Blood alcohol concentration and management of road trauma patients in the emergency department

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A 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.

Frequency of Alcohol Use Among Injured Adult Patients Presenting to a Ghanaian Emergency Department

STUDY OBJECTIVE

Injuries are the cause of almost 6 million deaths annually worldwide, with 15% to 20% alcohol associated. The frequency of alcohol-associated injury varies among countries and is unknown in Ghana. We determined the frequency of positive alcohol test results among injured adults in a Ghanaian emergency department (ED).

METHODS

This is a cross-sectional chart review of consecutive injured patients aged 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within 8 hours of injury. Patients were tested for presence of alcohol with a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death before admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals were calculated.

RESULTS

Injured adult patients (2,488) presented to the ED from November 2014 to April 2015, with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95% confidence interval 32% to 38%) tested alcohol positive. Forty-two percent of men (320/756), 40% of subjects aged 25 to 44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assault victims (82/166), 40% of those seriously injured (124/311), and 53% of subjects who died in the ED (8/15) had positive results for presence of alcohol.

CONCLUSION

The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary care hospital ED. These findings have implications for health policy-, ED- and legislative-based interventions, and acute care.

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.

Acute alcohol intoxication-induced microvascular leakage

BACKGROUND

Alcohol intoxication can increase inflammation and worsen injury, yet the mechanisms involved are not clear. We investigated whether acute alcohol intoxication increases microvascular permeability and investigated potential signaling mechanisms in endothelial cells that may be involved.

METHODS

Conscious rats received a 2.5 g/kg alcohol bolus via gastric catheters to produce acute intoxication. Microvascular leakage of intravenously administered fluorescein isothiocyanate (FITC)-conjugated albumin (FITC-albumin) from the mesenteric microcirculation was assessed by intravital microscopy. Endothelial-specific mechanisms were studied using cultured endothelial cell monolayers. Transendothelial electrical resistance (TER) served as an index of barrier function, before and after treatment with alcohol or its metabolite acetaldehyde. Pharmacologic agents were used to test the roles of alcohol metabolism, oxidative stress, p38 mitogen-activated protein kinase (MAPK), myosin light-chain kinase (MLCK), rho kinase (ROCK), and exchange protein activated by cAMP (Epac). VE-cadherin localization was investigated to assess junctional integrity. Rac1 and RhoA activation was assessed by ELISA assays.

RESULTS

Alcohol significantly increased FITC-albumin extravasation from the mesenteric microcirculation. Alcohol also significantly decreased TER and disrupted VE-cadherin organization at junctions. Acetaldehyde significantly decreased TER, but inhibition of alcohol dehydrogenase or application of a superoxide dismutase mimetic failed to prevent alcohol-induced decreases in TER. Inhibition of p38 MAPK, but not MLCK or ROCK, significantly attenuated the alcohol-induced barrier dysfunction. Alcohol rapidly decreased GTP-bound Rac1 but not RhoA during the drop in TER. Activation of Epac increased TER, but did not prevent alcohol from decreasing TER. However, activation of Epac after initiation of alcohol-induced barrier dysfunction quickly resolved TER to baseline levels.

CONCLUSIONS

Our results suggest that alcohol intoxication increases microvascular permeability to plasma proteins. The data also suggest the endothelial-specific mechanism involves the p38 MAPK, Rac1, and reorganization of VE-cadherin at junctions. Last, activation of Epac can quickly resolve alcohol-induced endothelial barrier dysfunction.

Blood alcohol content, injury severity, and adult respiratory distress syndrome

BACKGROUND

Elevated blood alcohol content (BAC) is a risk factor for injury. Associations of BAC with adult respiratory distress syndrome (ARDS) have not been conclusively established.We evaluated the association of a BAC greater than 0 mg/dL with the intermediate outcomes, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score, and their association with ARDS development.

METHODS

This is an observational retrospective cohort study of 26,305 primary trauma admissions to a statewide referral trauma center from July 11, 2003, to October 31, 2011. Logistic regression was performed to assess the relationship between admission BAC, ISS, GCS score, and ARDS development within 5 days of admission.

RESULTS

The case rate for ARDS was 5.5% (1,447). BAC greater than 0 mg/dL was associated with ARDS development in adjusted analysis (odds ratio, 1.50; 95% confidence interval [CI], 1.33-1.71; p < 0.001). High ISS (≥16) had a stronger association with ARDS development (odds ratio, 17.99; 95% CI, 15.51-20.86), as did low GCS score (≤8) (odds ratio, 8.77; 95% CI, 7.64-10.07; p < 0.001). Patients with low GCS score and high ISS had the most frequent ARDS (33.6%) and the highest case-fatality rate without ARDS (24.7%).

