Alcohol/drug abuse, driving convictions, and risk-taking dispositions among trauma center patients

The objective of this study was to evaluate the relationship between alcohol/drug abuse diagnoses, driving convictions (speeding, reckless driving, impaired driving, license violations), and risk-taking dispositions among a series of injured drivers admitted to a trauma center. The driving records of 778 patients were linked to diagnoses of psychoactive substance use disorders (PSUDs), admission blood alcohol concentration (BAC), mode of injury, and results of a risk-taking disposition survey. Twenty-nine percent of patients had one or more convictions in the 3 years before injury. Types of violation were not related to mode of injury. Although there was a positive association between prior impaired-driving convictions, current alcohol dependence, and a BAC + status, a consistent pattern relative to other violations, PSUDs, and BAC status was not apparent. Risk-taking disposition scale scores indicated that patients without PSUDs and without convictions tended toward less risk-taking behavior than patients with PSUDs and with convictions. The complex inter-relationships between PSUDs, risk-taking dispositions, and being convicted of driving dangerously require additional study so that intervention programs and injury prevention initiatives can be targeted effectively.

A longitudinal study of former trauma center patients: the association between toxicology status and subsequent injury mortality

BACKGROUND

Despite the current emphasis on injury prevention, little has been done to incorporate alcohol intervention programs into the care of the injured patient. The purpose of this study was to determine whether patients admitted to a trauma center with positive toxicology findings (TOX+) have a higher subsequent injury mortality than those without such findings (TOX-).

METHODS

We followed a cohort of 27,399 trauma patients discharged alive between 1983 and 1995 to determine subsequent mortality. Death certificates were obtained to identify the cause of death.

RESULTS

TOX+ patients had an injury mortality rate approximately twice that of the TOX- group (1.9% vs. 1.0%, p < 0.001). Overall, 22.7% of the deaths were due to injury; the TOX+ rate was 34.7% versus 15.4% for the TOX-.

CONCLUSION

These data add strength to the premise that untreated substance abuse-related injury remains an untapped injury prevention opportunity.

Epidemic increases in cocaine and opiate use by trauma center patients: documentation with a large clinical toxicology database

BACKGROUND

Although reports have documented alcohol and other drug use by trauma patients, no studies of long-term trends have been published. We assessed substance use trends in a large cohort of patients admitted to a regional Level I adult trauma center between July 1984 and June 2000.

METHODS

Positive toxicology results, collected via retrospective database review, were analyzed for patients admitted directly to the center. Data were abstracted from a clinical toxicology database for 53,338 patients. Results were analyzed for alcohol, cocaine, and opiates relative to sex, age (< 40/> or = 40 years), and injury type (nonviolence/violence). Positive toxicology test result trends were assessed for the 3 years at the beginning and end of the period (chi2). Testing biases were assessed for sex, race, and injury type.

RESULTS

The patient profile was as follows: men, 72%; age < 40 years, 69%; nonviolence victims, 77%. Alcohol-positive results decreased 37%, but cocaine-positive and opiate-positive results increased 212% and 543%, respectively (all p < 0.001). Cocaine-positive/opiate-positive results increased 152%/640% for nonviolence and 226%/258% for violence victims, respectively (all p < 0.001). In fiscal year 2000, cocaine-positive and opiate-positive results were highest among violence victims (27.4% for both drugs). Cocaine-positive and opiate-positive results among nonviolence victims were 9.4% and 17.6%, respectively. Patients who were minorities or victims of violence were not tested more frequently than other patients.

CONCLUSION

Epidemic increases in cocaine and opiate use were documented in all groups of trauma patients, with the greatest increases being in violence victims. Alcohol use decreased for all groups.

Use of alcohol as a risk factor for bicycling injury

CONTEXT

Bicycling is one of the leading causes of recreational injuries. Elevated blood alcohol concentrations (BACs) are found in about one third of fatally injured bicyclists aged 15 years or older.

OBJECTIVE

To assess the relative risk of fatal and serious bicycling injury according to BAC.

DESIGN

Matched case-control study.

SETTING AND SUBJECTS

Bicyclists aged 15 years or older who were fatally or seriously injured while riding a bicycle during the day in Maryland in 1985-1997 (cases, n = 124) and bicyclists aged 15 years or older who were interviewed and given a breath test for estimated BAC during roadside surveys that took place in June 1996 through May 1998 at the same site, time of day, day of week, and month of year in which a case bicyclist was injured (controls, n = 342).

MAIN OUTCOME MEASURE

Odds ratio of bicycling injury according to estimated BAC.

RESULTS

An estimated positive BAC (>/=0.02 g/dL) was detected in 12.9% of the case bicyclists (23.5% of the 34 fatally injured and 8.9% of the 90 seriously injured) compared with 2.9% of the control bicyclists (P<.001). Relative to an estimated BAC of less than 0.02 g/dL, the adjusted odds ratio of bicycling injury was 5.6 (95% confidence interval [CI], 2.2-14.0) for a BAC of 0.02 g/dL or higher and was 20.2 (95% CI, 4.2-96.3) for a BAC of 0.08 g/dL or higher. Rates of helmet use at the time of injury or interview were 5% and 35%, respectively, for those with and without a positive BAC (P =.007).

