Traumatic brain injury in patients screened for blood alcohol concentration based on the mechanism of injury

Implementation of mandatory blood alcohol screening in trauma patients: A retrospective study from a tertiary trauma center in a Middle Eastern country

BACKGROUND

Alcohol consumption is a significant risk factor for several types of injuries and trauma recidivism and remains an important public health concern worldwide. We aimed to describe the implementation of mandatory alcohol screening and the AUDIT tool among trauma patients admitted to a level 1 trauma center in a country with a partial ban on alcohol consumption.

METHODS

This was a retrospective analysis of trauma patients (>12 years old) who required hospital admission and underwent blood alcohol concentration (BAC) screening between 2014 and 2019. This was achieved via an enzymatic method using alcohol dehydrogenase for ethanol detection in the plasma and serum samples. Trauma patients with a BAC <2.2 mmol/L were referred to as "negative", and BAC >2.2 mmol/L was referred to as "BAC positive". A comparative analysis was performed between the two BAC groups. Alcohol Screening, Brief Intervention, Referral for Treatment [ASBIRT] program, and AUDIT were applied.

RESULTS

A total of 7326 BAC screening tests were performed on 7284 patients during the study period. With slight variation over the years, the compliance rate was 77% (70.4%-85.3%), and the test positivity rate was 10% (8.6%-12.5%). There were 42 repeated admissions, of which seven patients were BAC positive at every admission. Young age and non-Arab patients were more likely to test positive, and the main mechanism of injury (MOI) was road traffic-related trauma (p < 0.05). Assault and self-inflicted injuries were significantly higher in BAC-positive patients than in BAC-negative patients (18% vs. 4% and 2.7% vs. 1.3%, respectively; p = 0.001). The injury severity score (ISS) and mortality rate were comparable between the study groups. Patients with a positive BAC were significantly more likely to undergo pan-CT scan in the emergency department, intubation, and exploratory laparotomy than those with a negative BAC. In patients who sustained injuries due to assault, all-terrain vehicles, or motorcycle crashes, there was a significant association between the positivity of BAC tests and the patient's ISS.

CONCLUSION

Despite improvements in BAC screening in trauma admissions over the years, almost 20% of cases were missed. Although the mortality rates were comparable, alcohol consumption burdens resources in terms of excess imaging, intubation, open abdominal surgery, and possible disability. Further studies are needed to understand the key obstacles and challenges to achieving optimum compliance for screening in trauma settings.

Alcohol is not associated with increased mortality in adolescent traumatic brain injury patients

PURPOSE

Compared to adults, there is a paucity of data regarding the association of a positive alcohol screen (PAS) and outcomes in adolescent patients with traumatic brain injury (TBI). We hypothesize adolescent TBI patients with a PAS on admission to have increased mortality compared to patients with a negative alcohol screen.

METHODS

The 2017 Trauma Quality Improvement Program database was queried for patients aged 13-17 years presenting with a TBI and serum alcohol screen. Patients with missing information regarding midline shift on imaging and Glasgow Coma Scale (GCS) score were excluded. A multivariable logistic regression analysis for mortality was performed.

RESULTS

From 2553 adolescent TBI patients with an alcohol screen, 220 (8.6%) had a PAS. Median injury severity scores and rates of penetrating trauma (all p > 0.05) were similar between alcohol positive and negative patients. Patients with a PAS had a similar mortality rate (13.2% vs. 12.1%, p = 0.64) compared to patients with a negative screen. Multivariate logistic regression controlling for risk factors associated with mortality revealed a PAS to confer a similar risk of mortality compared to alcohol negative patients (p = 0.40).

CONCLUSION

Adolescent TBI patients with a PAS had similar associated risk of mortality compared to patients with a negative alcohol screen.