CONCLUSION

Elevated BAC is associated with ARDS development. In the analysis of alcohol exposure, ISS and GCS score occur after alcohol ingestion, making them intermediate outcomes. ISS and GCS score were strong predictors of ARDS and may be useful to identify at-risk patients. Elevated BAC may increase the frequency of the ARDS through influence on injury severity or independent molecular mechanisms, which can be discriminated only in experimental models.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Angiotensin (1-7) contributes to nitric oxide tonic inhibition of vasopressin release during hemorrhagic shock in acute ethanol intoxicated rodents

AIMS

Acute ethanol intoxication (AEI) attenuates the arginine vasopressin (AVP) response to hemorrhage leading to impaired hemodynamic counter-regulation and accentuated hemodynamic stability. Previously we identified that the ethanol-induced impairment of circulating AVP concentrations in response to hemorrhage was the result of augmented central nitric oxide (NO) inhibition. The aim of the current study was to examine the mechanisms underlying ethanol-induced up-regulation of paraventricular nucleus (PVN) NO concentration. Angiotensin (ANG) (1-7) is an important mediator of NO production through activation of the Mas receptor. We hypothesized that Mas receptor inhibition would decrease central NO concentration and thus restore the rise in circulating AVP levels during hemorrhagic shock in AEI rats.

MAIN METHODS

Conscious male Sprague-Dawley rats (300-325 g) received a 15 h intra-gastric infusion of ethanol (2.5 g/kg+300 mg/kg/h) or dextrose prior to a fixed-pressure (~40 mm Hg) 60 min hemorrhage. The Mas receptor antagonist A-779 was injected through an intracerebroventricular (ICV) cannula 15 min prior to hemorrhage.

KEY FINDINGS

PVN NOS activity and NO were significantly higher in AEI compared to DEX-treated controls at the completion of hemorrhage. ICV A-779 administration decreased NOS activity and NO concentration, partially restoring the rise in circulating AVP level at completion of hemorrhage in AEI rats.

SIGNIFICANCE

These results suggest that Mas receptor activation contributes to the NO-mediated inhibitory tone of AVP release in the ethanol-intoxicated hemorrhaged host.

Alcohol abuse and the injured host: dysregulation of counterregulatory mechanisms review

Traumatic injury ranks as the number one cause of death for the younger than 44 years age group and fifth leading cause of death overall (www.nationaltraumainstitute.org/home/trauma_statistics.html). Although improved resuscitation of trauma patients has dramatically reduced immediate mortality from hemorrhagic shock, long-term morbidity and mortality continue to be unacceptably high during the postresuscitation period particularly as a result of impaired host immune responses to subsequent challenges such as surgery or infection. Acute alcohol intoxication (AAI) is a significant risk factor for traumatic injury, with intoxicating blood alcohol levels present in more than 40% of injured patients. Severity of trauma, hemorrhagic shock, and injury is higher in intoxicated individuals than that of sober victims, resulting in higher mortality rates in this patient population. Necessary invasive procedures (surgery, anesthesia) and subsequent challenges (infection) that intoxicated trauma victims are frequently subjected to are additional stresses to an already compromised inflammatory and neuroendocrine milieu and further contribute to their morbidity and mortality. Thus, dissecting the dynamic imbalance produced by AAI during trauma is of critical relevance for a significant proportion of injured victims. This review outlines how AAI at the time of hemorrhagic shock not only prevents adequate responses to fluid resuscitation but also impairs the ability of the host to overcome a secondary infection. Moreover, it discusses the neuroendocrine mechanisms underlying alcohol-induced hemodynamic dysregulation and its relevance to host defense restoration of homeostasis after injury.

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.

A public health enforcement initiative to combat underage drinking using Emergency Medical Services call data

OBJECTIVE

The objective of this study was to determine whether Emergency Medical Services (EMS) records can identify bars that serve a disproportionate number of minors, and if government officials will use this data to direct underage drinker enforcement efforts.

METHODS

Emergency Medical Services call logs to all bars in the study area were cross-referenced with a local hospital's records. The records of patients with alcohol-related complaints were analyzed. Outlier bars were identified, and presented to government officials who completed a survey to assess if this information would prompt new enforcement efforts.

RESULTS

Emergency Medical Services responded to 149 establishments during the study period. Eighty-four responses were distributed across six bars, and 78 were matched with the hospital's records. Fifty-one patients, 18 (35%) of whom were underage, were treated for alcohol intoxication, with 46% of the cases originating from four bars. Government officials found the information useful, and planned to initiate new operations based on the information.