CONCLUSION

Alcohol use while bicycle riding is associated with a substantially increased risk of fatal or serious injury.

Alcohol use in relation to driving records among injured bicyclists

To prevent alcohol-related occupational mishaps, employers often conduct background checks on prospective employees for history of driving while intoxicated (DWI) and driving under the influence of alcohol (DUI) to screen out candidates with drinking problems. Few studies, however, have examined the pervasive nature of drinking behavior across activity domains. Based on trauma registry data, we constructed a historical cohort of 120 Maryland residents ages 18 years or older who were injured while riding a bicycle between 1990 and 1997. Driving records for the 120 bicyclists for the 3 years between May 6, 1995 and May 5, 1998 were obtained from the state motor vehicle administration and were analyzed in relation to BAC-positive status at the time of injury. Bicyclists with positive BACs at the time of admission to the trauma center were significantly more likely than those with negative BACs to have a record of license suspension/revocation (52% vs 14%, P < 0.01) and to have DWI/DUI convictions (30% vs 3%, P < 0.01). Despite the modest sample size, this study provides compelling evidence of the pervasive nature of risky drinking between bicycling and driving activities.

Use of blood alcohol concentration and laboratory tests to detect current alcohol dependence in trauma center patients

OBJECTIVE

To assess the utility of laboratory markers of severe alcoholism in a cross-sectional population of male trauma center patients, who have a high rate of current alcohol dependence (CAD).

METHODS

A total of 684 men were assessed for CAD by using standard criteria, all of whom had complete laboratory data. The ability of tests to predict CAD was ascertained by using Student's t test, sensitivity, specificity, and area under the curve (AUC) of receiver operating characteristic curves.

RESULTS

Mean values of five tests were individually associated with a CAD diagnosis. Gamma-glutamyltransferase, aspartate aminotransferase, and mean corpuscular volume had sensitivities less than or equal to 0.51 and AUC less than or equal to 0.67. Blood alcohol concentration (BAC) and serum osmolality had sensitivities of 0.64 and 0.74 and AUC of 0.74 and 0.76, respectively. Each marker, when combined with BAC, showed little improvement in AUC over BAC alone.

CONCLUSIONS

Laboratory tests are not highly predictive of CAD in male trauma patients. A combination of BAC tests and interview screens is suggested for use in this patient population.

Screening trauma patients for alcoholism according to NIAAA guidelines with alcohol use disorders identification test questions

Drinking pattern criteria (drinking frequency and number of drinks per occasion) issued by the National Institute on Alcohol and Abuse and Alcoholism (NIAAA) to screen primary practice patients for alcohol problems were evaluated in 1216 injured patients treated in a regional trauma center. Vehicular crash victims predominated (50.2%, of whom 64.5% were drivers), followed by victims of violence (31.2%) and nonviolent-injury victims (18.5%). Alcohol Use Disorders Identification Test (AUDIT) questions #1 (drinking frequency) and #2 (drinks/day) were used to assess the patients for current alcohol dependence (CAD). AUDIT responses roughly approximating NIAAA guidelines (high threshold: drinks > or = 4 times/week, > or = 5 drinks/day) and those indicating less drinking (low threshold: drinks > or = 2-3 times/ week, > or = 3 drinks/day) were chosen. Comparisons were made relative to sensitivity and specificity of responses in detecting CAD. When low threshold responses were used for either question, sensitivity to detect CAD increased overall (#1 from 0.53 to 0.80, #2 from 0.62 to 0.88) as well as among the subgroups of patients, whereas specificity remained high or at acceptable levels overall (#1 from 0.95 to 0.82, #2 from 0.92 to 0.71) and among the subgroups of patients. Study findings suggest that, among injured drivers and other groups of trauma center patients, lesser amounts of drinking should be used as screening criteria for CAD than are used for the general population.

The accuracy of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test in screening trauma center patients for alcoholism

OBJECTIVE

To evaluate the accuracy of questionnaire screening instruments to identify lifetime alcohol dependence among trauma center patients.

METHODS

The study was conducted at a Level I trauma center between September 1994 and November 1996. Patients meeting eligibility requirements (> or = 18 years old, admission from injury scene, > or = 2 days of hospitalization, intact cognition) were evaluated for alcohol abuse and dependence. Screening instruments consisted of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test. Screening results were compared with lifetime alcohol dependence diagnoses made using the in-depth Psychoactive Substance Use Disorders section of the Structured Clinical Interview. Accuracy was quantified as sensitivity, specificity, positive/negative predictive values, and receiver operating characteristic curves (used to calculate area under the curve).

RESULTS

Of the 1,118 patients studied, lifetime alcohol dependence was diagnosed by Structured Clinical Interview in 397 (35.5%), and abuse was diagnosed in 90 (8.1%) others. The CAGE was the best predictor of lifetime alcohol dependence, i.e., had the largest area under the curve (93%) and the highest sensitivity (84%), specificity (90%), positive predictive value (82%), and negative predictive value (91%). Among patients testing positive for alcohol, 63% had a lifetime alcohol dependence diagnosis.