Rotterdam and Marshall Scores for Prediction of in-hospital Mortality in Patients with Traumatic Brain Injury: An observational study

Background: We aimed to assess the prognostic value of Rotterdam and Marshall scoring systems to predict in-hospital mortality in patients with traumatic brain injury (TBI).Methods: A retrospective analysis was conducted for patients with TBI who underwent head computerized tomography (CT) scan at a Level I trauma center between 2011 and 2018. Receiver operating characteristic (ROC) curves were used to determine the cutoff values for predicting in-hospital mortality.Results: A total of 1035 patients with TBI were included with a mean age of 30 years. The mean Rotterdam and Marshall scores were higher among non-survivors (p = .001). Patients with higher Rotterdam (>3) or Marshall (>2) CT scores were older, had higher injury severity scores and in-hospital mortality and had lower GCS and blood ethanol levels than those with lower scores. The cutoff point of Rotterdam score was 3.5 (sensitivity, 61.2%; specificity, 85.6%) and Marshall score was 2.5 (74.3% sensitivity and 76.3% specificity). Multivariable logistic regression analyses showed that Marshall and Rotterdam scoring systems were independent predictors of mortality (odds ratio 8.4; 95% confidence interval 4.95-14.17 and odds ratio 4.4; 95% confidence interval 2.36-9.39, respectively).Conclusion: Rotterdam and Marshall CT scores have independent prognostic values in patients with TBI even in alcoholic patients.

Dentate Gyrus Proliferative Responses After Traumatic Brain Injury and Binge Alcohol in Adult Rats

BACKGROUND

Traumatic brain injury is a significant public health issue that results in serious disability in survivors. Traumatic brain injury patients are often intoxicated with alcohol when admitted to the hospital; however, it is not clear how acute intoxication affects recovery from a traumatic brain injury. Our group has previously shown that binge alcohol prior to traumatic brain injury resulted in long-term impairment in a fine sensorimotor task that was correlated with a decreased proliferative and neuroblast response from the subventricular zone. However, whether binge alcohol prior to traumatic brain injury affects the proliferative response in the hippocampal dentate gyrus is not yet known.

METHODS

Male rats underwent binge alcohol (3 g/kg/day) by gastric gavage for 3 days prior to traumatic brain injury. Cell proliferation was labeled by BrdU injections following traumatic brain injury. Stereological quantification and immunofluorescence confocal analysis of BrdU+ cells in the hippocampal dorsal dentate gyrus was performed at 24 hours, 1 week and 6 weeks post traumatic brain injury.

RESULTS

We found that either traumatic brain injury alone or binge alcohol alone significantly increased dentate gyrus proliferation at 24 hours and 1 week. However, a combined binge alcohol and traumatic brain injury regimen resulted in decreased dentate gyrus proliferation at 24 hours post-traumatic brain injury. At the 6 week time point, binge alcohol overall reduced the number of BrdU+ cells. Furthermore, more BrdU+ cells were found in the dentate hilar region of alcohol traumatic brain injury compared to vehicle traumatic brain injury groups. The location and double-labeling of these mismigrated BrdU+ cells was consistent with hilar ectopic granule cells.

CONCLUSION

The results from this study showed that pre-traumatic brain injury binge alcohol impacts the injury-induced proliferative response in the dentate gyrus in the short-term and may affect the distribution of newly generated cells in the dentate gyrus in the long-term.

Updating the risk profile of fatal head trauma: an autopsy study with focus on age- and sex-dependent differences

Fatal head trauma (FHT) represents one of the most frequent causes of death diagnosed in forensic pathology. However, profound statistic autopsy data on FHT is still sparse. Therefore, the purpose of this study was to investigate the circumstances and injury patterns of FHT with particular focus on age and sex, and additionally, to describe a recent risk profile of FHT. To this end, the forensic autopsy records of each FHT case at a large German university hospital during a 10-year period (2006-2015) were analyzed retrospectively (n = 372). The male-female ratio was 2.6:1. Regarding median age, females were 12.5 years older than males. Traffic-associated FHT represents the major mechanism of death, followed by fall-associated FHT. While accident was the major manner of death and presented a similar distribution of age and sex, homicides were the only subgroup with a significantly lower ratio between males and females. Skull fractures occurred in 78.2% and intracranial hemorrhages in 80.6% of all cases. In summary and partly in contrast to clinical data on head trauma, FHT still occurs predominantly in male individuals under the age of 45 years, in the context of traffic accidents and affected by alcohol intake. Improvements in traffic security as well as continuing surveillance of the incidence of FHT by forensic autopsies are necessary to further reduce the incidence of FHT.