CONCLUSIONS

Alcohol consumption by minors can lead to life-long abuse, with high personal, financial, and societal costs. Emergency Medical Services response data and hospital records can be used to identify bars that allow underage drinking, which is useful in directing law enforcement efforts.

Global burden of injuries attributable to alcohol consumption in 2004: a novel way of calculating the burden of injuries attributable to alcohol consumption

Background

Alcohol consumption is a major risk factor for injuries; however, international data on this burden are limited. This article presents new methods to quantify the burden of injuries attributable to alcohol consumption and quantifies the number of deaths, potential years of life lost (PYLL), and disability-adjusted life years (DALYs) lost from injuries attributable to alcohol consumption for 2004.

Methods

Data on drinking indicators were obtained from the Comparative Risk Assessment study. Data on mortality, PYLL, and DALYs for injuries were obtained from the World Health Organization. Alcohol-attributable fractions were calculated based on a new risk modeling methodology, which accounts for average and heavy drinking occasions. 95% confidence intervals (CIs) were calculated using a Monte Carlo simulation method.

Results

In 2004, 851,900 (95% CI: 419,400 to 1,282,500) deaths, 19,051,000 (95% CI: 9,767,000 to 28,243,000) PYLL, and 21,688,000 (95% CI: 11,097,000 to 32,385,000) DALYs for people 15 years and older were due to injuries attributable to alcohol consumption. With respect to the total number of deaths, harms to others were responsible for 15.1% of alcohol-attributable injury deaths, 14.5% of alcohol-attributable injury PYLL, and 11.35% of alcohol-attributable injury DALYs. The overall burden of injuries attributable to alcohol consumption corresponds to 17.3% of all injury deaths, 16.7% of all PYLL, and 13.6% of all DALYs caused by injuries, or 1.4% of all deaths, 2.0% of all PYLL, and 1.4% of all DALYs in 2004.

Conclusions

The novel methodology described in this article to calculate the burden of injuries attributable to alcohol consumption improves on previous methodology by more accurately calculating the burden of injuries attributable to one’s own drinking, and for the first time, calculates the burden of injuries attributable to the alcohol consumption of others. The burden of injuries attributable to alcohol consumption is large and is entirely avoidable, and policies and strategies to reduce it are recommended.

The relationship between alcohol consumption and fatal motor vehicle injury: high risk at low alcohol levels

BACKGROUND

Alcohol consumption causes motor vehicle accident (MVA) injury in a dose-response fashion. However, the relationship between how this risk is different with respect to fatal and nonfatal outcomes is not clear. A meta-analysis has already been completed for alcohol consumption and nonfatal MVA injury, but none exists for fatal injury. Thus, an analysis of the acute dose-response relationship between alcohol and motor vehicle injury death is warranted to generate single occasion- and dose-specific relative risks for the first time.

METHODS

A systematic literature review and inverse-variance weighted, random effects meta-analysis were conducted to fill this gap. Fractional polynomial regression was used to model the dose-response relationship. Usual tests of heterogeneity and publication bias were run.

RESULTS

Five studies meeting the inclusion criteria of this analysis were selected. At all levels of blood alcohol concentration (BAC), the odds ratio (OR) of fatal motor vehicle injury was significant. Overall, the 5 combined studies yielded an OR of fatal injury of 1.74 (95% CI: 1.43-2.14) for every 0.02% increase in BAC. At 0.08, the legal limit in most countries, the OR was 13.0 (95% CI: 11.1-15.2).

CONCLUSIONS

This study is able to definitively show and quantify, for the first time, the significantly increased OR for fatal motor vehicle injury. This analysis showed some evidence of both study heterogeneity and publication bias, likely due to the increased variation we could expect from a small study number. The alcohol-caused fatal motor vehicle injury literature is sparse with respect to dose-response information. More studies investigating this relationship and other injury types are recommended in this area to be able to calculate stable estimates of risk overall and by injury type specifically.

Augmented central nitric oxide production inhibits vasopressin release during hemorrhage in acute alcohol-intoxicated rodents