CONCLUSION

The CAGE is an efficient screening test to detect alcohol dependence in trauma center populations. It should be used in combination with alcohol testing to identify patients at risk of alcohol use problems.

Alcoholism at the time of injury among trauma center patients: vehicular crash victims compared with other patients

A structured in-depth interview employing standardized criteria was used to determine the prevalence of lifetime and current alcohol dependence (alcoholism) in unselected consecutive patients admitted to a regional Level I trauma center. Of 629 patients, 157 (25.0%) were current alcoholics at the time of injury. An additional 87 (13.8%) were diagnosed as lifetime non-current alcoholics. There was no significant difference in the rates of current alcohol dependence among patients injured in vehicular crashes (23.5%), other unintentional trauma victims (29.3%), and those injured as a result of violence (24.6%). Of BAC+ (blood alcohol concentration positive) patients, 54.5% were current alcoholics. However, 14.4% of alcohol-negative patients were also diagnosed as alcohol dependent.

Psychoactive substance use disorders among seriously injured trauma center patients

OBJECTIVE

To assess the prevalence of psychoactive substance use disorders (PSUDs) among a large, unselected group of seriously injured trauma center patients, using a standardized diagnostic interview and criteria.

DESIGN

Prevalence study.

SETTING

A level I regional trauma center.

PATIENTS

Trauma center patients fulfilling the following criteria were eligible subjects: aged 18 years or older, admission from injury scene, length of stay of 2 days or longer, and intact cognition.

OUTCOME MEASURES

The PSUDs were diagnosed using the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) and were categorized as abuse or dependence and past or current (within past 6 months). The SCID results were analyzed with respect to demographic factors, injury type, and blood alcohol concentration and urine toxicology results, using chi2 and logistic regression techniques.

RESULTS

Of the 1220 patients approached for study, 1118 (91.6%) consented. More than half (54.2%) had a diagnosis of a PSUD in their lifetime. Approximately 90% of alcohol and other drug use diagnoses were for dependence and more than 62% were current. Overall, 24.1% of patients were currently alcohol dependent (men, 27.7%; women, 14.7%; P<.001), and 17.7% were currently dependent on other drugs (men, 20.2%; women, 11.2%; P<.001). Current alcohol dependence rates were not associated with race; rates of dependence on other drugs were higher among nonwhites and victims classified with intentional injuries. While 54.3% of blood alcohol-positive patients were currently alcohol dependent and 38.7% of patients with positive urine screening test results for drugs other than alcohol and nicotine were currently drug dependent, 11.7% of blood alcohol-negative and 3.9% of drug-negative patients, respectively, had current diagnoses of dependence on psychoactive substances.

CONCLUSIONS

A high percentage of seriously injured trauma center patients are at risk of having current PSUDs. Patients with positive toxicology screening test results and/or positive screening questionnaire responses should be referred for formal evaluation and treatment.

Predictive model to identify trauma patients with blood alcohol concentrations > or = 50 mg/dl

OBJECTIVE

To develop a simple model for identification of trauma patients who are likely to have a blood alcohol concentration > or = 50 mg/dL (BAC + 50).

METHODS

Demographic, clinical, and BAC data were collected from the clinical trauma registry and toxicology data base at a Level I trauma center. Logistic regression was used to analyze data from 11,206 patients to develop a predictive model, which was validated using a subsequent cohort of 3,523 patients.

RESULTS

In the model development cohort, alcohol was detected in the blood of 3,180 BAC-tested patients (28.7%), of whom 91.2% had a BAC + 50 status. Preliminary analysis revealed associations between a BAC + 50 status and sex, age, race, injury type (intentional vs. unintentional), and time of injury (night vs. day and weekend vs. weekday). A predictive model using four attributes (sex and injury type) identified patients at low, medium, and high risk for being BAC + 50. The model was validated using the second group of patients.

CONCLUSION

Injured patients with a high probability of being alcohol positive can be identified using a simple scoring system based on readily available demographic and clinical information.

A comparative analysis of alcohol in fatal and nonfatal bicycling injuries

Bicycling is the leading cause of recreational injury, resulting in more than half a million emergency department visits and about 900 deaths each year in the United States. Previous research on bicycling injury was conducted predominantly in children and focused on the effectiveness of safety helmets. Few studies have examined the role of alcohol in bicycling injuries. This study examined the magnitude of and factors related to alcohol involvement in fatal and nonfatal bicycling injuries, and tested the hypothesis that alcohol intoxication is associated with significantly increased likelihood of fatality given a serious bicycling injury. Medical examiner data on all fatally injured bicyclists aged 10 years or older from 1987 to 1994 in Maryland (fatal cases, n = 63) were compared with trauma registry data on all injured bicyclists who were treated at a regional trauma center during the same time period (nonfatal cases, n = 253) on variables related to blood alcohol concentrations (BACs), demographic characteristics, and injury circumstances. The fatal cases were more likely than the nonfatal cases to have positive BACs (30% vs. 16%, p < 0.01) and to be legally intoxicated (i.e., BACs > or = 0.10%) (22% vs. 13%, p < 0.01). For both fatal and nonfatal cases, intoxication was more prevalent among victims who were male, aged 20 to 39 years, or who were injured at nighttime (7:00 PM to 6:59 AM). Bicyclists who died at the scene were four times as likely as those who died at hospitals to be legally intoxicated (35% vs. 9%, p < 0.02). Given a serious bicycling injury, intoxication was associated with significantly increased likelihood of fatality, with an adjusted odds ratio of 2.8 (95% confidence interval, 1.3 to 6.3). This increased likelihood of fatality was probably due in part to the fact that the rate of helmet use at the time of injury among the intoxicated was much lower than among the sober (6% vs. 31%, p < 0.05). Results indicate that alcohol plays an important role in fatal and serious bicycling injuries. Preventing intoxicated biking should be incorporated into helmet campaigns and other bicycle safety programs.

