores were associated with the time elapsed since the event (r = -0.16, P = 0.03).

CONCLUSIONS

This study provides preliminary support for the TM after assault injuries. The TM index may be a first step toward an assessment that can differentiate individuals who are amenable to violence prevention intervention from those who are not.

Alcohol use disorders increase the risk for mechanical ventilation in medical patients

BACKGROUND

Annually, more than 300,000 patients receive mechanical ventilation in an intensive care unit in the United States. The hospital mortality for ventilated patients may approach 50%, depending on the primary diagnosis. In trauma and surgical patients, a diagnosis of alcohol use disorder (AUD) is common and is associated with a prolonged duration of mechanical ventilation. The objective of this study is to determine whether the presence of AUD and the development of alcohol withdrawal are associated with an increased use and duration of mechanical ventilation in patients with medical disorders that commonly require intensive care unit admission.

METHODS

We performed a retrospective cohort study using the Nationwide Inpatient Sample, a large all-payer inpatient database representing approximately 1,000 hospitals. For the years 2002 to 2003, adult patients with 1 of the 6 most common diagnoses associated with medical intensive care unit admission were included in the study. Both univariate analysis and multivariable logistic regression were performed to determine whether AUD and alcohol withdrawal were independently associated with the use and duration of mechanical ventilation in these patients.

RESULTS

There were a total 785,602 patients who fulfilled 1 of the 6 diagnoses, 26,577 (3.4%) had AUD, 3,967 (0.5%) had alcohol withdrawal, and 65,071 (8.3%) underwent mechanical ventilation (53% <96 hours, 47%> or =96 hours). Independent of the medical diagnosis, AUD was associated with an increased risk of requiring mechanical ventilation (13.7 vs 8.1%, odds ratio=1.49, 95% confidence interval [1.414; 1.574], p<0.0001) but was not associated with a prolonged duration of mechanical ventilation. However, the presence of alcohol withdrawal was associated with a longer duration of mechanical ventilation (57 vs 47%> or =96 hours, odds ratio=1.48, 95% confidence interval [1.266; 1.724], p<0.0001).

CONCLUSIONS

In patients with medical diagnoses associated with intensive care unit admission, AUD increases the risk for mechanical ventilation while the development of alcohol withdrawal is associated with a longer duration of mechanical ventilation.

Increased incidence of complications in trauma patients cointoxicated with alcohol and other drugs

BACKGROUND

Alcohol and drug intoxication is prevalent in trauma patients. Although intoxication and cointoxication can have a range of physiologic effects, their implications for clinical management are unclear. The current investigation aims to assess the effects of alcohol and substance use as well as the interaction between these two states on outcomes and in-hospital complications.

METHODS

All trauma patients with an Injury Severity Score (ISS) >or=12 during a 5-year period who were tested for both alcohol and other drugs were included. Alcohol-positive, drug-positive, and both-positive patients were compared with patients who tested negative. Logistic regression analysis was performed controlling for age and ISS to assess the relative contribution of intoxication or cointoxication in determining clinical outcomes and in-hospital complications.

RESULTS

For alcohol-positive and drug-positive patients, intoxication status did not appear to influence outcomes. However, cointoxicated individuals were found to have an increased incidence of complications overall (odds ratio [OR] = 2.06), an increased incidence of pneumonia specifically (OR = 3.34) and an increased incidence of the requirement for mechanical ventilation (OR = 2.37).

CONCLUSIONS

Cointoxication with alcohol and other drugs is a risk factor for increased in-hospital complications.

Alcohol abuse in the critically ill patient

Alcohol abuse and dependence disorders are common in the 10% of hospitalised patients who need admission to the intensive care unit (ICU), but these disorders are often undiagnosed. The systemic effects from the excessive use of alcohol increase susceptibility to, or directly cause various important disorders in the critically ill. Early recognition of alcohol abuse and dependence is necessary and should prompt consideration of several alcohol-specific diagnoses that have important prognostic and therapeutic implications for these patients. We discuss the use of screening tests to improve the identification of alcohol abuse and dependence disorders, the epidemiology and pathogenesis of important alcohol-related disorders, differences in the presentation of several common alcohol-related diagnoses in the ICU, and important alcohol-specific therapies.

Substance Use and Abuse in Trauma: Implications for Care

Trauma long has been associated with substance use and abuse. Caring for trauma patients who are intoxicated, withdrawing, or otherwise experiencing the negative outcomes of their substance use is difficult under the best of circumstances. The burden of this association can be described in many terms, from economic consequences, to health outcomes, to personal problems. Evidence indicates that untreated substance-associated trauma carries with it extended hospital stays, diminished quality of life, repeat emergency department use, and significant mortality and morbidity. No matter how one examines the burden of the association between substance use and trauma, one is left with the awareness that nurses can improve patient care through better screening, assessment, intervention, an evaluation. Because of the complex nature of the association between substance use and trauma, nursing care for these patients is difficult. Fig. 1 provides an overview of the factors to consider when planning care for these patients. Nurses need to focus on issues of temporality, directionality, and correlates of care as they plan for the needs of their patients. Only with careful considerations of these factors can the nurse clarify the confounding clinical presentation of the trauma overlaid on substance use. Evidence supports the need for all trauma patients to be screened for substance use and for those who have positive screens to receive early intervention. Although there is almost universal awarenes of the of the association between substance use and trauma and of the value of screening, screening rates for trauma patients are surprisingly low. Screening for substance use followed by BMI intervention is cost effective and should be implemented routinely. The high prevalence of substance-associated trauma, coupled with the heterogeneous nature of that association, warrants more study, particularly nursing research, to determine best-care practices. More research is needed to increase the understanding of patterns of use, etiologic models, and effective clinical care strategies. The need for this research is heightened by the awareness that substance-associated trauma is preventable, and the risk is modifiable. Nurses, everyday, are faced with the daunting challenge of meeting the health needs of trauma patients who have associated substance use. More research is needed to help nurses separate out the confounding health needs of these complex patients. That work has begun, and it assuredly will continue to support the need for high-quality nursing interventions to improve the health of trauma patients.

Aspectos da interconsulta psiquiátrica em hospital de trauma

Os autores se propõem a abordar os aspectos particulares da interconsulta psiquiátrica em um hospital de trauma. Para isso, revisam os aspectos gerais de uma interconsulta em um hospital geral, e, posteriormente, destacam as características que diferenciam a consultoria psiquiátrica em um hospital de trauma. Os eventos psiquiátricos mais relevantes no trauma são as tentativas de suicídio violentas, o abuso de substâncias e as reações psíquicas ao traumatismo. O ponto de destaque se refere à especificidade da relação entre trauma e doenças psiquiátricas: ambos podem ser causa ou conseqüência. A interconsulta psiquiátrica é um novo campo de atuação interdisciplinar e de produção científica para a psiquiatria.

The identification of high-cost patients

The authors examine whether retrospective claims data are useful to distinguish future high-cost cases among the uninsured. They rely on internal claims and accounting data for the calendar years from 1999 to 2001 from a representative safety net facility to describe the distribution of costs and any characteristics that distinguish high-cost patients from other uninsured patients. They conclude that administrative data combined with in-depth survey information could be a useful approach for identifying cases for intensive case management.

Out-of-hospital endotracheal intubation and outcome after traumatic brain injury

STUDY OBJECTIVE

Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury.

METHODS

From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage).

RESULTS

There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52).

CONCLUSION

Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.