Acute alcohol intoxication (AAI) attenuates the AVP response to hemorrhage, contributing to impaired hemodynamic counter-regulation. This can be restored by central cholinergic stimulation, implicating disrupted signaling regulating AVP release. AVP is released in response to hemorrhage and hyperosmolality. Studies have demonstrated nitric oxide (NO) to play an inhibitory role on AVP release. AAI has been shown to increase NO content in the paraventricular nucleus. We hypothesized that the attenuated AVP response to hemorrhage during AAI is the result of increased central NO inhibition. In addition, we predicted that the increased NO tone during AAI would impair the AVP response to hyperosmolality. Conscious male Sprague-Dawley rats (300-325 g) received a 15-h intragastric infusion of alcohol (2.5 g/kg + 300 mg·kg(-1)·h(-1)) or dextrose prior to a 60-min fixed-pressure hemorrhage (∼40 mmHg) or 5% hypertonic saline infusion (0.05 ml·kg(-1)·min(-1)). AAI attenuated the AVP response to hemorrhage, which was associated with increased paraventricular NO content. In contrast, AAI did not impair the AVP response to hyperosmolality. This was accompanied by decreased paraventricular NO content. To confirm the role of NO in the alcohol-induced inhibition of AVP release during hemorrhage, the nitric oxide synthase inhibitor, nitro-l-arginine methyl ester (l-NAME; 250 μg/5 μl), was administered centrally prior to hemorrhage. l-NAME did not further increase AVP levels during hemorrhage in dextrose-treated animals; however, it restored the AVP response during AAI. These results indicate that AAI impairs the AVP response to hemorrhage, while not affecting the response to hyperosmolality. Furthermore, these data demonstrate that the attenuated AVP response to hemorrhage is the result of augmented central NO inhibition.

Factors associated with alcohol and drug use among traffic crash victims in southern Brazil

OBJECTIVE

To investigate the prevalence of and factors associated with alcohol- or drug-related traffic crashes (TC) in a sample of TC victims who were admitted to the two emergency rooms of Porto Alegre in southern Brazil.

METHODS

A cross-sectional study with consecutive samples was used. Victims of non-fatal TCs (as drivers, passengers or pedestrians) who had presented at emergency rooms during the 45 days of data collection were selected. Subjects participated in a structured interview, were breathalyzed and underwent salivary drug testing. A multinomial logistic regression model was used to verify factors associated with alcohol or drug use.

RESULTS

Of the 609 victims who participated in the interview, 72% were male, and the median age was 29 years (interquartile range 23.0-40.0 years). The drivers were mostly men (p<0.001), with a higher binge drinking rate (p=0.003) and marijuana use (p=0.005) than seen in pedestrian and passengers. The prevalence of a positive blood alcohol concentration (BAC) ranged from 7.8% among the drivers to 9.2% among the pedestrians (p=0.861), and the cannabis prevalence was 13.3% among the drivers. The variables associated with an alcohol-related accident were binge drinking in the prior 12 months (OR 2.4; CI 95% 1.1-5.1) and coming from a party/bar (OR 8.7; CI 95% 2.8-26.7). Alcohol abuse or dependence increased by 5.2-fold the chance of another substance-related TC.

CONCLUSION

The large number of individuals found in TC-related emergency room visits in a short time frame is evidence of the Brazilian epidemic of TC. The data showed that alcohol abuse or dependence also increases the risk of intoxication by other drugs, and they point to alcohol and drug use as a major problem requiring specific TC-related public policies and law enforcement.

Alcohol and multiple trauma: is there an influence on the outcome?

A relevant number of trauma patients are intoxicated with alcohol at admission in trauma centers. Meanwhile, some studies provide data suggesting a profound influence of ethanol on the posttraumatic clinical course; others could not confirm these findings. Knowledge of the influence of ethanol in a multiple trauma cohort is lacking. Therefore, we performed a retrospective outcome study of initially intoxicated multiple trauma patients in a German level-1 trauma center. Patients with an Injury Severity Score greater than or equal to 16 and aged 16-65 years were included in our study. Ventilation time, duration of intensive care unit treatment, the course of cytokines, and the incidence of systemic inflammatory response syndrome (SIRS), sepsis, and multiple organ dysfunction syndrome (MODS) were analyzed. Total in-patient time, mortality, and the requirement for blood products were evaluated. Logistic regression analyses were performed. Injury severity was comparable in both groups but there were more severe abdominal injuries in alcohol-intoxicated patients. The clinical course was comparable in both groups. Alcohol consumption was not an independent risk factor to sustain SIRS (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.59-1.70), sepsis (OR, 0.84; 95% CI, 0.54-1.31), or for mortality (OR, 1.08; 95% CI, 0.53-2.13). There was a trend toward an increased incidence of MODS in alcohol-intoxicated patients (OR, 2.74; 95% CI, 0.90-8.35). Blood alcohol level at the time of admission is not a valuable marker for worse or improved outcome in multiple trauma patients. There were no ethanol-related differences concerning overall injury severity; however, more severe abdominal injuries were found in alcohol-intoxicated patients. There was no increased risk for posttraumatic complications in primarily alcohol-intoxicated multiple trauma patients.

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.