Alcohol use among injured sets of drivers and passengers

Crash report and blood alcohol concentration (BAC) data were linked for 109 injured driver/passenger pairs admitted to a Level I trauma center. Among those occupants, 47 drivers (43%) (mean BAC, 147 mg/dl) and 45 passengers (41%) (mean BAC, 127 mg/dl) were BAC+. No occupant was BAC+ in 57 crashes (52%); both were BAC+ in 40 (37%); and only one was BAC+ in 12 (11%). When both occupants were BAC+, the driver had the higher BAC in 68% of cases, and when one was BAC+, it was the driver 58% of the time. In 6 additional alcohol-related crashes with one driver and two passengers, the "wrong" occupant was driving on 5 occasions. Hence, in the 58 crashes involving BAC+ occupants, the least appropriate occupant was driving 67% of the time.

Marijuana and other drug use among automobile and motorcycle drivers treated at a trauma center

Serum from injured automobile and motorcycle drivers treated at a trauma center was tested for delta-9-tetrahydrocannabinol activity to determine precrash marijuana use. From June 1990 to March 1991, samples from approximately 20 automobile drivers per month and all motorcycle drivers were available for testing. Also, toxicology screens were performed for ethyl alcohol, cocaine, and phencyclidine (PCP) among the driver groups. Six (2.7%) of the 225 automobile (AUT) drivers and 34 (32.0%) of the 106 motorcycle (MTC) drivers were THC+ (p < .001). Compared with a prior study, the THC+ rate decreased significantly from 31.8% among AUT drivers (p < .001) but had not changed significantly from the 38.6% rate among MTC drivers. Positive toxicology rates were higher among the 261 MTC drivers compared to the 1,077 AUT drivers tested for ETOH, CO, and PCP, being 47.1% vs 35.2% (p < .001), 5.0% vs 8.0% (p < .08), and 1.5% vs 3.1% (NS), respectively.

Substance use disorders in trauma patients. Diagnosis, treatment, and outcome

The consequences of acute and chronic drug abuse pose significant problems for physicians managing the trauma victim in the resuscitative, perioperative, intensive care, and hospitalization periods. Substance abuse, whether acute or chronic, modifies the physiologic response to injury and to resuscitative and operative measures. Trauma and critical care physicians must have insight into ways to improve the detection, resuscitation, and management of trauma patients with acute substance intoxication or chronic abuse history. The need for prophylaxis of withdrawal syndrome differs with drug type. The major difficulty is proper identification of individuals at risk, which is complicated by patients' unconsciousness, reluctance, or medical inability to give detailed history of substance use. Failure to recognize withdrawal symptoms may both confuse the diagnosis of traumatic injury and be life-threatening. The goal in treating the trauma patient who is also a substance abuser is both to fully assess that person's injuries and achieve physiologic stability and use the hospitalization as an opportunity to educate and counsel the patient to abandon his or her destructive behavior.

Alcohol and other drugs: an assessment of testing and clinical practices in U.S. trauma centers

INTRODUCTION

The American College of Surgeons' (ACS) Committee on Trauma recommends drug and alcohol screening as "essential" for level I and II or "desirable" for level III trauma centers.

METHODS

Trauma centers were surveyed concerning alcohol and other drug testing policies and clinical practices during fiscal year 1989.

RESULTS

Surveys were returned from 125 level I, 153 level II, and 38 other centers (n = 316; 47 states and the District of Columbia). Resources to measure blood alcohol concentrations (BAC) and perform urine drug screens were available in 99.4% and 96.8% of centers, respectively. In 63.7% of level I and level II and 47.4% of other centers, BACs were "routinely" obtained. The 63.7% testing rate for level I and level II centers was not significantly higher than a 55.2% rate for such centers documented in a survey conducted 5 years earlier. In 40.0% of level I and level II and 26.3% of other centers, drug screens were obtained routinely. The higher overall BAC testing policy compared with that for other drugs was significant (p < 0.001). Substance abuse counselors were employed at 59.3% of the trauma centers, a rate significantly higher than the 31.8% rate identified in a previous survey (p < 0.001).

CONCLUSION

Despite available resources and repeated ACS recommendations, measurements of BACs and drug screens are routine in only 63.7% of level I and 40.0% of level II trauma centers.

Alcohol use, driving records, and crash culpability among injured motorcycle drivers

Alcohol use, driving records, crash culpability, and crash conviction rates for 165 injured motorcycle drivers (MTCDs) were studied. Of the 165 MTCDs, 53.3% tested positive for alcohol (BAC+). Culpability determinations (n = 150) revealed that 83% of BAC+ and 46% of BAC-MTCDs caused their crashes (p < 0.001). Driving records (n = 145) revealed the following prevalence of one or more convictions for BAC+ and BAC-MTCDs: impaired driving (29% vs. 7%, p < 0.001); speeding (74% vs. 58%, p < 0.05); and reckless driving (68% vs. 44%, p < 0.002). Of the surviving culpable impaired MCTDs (n = 48), 16.7% received crash-related convictions, 12.5% received alcohol-related convictions. The reasons for the low conviction rates are probably multifactorial.

[When is Scandinavia getting specialized trauma care? Report from a leading trauma center in the USA]

The specialized care provided at the trauma centre in Baltimore, Maryland, in the USA is described. By means of a sophisticated communications system, prehospital and hospital care are coordinated with a view to providing optimal care to people with various types of injuries. It is suggested how the American experience might be applied to conditions in the Nordic countries in order to improve the quality of trauma care.

Psychoactive substance dependence among trauma center patients

INTRODUCTION

The practice of assessing only trauma patients with elevated blood alcohol concentrations (BACs) or positive drug screens for psychoactive substance use disorders (PSUDs) was evaluated.

METHODS

Twenty-four BAC-negative (BAC-) (BAC, 0) and 21 BAC-positive (BAC+) (BAC, greater than or equal to 22 mmol/L or 100 mg/dL; mean, 41 mmol/L; range, 24.3 to 79 mmol/L) adult trauma patients were evaluated for alcoholism and other PSUDs using the Structured Clinical Interview (SCI) from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R). Approximately half were vehicular crash victims and 78% were men.

RESULTS

A total of 64 PSUDs were diagnosed in 31 (68.9%) of the 45 patients; all but one was for dependence (vs abuse). Of the BAC+ patients, 14 (66.7%) met DSM-III-R criteria for alcohol dependence, 11 (78.6%) of whom also had other PSUDs not related to alcohol. Two other BAC+ patients had nonalcohol PSUDs. Of the BAC- patients, 11 (45.8%) had alcohol dependence, six (54.5%) of whom also had nonalcohol PSUDs. Another four BAC- patients had nonalcohol PSUDs. Overall, 76.2% of the BAC+ patients and 62.5% of the BAC- patients had a diagnosis of psychoactive substance dependence.

CONCLUSION

All patients admitted to trauma centers should be assessed for alcoholism and other PSUDs.

Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score

Improvement in trauma management requires a better understanding of the effect of a patient's preinjury health status on outcome. Specific historical findings and laboratory criteria were used to define pre-existing disease (PED) states and determine if they were independent predictors of fate in trauma victims. Of 7,798 adult patients admitted to a level I trauma center from July 1986 through June 1990, 16.0% (1,246) had greater than or equal to 1 PED. The PED+ and PED- patients had no significant difference in Injury Severity Scores (ISSs) (15.7 versus 15.6) and admission Glasgow Coma Scale (GCS) scores (13.9 versus 13.8). The PED+ patients were older (49.2 versus 30.6 years) (p less than 0.001) and had a higher mortality rate (9.2% versus 3.2%) (p less than 0.001) than PED- patients. Mortality rates were also elevated for patients with greater than or equal to 2 PEDs (18%) and for those with renal disease (38%), malignancy (20%), and cardiac disease (18%) (p less than 0.001) compared with PED- patients. Controlling for age and ISS, there was an association between PED and mortality (Mantel-Haenszel p less than 0.03). Multivariate regression showed that PED is an independent predictor of mortality (R2 = 0.1918; p less than 0.0001). The greatest increases in mortality were found among patients less than 55 years and with ISS less than 20. Changes in prehospital triage criteria and outcome scoring are needed. Improvements in the management of trauma victims with chronic disease may decrease their mortality rate.

Injured drivers and alcohol use: culpability, convictions, and pre- and post-crash driving history

The culpability, crash-related traffic convictions, and pre- and post-crash driving records of a group of injured impaired (blood alcohol level greater than 80 mg/dl) drivers (N = 58) who were admitted to a Level I trauma center were compared with a group of admitted unimpaired drivers (N = 92). Both groups of drivers were 21 years of age or older, sustained moderate injuries (defined as having no injury of the brain, spinal column or cord, extremity, or pelvis with an Abbreviated Injury Score of greater than 2), and were discharged home. In the 140 crashes in which culpability was clearly defined, the impaired drivers caused a significantly greater percentage of their crashes (92.7%) compared to unimpaired (64.7%) drivers (p less than 0.001). Of the 55 unimpaired drivers who were considered culpable of causing their crashes, 12.7% received a traffic conviction compared with 39.2% of the 51 culpable impaired drivers. The mean number of total pre-crash traffic violations was higher for impaired drivers than for unimpaired drivers (p less than 0.01). While the mean number of total post-crash convictions for unimpaired and impaired was not significantly different, the mean number of pre- and post-crash alcohol convictions was significantly higher for impaired drivers compared to unimpaired drivers (p less than 0.02). The data suggest that injury protects from legal prosecution and does not alter impaired driving practices.