The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together

Alcohol consumption causes injury in a dose-response manner. The most common mode of sustaining an alcohol-attributable injury is from a single occasion of acute alcohol consumption, but much of the injury literature employs usual consumption habits to assess risk instead. An analysis of the acute dose-response relationship between alcohol and injury is warranted to generate single occasion- and dose-specific relative risks. A systematic literature review and meta-analysis was conducted to fill this gap. Linear and best-fit first-order model were used to model the data. Usual tests of heterogeneity and publication bias were run. Separate meta-analyses were run for motor vehicle and non-motor vehicle injuries, as well as case-control and case-crossover studies. The risk of injury increases non-linearly with increasing alcohol consumption. For motor vehicle accidents, the odds ratio increases by 1.24 (95% CI: 1.18-1.31) per 10-g in pure alcohol increase to 52.0 (95% CI: 34.50-78.28) at 120 g. For non-motor vehicle injury, the OR increases by 1.30 (95% CI: 1.26-1.34) to an OR of 24.2 at 140 g (95% CI: 16.2-36.2). Case-crossover studies of non-MVA injury result in overall higher risks than case-control studies and the per-drink increase in odds of injury was highest for intentional injury, at 1.38 (95% CI: 1.22-1.55). Efforts to reduce drinking both on an individual level and a population level are important. No level of consumption is safe when driving and less than 2 drinks per occasion should be encouraged to reduce the risk of injury.

ALCOHOL AND VIOLENCE-RELATED INJURIES AMONG EMERGENCY ROOM PATIENTS IN AN INTERNATIONAL PERSPECTIVE

While alcohol has been found to be more closely associated with violence-related injury than with injury from other causes, little data is available which documents heterogeneity in this association across countries or cultures, taking into consideration usual drinking patterns and other socio-cultural variables. Data are reported from 15 countries comprising the Emergency Room Collaborative Alcohol Analysis Project and the WHO Collaborative Study on Alcohol and Injury. Case-crossover analysis was used to analyze the risk of injury (among current drinkers) from drinking six hours prior to the event, based on frequency of usual drinking, for violence-related injuries and separately for non-violence related injuries. Relative risk (RR) for a violence-related injury was significantly greater than for injuries from other causes across all countries (pooled RR=22.22 vs. 4.33), but the magnitude of risk varied considerably (ranging from 4.68 in Spain to 942 in Canada). Pooled effect size was found to be heterogeneous across countries, and was explained, in part, by the level of detrimental drinking pattern in a country. Risk for a violence-related injury was not significantly different by age (<30 and 30+), reporting 5 or more drinks on at least one occasion during the last year, or reporting symptoms of alcohol dependence. A number of methodological concerns suggest that risk of a violence-related injury compared to injuries from other causes may be inflated, and such variables as context of drinking should be taken into consideration in establishing relative risk and alcohol attributable fraction of violence-related injury across countries and cultures.

Prediction of blunt traumatic injury in high-acuity patients: bedside examination vs computed tomography

OBJECTIVE

The addition of spiral computed tomography (SCT) to bedside assessment in patients with major trauma may improve detection of significant injury. We hypothesized that in high-acuity trauma patients, emergency physicians' ability to detect significant injuries based solely on bedside assessment would lack the sensitivity needed to exclude serious injuries when compared with SCT.

METHODS

This was a prospective single-cohort study of high-acuity trauma patients routinely undergoing whole-body SCT at a level 1 trauma center from January to September 2006. Before SCT, emergency physicians assigned ratings for likelihood of injury to 5 body regions on the basis of bedside assessment. These ratings were compared with final SCT interpretations.

RESULTS

We enrolled 400 patients as a convenience sample; 71 were excluded. When a "very low" rating was considered negative and "low," "intermediate," "high," and "very high" were considered positive, emergency physicians were able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% confidence interval) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95% confidence interval) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively.

CONCLUSIONS

Bedside assessment by emergency physicians before SCT was sensitive in ruling out serious injuries in high-acuity trauma patients with a "very low" rating for injury. However, overall diagnostic accuracy was low, suggesting that SCT should be considered in most high-acuity patients to prevent missing injuries.

Can the blood alcohol concentration be a predictor for increased hospital complications in trauma patients involved in motor vehicle crashes?