HIV infection rates in a trauma center treating predominantly rural blunt trauma victims

Human immunodeficiency virus (HIV) infection rates among 1,497 consecutive adult trauma victims triaged from rural and urban sectors to a statewide trauma center in Baltimore were studied. Those studied were 71.7% men, 77.4% whites, 63.2% vehicular trauma victims, 11.2% assault victims, and 25.7% other trauma victims. Non-Baltimoreans predominated (86.0%) and 32.7% were 25 to 39 years of age. Overall, 1.67% of the victims were HIV antibody positive. Significantly higher infection rates were seen in men (1.96% vs. 0.95%; p less than 0.02), non-whites (4.13% vs. 0.95; p less than 0.005), assault victims compared with vehicular and other trauma victims (5.99% vs. 1.06% vs. 1.30%, respectively; p less than 0.001), and Baltimore City residents (3.81% vs. 1.32%; p less than 0.03). Among those 25 to 39 years of age, 68.0% of the HIV infections were noted. Results suggest that HIV infection rates among trauma center patients are a reflection of the patient population served.

Marijuana and alcohol use among 1023 trauma patients. A prospective study

Marijuana use prior to injury was determined prospectively in 1023 patients injured as the result of vehicular (67.6%) and nonvehicular (32.4%) trauma. Most were men (72.8%); most were 30 years of age or younger (58.4%). All were admitted directly from the scene of injury. Serum delta-9-tetrahydrocannabinol activity was ascertained using a radioimmunoassay. Activity of 2 ng/mL or more was detected in 34.7% of subjects. Blood alcohol determinations were made in 1006 patients; 33.5% were positive. Marijuana use among vehicular and nonvehicular trauma victims was not significantly different. Marijuana use was higher among those 30 years of age or younger and among men. Vehicular crash victims consumed alcohol more frequently. Use of marijuana and alcohol in combination (16.5%) was highly significant compared with marijuana alone (18.3%), alcohol alone (16.1%), or neither drug (49.1%).

A national alcohol and trauma center survey. Missed opportunities, failures of responsibility

The results of a national survey of trauma centers concerning their assessment and response to the problem of alcohol and trauma are reported. Surveys were returned from 154 trauma centers located in 43 states and the District of Columbia. The profile of the 125,000 patients treated at the centers is a 30-year-old man sustaining blunt trauma, usually in a vehicular crash. Two-thirds of centers estimated that the majority of their patients had abused alcohol. While acknowledging alcohol as a significant cause of trauma, only 55.2% of centers routinely obtain admitting blood alcohol levels. Less than a third of the centers employ alcoholism counselors. Most trauma centers are not providing services that allow them to fulfill their responsibility to detect and initiate treatment of alcohol abuse, a major cause of traumatic injury.

Early care of the patient with cervical spine injury

For almost two decades, great strides have been made in improving the early care of trauma patients both at the trauma scene and in the hospital. Highly skilled providers in the field rapidly extricate, stabilize, and transport patients to trauma centers. In those centers, teams of clinicians can quickly resuscitate, evaluate, and treat life-threatening conditions. These improvements should lead to an increase in survival and functional capacity of all trauma victims, including those with cervical spine injury.

Increased susceptibility of patients with cervical cord lesions to peptic gastrointestinal complications

The incidence and risk factors in the development of hemorrhaging and perforating gastrointestinal (GI) lesions in 408 patients with cervical column/cord injury were studied retrospectively. Most injuries were caused by blunt trauma (94.1%). Male patients predominated (83.6%); the mean patient age was 35.8 years. Of the 408 patients, 190 (46.6%) had complete cord deficits, 111 (27.2%) had incomplete deficits, and 107 (26.2%) were intact. Admission shock (systolic BP less than 100 mm Hg) was present in 31.6% and 20.7% of patients with complete and incomplete lesions, respectively, and in 4.7% of those intact. Patients with complete deficits received corticosteroids for 2 days; patients with incomplete deficits received them for 7 to 10 days. Eleven of the 107 intact patients (10.3%) received steroids. All patients received standard antacid therapy. Nine patients without previous GI disease developed peptic ulcerations: six gastric and three duodenal lesions (six were perforated) that required surgical intervention; all occurred in patients with complete deficits. Both the 4.7% incidence of the lesions in those patients compared with the other victims of cervical trauma and an estimated 0.1% incidence among more than 6,000 other seriously injured patients are significant (p less than 0.005, p less than 0.001). Steroids were not an ulcerogenic factor.

Vascular injuries

Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Diagnosis rests upon an acute clinical awareness, supplemented by the appropriate use of noninvasive techniques and contrast radiography. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present. Early surgical consultation is essential.