The goal of this report is to assess the relationship of varying levels of blood alcohol concentration (BAC) and hospital complications in patients admitted after motor vehicle crashes. Data for the study was collected by a retrospective review of the University of Wisconsin Hospital trauma registry between 1999 and 2007 using the National Trauma Registry of the American College of Surgeons (NTRACS). Of 3729 patients, 2210 (59%) had a negative BAC, 338 (9%) <100 mg/dL, 538 (14%) 100-199 mg/dL, and 643 (17%) >200 mg/dL. Forty-six percent of patients had one or more hospital related complications. The odds ratio (OR) for the occurrence of alcohol withdrawal in the three alcohol groups compared to the no alcohol group was 12.02 (CI 7.0-20.7), 16.81 (CI 10.4-27.2), and 30.96 (CI 19.5-49.2) as BAC increased with a clear dose response effect. While there were no significant differences in the frequency of the total hospital events following trauma across the four groups, rates of infections, coagulopathies, central nervous system events and renal complications were lower in the high BAC group. Prospective studies are needed to more precisely estimate the frequency of hospital complications in patients with alcohol use disorders and in persons intoxicated at the time of the motor vehicle accident. The study supports the use of routine BAC to predict patients at high risk for alcohol withdrawal and the early initiation of alcohol detoxification.

Alcohol does not modulate the augmented acetylcholine-induced vasodilatory response in hemorrhaged rodents

Our previous studies have shown that acute alcohol intoxication (AAI) decreases blood pressure, exacerbates hypotension after hemorrhagic shock, impairs the pressor response to fluid resuscitation, and blunts neuroendocrine activation. We hypothesized that impaired hemodynamic compensation during and after hemorrhagic shock in the acute alcohol-intoxicated host is the result of blunted neuroendocrine activation or, alternatively, of an impaired vascular responsiveness to vasoactive agents. The aim of this study was to examine the effects of AAI, AAI and hemorrhagic shock, and AAI and hemorrhagic shock and resuscitation on reactivity of isolated blood vessel rings to phenylephrine and acetylcholine. Chronically instrumented, conscious male Sprague-Dawley rats (300-350 g) received a primed continuous 15-h intragastric alcohol infusion (2.5 g x kg(-1) + 300 mg x kg(-1) x h(-1)), and time-matched controls received an isocaloric-isovolumic dextrose infusion. At completion of infusions, animals were randomized to sham, 60-min fixed-pressure hemorrhage, or hemorrhagic shock followed by resuscitation with lactated Ringer's solution. At the completion of the experimental protocols, animals were killed, and thoracic aorta and mesenteric artery ring segments (1-2 mm) were prepared and studied in myograph baths. Acute alcohol intoxication did not produce significant alterations in either pressor or dilator responses in aortic or mesenteric rings. These findings suggest that impaired hemodynamic counterregulation during hemorrhagic shock in AAI is not due to decreased vasopressor responsiveness. However, our results suggest a role for accentuated vasodilatory responses that may be central in progression to decompensatory shock.

Alcohol-positive multiple trauma patients with and without blood transfusion: an outcome analysis

Background

Patients

Results

Conclusion

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.

Traumatic brain injury in intoxicated patients

BACKGROUND

We sought to evaluate the effect alcohol intoxication may have had in nonsurgically treated patients with severe traumatic brain injury.

METHODS

The Montreal General Hospital Traumatic Brain Injury Registry was used to identify all adult patients with a Glasgow Coma Scale score < or =8 at admission, within a 15-month period. All charts were retrospectively reviewed.

RESULTS

Twenty-three patients had toxic blood alcohol levels (BAL > or =21.7 mmol/L), 24 were alcohol negative (BAL <3 mmol/L), and 10 were alcohol-influenced or had unknown BAL. Patients were more likely to have intracranial pressure monitoring if they had multiple intracranial hemorrhages, sustained multiple injuries, or had a post-resuscitative Glasgow Coma Scale score < or =8. Intoxicated patients had a mean delay of 151 minutes more in the insertion time of an intracranial pressure monitoring device, compared with alcohol-negative patients.

CONCLUSIONS

Alcohol was a confounding factor in the treatment of some of our patients.

Injury severity: role of alcohol, substance use and risk-taking

OBJECTIVE

The objective of the present study was to quantify the relationship between acute alcohol consumption and injury severity.

METHODS

A cross-sectional study was conducted at the Gold Coast Hospital, Gold Coast, Queensland, Australia between October 2000 and October 2001. Data were collected from a systematic sample of patients greater than 15 years of age who presented to the ED for treatment of an injury sustained less than 24 h prior to presentation. Study participants were interviewed face to face on-site. Information obtained included: demographics details; situational variables relative to time of injury (i.e. location, activity and companions at time of injury); self-reported alcohol consumption in the 6 and 24 h prior to time of injury; usual alcohol consumption patterns; self-reported substance use in the 6 and 24 h prior to time of injury; and risk-taking behaviour. Injury severity was coded from patient medical records using the New Injury Severity Score.

RESULTS

Of 789 eligible patients presenting during the study periods, 593 were interviewed (75.2%). Patients who reported drinking above low-risk levels (odds ratio [OR] = 3.35; 95% confidence interval [CI] 1.2-9.6) or who drank beer (OR = 3.54; 95% CI 1.1-11.1) in 6 h prior to injury were significantly more likely to sustain serious than minor injury. Drinking setting and usual drinking patterns were not significantly associated with injury severity, either in crude analyses, or after adjusting for relevant variables.

CONCLUSION

The results of the present study support the conclusion that among injured patients who presented for treatment at a large metropolitan ED, although acute alcohol consumption does not appear to be associated with minor or moderate injury, there is some evidence to suggest that acute alcohol consumption is associated with serious injury.

Alcohol Intoxication Impairs Phosphorylation of S6K1 and S6 in Skeletal Muscle Independently of Ethanol Metabolism

BACKGROUND

The purpose of this study was to characterize the ability of alcohol to suppress insulin-like growth factor (IGF)-I stimulation of ribosomal S6 kinase 1 (S6K1) and 4E-BP1 phosphorylation, which are central elements in the signal transduction pathway used to coordinate the protein synthetic response and may contribute to the development of alcoholic myopathy.

METHODS

In vivo studies examined the dose and time dependency of the ability of alcohol to impair signal transduction under basal and IGF-I-stimulated conditions. Additional studies examined the effect of gender, nutritional state, and route of alcohol administration. A separate study determined the direct effects of alcohol on muscle metabolism by using the isolated perfused hindlimb preparation.

RESULTS

The phosphorylation of S6K1 and S6 in muscle was increased after injection of IGF-I in control rats. In contrast, IGF-I failed to stimulate S6K1 or S6 phosphorylation 2.5 hr after intraperitoneal administration of alcohol when the blood alcohol concentration was increased between approximately 165 and 300 mg/dl. With a maximal suppressive dose of alcohol, the inhibitory effect on S6K1/S6 phosphorylation was observed as early as 1 hr and for up to 8 hr. The ability of alcohol to impair phosphorylation of S6K1 and S6 was independent of gender (male versus female), nutritional status (fed versus fasted), and route of alcohol administration (intraperitoneal versus oral). Furthermore, the suppressive effect of alcohol was still observed in rats pretreated with 4-methylpyrazole, suggesting that the response was independent of the oxidative metabolism of ethanol. The direct effect of alcohol on IGF-stimulated S6K1/S6 phosphorylation was also present when the isolated hindlimb was perfused in situ with buffer containing alcohol. In contrast to S6K1, acute alcohol intoxication did not consistently impair the ability of IGF-I to stimulate 4E-BP1 phosphorylation under any of the experimental conditions.

CONCLUSIONS

These data indicate that acute alcohol intoxication selectively impairs IGF-I signaling via S6K1, but not 4E-BP1, and that this defect is independent of gender, nutritional state, route of administration, and alcohol metabolism. The IGF-I resistance may represent a participating mechanism by which alcohol directly limits the translation of selected messenger RNAs and, ultimately, protein synthesis in skeletal muscle.

Effects of alcohol and other drugs on driver performance

In the past century we have learned that driving performance is impaired by alcohol even in low dosage, and that many other drugs are also linked to impairment. This paper is a summary of some of the more relevant studies in the past fifty years--an overview of our knowledge and unanswered questions. There is no evidence of a threshold blood alcohol (BAC) below which impairment does not occur, and there is no defined category of drivers who will not be impaired by alcohol. Alcohol increases not only the probability of collision, but also the probability of poor clinical outcome for injuries sustained when impaired by alcohol. This review samples the results of the myriad studies that have been performed during the last half century as experiments have moved from examination of simple sensory, perceptual and motor behaviours to more complex measures of cognitive functioning such as divided attention and mental workload. These more sophisticated studies show that significant impairment occurs at very low BACs (< 0.02 gm/100 ml). However, much remains to be determined regarding the more emotional aspects of behaviour, such as judgment, aggression and risk taking. Considering that the majority of alcohol related accidents occur at night, there is a need for increased examination on the role of fatigue, circadian cycles and sleep loss. The study of the effects of drugs other than alcohol is more complex because of the number of substances of potential interest, the difficulties estimating drug levels and the complexity of the drug/subject interactions. The drugs of current concern are marijuana, the benzodiazepines, other psychoactive medications, the stimulants and the narcotics. No one test or group of tests currently meets the need for detecting and documenting impairment, either in the laboratory or at the roadside.