Superior mesenteric artery and vein injuries from blunt abdominal trauma

During an 8-year period, from 1974 to 1982, 13 patients were treated for superior mesenteric vascular injury secondary to blunt abdominal trauma. Ten male and three female patients ranged in age from 18 to 68 years (average age, 42.7 years). Six patients presented in profound shock, two presented in cardiopulmonary arrest, and five presented with mild shock. The 13 patients had an average of 3.2 associated intra-abdominal injuries. Six patients had devitalized bowel as a direct consequence of injury to the superior mesenteric vessels. One patient developed intestinal necrosis postoperatively from thrombosis of the superior mesenteric vein which led to extensive small bowel resection. The blood replacement ranged from 2 to 30 units, averaging 11.7 units per patient. Operative procedures included lateral arteriorrhaphy (five patients) and venorrhaphy (11 patients). Four patients required combined vessel repair and one patient required ligation of both vessels and bowel resection. The mortality rate of 57% was primarily due to massive acute hemorrhage, which was larger than could be accounted for by the associated intraabdominal injuries. Free intraperitoneal hemorrhage from the valveless portal system, which can carry up to 60% of cardiac output, causes massive bleeding until abdominal tamponade supervenes.

Alcohol consumption among vehicular occupants injured in crashes

Admission blood alcohol levels (BAL) were obtained in 111 adult passenger/driver pairs injured in vehicular crashes. Drinking patterns were studied, including the influence of the sex of the occupants on alcohol consumption. Alcohol was not a factor in 44 of the crashes. In 48 of 62 crashes (77%), the driver was either the sole drinker or had a higher BAL than the passenger. In five crashes, the passenger was the only drinker. Female drivers were drinking 40% of the time, compared to 60% of male drivers. Overall, 77.4% of the drinking drivers had a BAL of greater than or equal to 100 mg/100 ml. When vehicular occupants were of the same sex, as opposed to both sexes, the drivers drank more frequently (62.9% vs. 43.9%). In 13 of 14 cases of a drinking male driver transporting a female passenger, the female passenger had not been drinking or had done so to a lesser degree. The data indicate that educational efforts should be directed at discouraging passengers from riding with drinking drivers.

The diagnosis of intra-abdominal injury in patients with cervical cord trauma

A review of the records of 288 patients sustaining blunt cervical column and/or cord injuries revealed that twelve (4.2%) had significant intra-abdominal injuries, all occult, and all detected by peritoneal lavage. Three of 58 patients in shock (BP less than 100 mm Hg) with neurologic deficits were found to have intra-abdominal injuries. Shock in another 15 was the result of major associated injuries and/or the loss of sympathetic vascular tone. Thus 40 of these 58 patients (69%) had neurogenic shock. An analysis of the mechanisms of injury and associated injuries indicated that those at risk of having significant intra-abdominal injury are those who have been injured in a vehicular crash and those who have other obvious major injuries that can cause shock. The data indicate that patients not at risk of having intra-abdominal injury can be selected for early attempts at anatomic cervical realignment in an effort to achieve return of neurologic function.

Infected false femoral artery aneurysms secondary to monitoring catheters

Six patients who developed infected false femoral artery aneurysms secondary to monitoring catheters are reported. All aneurysms were infected and resulted in systemic sepsis. Initially the origin of the sepsis was not obvious. Findings which suggest this lesion include staphylococci. Appearance of distal petechial hemorrhages should lend a strong suspicion to the possibility of the lesion. Appearance of the pulsatile groin mass completes the diagnosis. Only aneurysmal resection combined with appropriate antimicrobial therapy is curative. For necessary revascularization procedures, autogenous vein grafts should be used when available.

Severe pelvic fractures: problems and possible solutions

A host of injuries are associated with pelvic fractures, particularly of the severe disruptive type. It is important to recognize and treat severe pelvic fractures and associated injuries quickly. Multispecialty consultations should be sought when necessary. The control of hemorrhage secondary to pelvic fracture may be a difficult problem. A host of procedures have been described. Hypogastric artery interruption appears to be ineffective. However, angiographic embolization, compressive trousers, and, in a few selected patients, direct surgical intervention appear to be effective in controlling hemorrhage. The control of hemorrhage secondary to pelvic fracture may necessitate the use of more than the therapeutic modality. As emphasized by the Flint group,39 it is important to adopt an attack protocol. All too often, strategy has to be planned while a patient suffering a severe pelvic fracture continues to hemorrhage. When a particular method to control hemorrhaging fails, another should be employed. Open pelvic fractures are often difficult to manage. Initial efforts must be directed toward the control of hemorrhage. Secondary measures are required to minimize soft tissue soilage and infection, especially when there is deep perineal involvement. A logical, planned approach to pelvic trauma, with its associated injuries and blood loss, and appropriate specialty input are necessary for a successful outcome.

Superiority of the femoral artery of monitoring. A prospective study

Continuous hemodynamic monitoring and ease of blood sampling are advantages of indwelling arterial catheters. The use and associated morbidity of arterial monitoring catheters were studied prospectively. Ninety-five percent of patients catheterized had multiple injuries, and almost 75 percent were 40 years of age or younger. Major and minor complication rates were similar with radial and femoral catheters, while the longevity of femoral catheters was almost twice that of radial catheters. Radial catheter-related sepsis did not occur when the duration of catheterization was less than 4 days. Tissue loss secondary to radical catheters can be minimized by immediate catheters can be minimized by immediate catheter removal upon appearance of ischemic changes. Our data support the preferential use of the femoral artery for long-term monitoring catheters in a younger patient population.