Consequences of alcohol-induced early dysregulation of responses to trauma/hemorrhage

Acute alcohol intoxication is a frequent underlying condition associated with traumatic injury. Studies from our laboratory have been designed to examine the early hemodynamic, proinflammatory, and neuroendocrine alterations in responses to hemorrhagic shock in surgically catheterized, conscious, unrestrained, male Sprague-Dawley rats during acute alcohol intoxication (1.75-g/kg bolus, followed by a constant 15-h infusion at a rate of 250-300 mg/kg/h). With both fixed-pressure (40 mm Hg) and fixed-volume (50%) hemorrhagic shock, followed by fluid resuscitation with Ringer's lactate, acute (15 h) alcohol intoxication has been shown to impair significantly the immediate hemodynamic, metabolic, and inflammatory counterregulatory responses to hemorrhagic shock. Alcohol intoxication enhanced hemodynamic instability during blood loss and impaired the recovery of mean arterial blood pressure during fluid resuscitation. Activation of neuroendocrine pathways involved in restoring hemodynamic stability was significantly attenuated in alcohol-intoxicated hemorrhaged animals. The hemodynamic and neuroendocrine impairment is associated with enhanced expression of lung and spleen tumor necrosis factor, and it suppressed circulating neutrophil function. In addition, neuroimmune regulation of cytokine production by spleen-derived macrophages obtained from alcohol-intoxicated hemorrhaged animals was impaired when examined in vitro. We hypothesize that impaired neuroendocrine activation contributes to hemodynamic instability, which, in turn, prolongs tissue hypoperfusion and enhances risk for tissue injury. Specifically, the early dysregulation in counterregulatory responses is hypothesized to affect host defense mechanisms during the recovery period. We examined host response to systemic (cecal ligation and puncture) and localized (pneumonia) infectious challenge in animals recovering from hemorrhage during acute alcohol intoxication. Increased morbidity and mortality from infection were observed in alcohol-intoxicated hemorrhaged animals. Our results indicate that alcohol-induced alterations in early hemodynamic and neuroimmune responses to shock have an impact on susceptibility to an infectious challenge during the early recovery period.

The Effects of Admission Alcohol Level on Cerebral Blood Flow and Outcomes after Severe Traumatic Brain Injury

This study examined the relationship between admission serum alcohol level (ETOH) and cerebral blood flow (CBF) and outcomes in the adult traumatic brain injured (TBI) population. We hypothesized that individuals with ETOH > 100 mg/dL will have decreased blood flow on admission and poorer outcomes. Eighty subjects, age 16-65, with severe TBI (Glasgow Coma Score [GCS] </= 8) were entered into the study. Correlational analysis assessed the relationship between ETOH and admission severity of injury scores as measured by Marshall and APACHE III scores, CBF, and outcomes. Comparison of CBF and outcomes between groups based on admission serum ETOH level was conducted with analysis of variance and post hoc Scheffé analyses as well as regression analysis. There was a significant relationship between serum ETOH level and GCS (p = 0.02), but not APACHE III scores (p = 0.12) or Marshall scores (p = 0.27). There was a significant correlation between global CBF and serum ETOH level (p = 0.02). There was no statistically significant association between serum ETOH level and GOS at 3 (p = 0.97), 6 (p= 0.56), or 12 (p = 0.73) months after injury. The data indicated that serum ETOH levels > 100 mg/dL at the time of admission after a TBI were associated with a decrease in global CBF. Elevated serum ETOH level at time of injury did not, however, impact outcomes.

Características de los lesionados por accidente de tráfico con alcoholemia positiva

OBJECTIVE

To identify the differential features of positive blood alcohol level (BAL) in people injured in road crashes who were attended an acute care service.

METHODS

Cross-sectional study of persons aged 18 years old or older injured in motor vehicle crashes who were attended in the Traumatology Emergency Department of Vall d'Hebron Hospital (Spain) between July 2001 and February 2002.

RESULTS

The study sample included 431 patients. A positive alcohol test was found in 13.7% of the sample. A statistically significant and independent association was found between positive BAL and male sex (odds ratio [OR] = 2.5 [95% CI, 1.3-5.4]), hospital admission (OR = 2.7 [95% CI, 1.3-5.4]), being attended on a weekend (OR = 3.7 [95% CI, 2.0-6.9]) and being attended during the night and early morning (OR = 4.6 [95% CI, 2.0-10.3]) or in the morning (OR = 3.6 [95% CI, 1.5-8.4]).

CONCLUSIONS

The present study identifies a subgroup of people injured in motor vehicle crashes with a greater likelihood of positive BAL, in whom more active screening and secondary prevention activities should be implemented within traumatology and acute care settings.