Racquetball. A game with preventable injuries

One hundred fifty-seven racquetball injuries were identified. Eighty-two involved the face, but ocular injuries were probably underrepresented as a result of patient triage protocols. Facial trauma occurred more frequently among novice players. Only 9.9% of the players wore protective facial equipment and 23.1% had taken lessons before being injured. We propose that injuries could be reduced with proper player education, including the wearing of protective facial equipment. A modification in the design of conventional facial equipment is suggested to further reduce injury.

Management of severe bleeding in fractures of the pelvis

The successful control of severe hemorrhage secondary to pelvic fracture can be a difficult problem. This is not surprising considering the extensive vascularity of the pelvic sink with its collateral circulation of major vascular loops. Appreciation of this complex anatomy should alert physicians to sources of severe hemorrhage and guide their therapeutic decisions. Although many techniques are available for reducing hemorrhage, no one technique has universally produced successful results. Whatever method is initially used, surveillance to recognize a therapeutic failure is necessary. If bleeding continues, other methods should be used. A planned systematic approach based on the availability of various modalites to achieve hemostasis is suggested.

Gallbladder injuries resulting from blunt abdominal trauma: an experience and review

Over a seven-year period from 1973 through 1979, 31 patients with blunt gallbladder trauma were treated at the Maryland Institute for Emergency Medical Services Systems. Twenty patients had contusions, ten patients had avulsions and one patient had a perforation of the gallbladder. None of the gallbladder injuries were suspected preoperatively. Twenty-eight of the 31 patients had a diagnostic peritoneal lavage performed on admission, all were positive for blood; bile was not grossly evident. Among the 30 patients, there were 75 associated intraabdominal injuries; there were 25 liver injuries. Five patients died, none as a result of their gallbladder injury. Cholecystectomy is suggested as the definitive procedure of choice for severe contusions and for perforating and avulsive injuries to the gallbladder. Cholecystostomy is indicated in a few patients and should be regarded as a temporary procedure. A review of the English literature shows a total of 101 patients (including the 31 of this study) with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The 20 contusions described in the present study are the first such injuries reported.

Pitfalls of peritoneal lavage in blunt abdominal trauma

Peritoneal lavage is a sensitive detector of intra-abdominal injury following blunt trauma. The open method of diagnostic lavage is advocated, because it is associated with less morbidity. Although quantitative and qualitative methods are available to interpret lavage returns, the results, in some patients, do not correlate with the severity of injury found at laparotomy. Diaphragmatic and extraperitoneal injury are illusive to detection by peritoneal lavage. Despite the pitfalls of peritoneal lavage, we still recommend its use for all patients suspected of having an intra-abdominal injury.

Open diagnostic peritoneal lavage in blunt trauma victims

Open diagnostic peritoneal lavage was 97.8 per cent accurate for diagnosis of intra-abdominal injury in 2,072 blunt trauma victims. The only significant injuries missed were in certain patients with a ruptured hemidiaphragm, renal trauma and extraperitoneal bladder rupture. However, these injuries were identified by other means. False-postive lavage results are generally a consequence of technical error and can be minimized by careful surgical technique. Hemoperitoneum must be explained for all patients to prevent needless morbidity and mortality. Only diagnostic tests of proved value in blunt abdominal trauma should be used and risk to the patient must be minimized. We currently rely upon diagnostic laparotomy to evaluate hemoperitoneum in patients with a weakly positive lavage result confirmed by a second infusion. With this policy, approximately one of every four to five laparotomies was for injuries not requiring surgical therapy; and, the over-all morbidity rate and mortality was 12 and 3.5 per cent, respectively, in this group. By using open diagnostic peritoneal lavage in essentially all blunt trauma victims, we have had no deaths from either unrecognized intra-abdominal injury or delayed treatment.

A new nonpenetrating ballistic injury

A new, nonpenetrating ballistic injury mechanism involving individuals protected by soft body armor is described. Experimental studies using laboratory animals have demonstrated that despite stopping missile penetration, the heart, liver, spleen, and spinal cord are vulnerable to injury. The rapid jolting force of an impacting bullet is contrasted with the usually encountered mechanisms producing blunt trauma injury. The experimental methodology used to assess a 20% increase in survival probability and an 80% decrease in the need for surgical intervention with a new soft body armor is reviewed. Five cases of ballistic assaults on law enforcement personnel protected by soft body armor are presented. Four emphasize the potentially lifesaving qualities of the armor, while the fifth indicates the need for torso encircling design. Hospitalization should follow all assaults, regardless of the innocuous appearance of the skin lesion and the apparent well being on the assaulted individual. Therapeutic guidelines for patient management are suggested.

Transcatheter embolization of autologous clot in the management of bleeding associated with fractures of the pelvis

Extraperitoneal hemorrhage, associated with a fracture of the pelvis, is a major cause of death in pedestrian accidents. Transfusion alone may be unsatisfactory. Direct control of bleeding may be required. Surgically, this may be technically difficult or inadequate. Transcatheter embolization of autologous clot was used to control hemorrhage in three patients with such a fracture. If laparotomy is required immediately, arteriography of the pelvic area may be done postoperatively, If laparotomy is not performed, arteriography may define pelvic bleeding sites. Transcatheter embolization of autologous clot controls hemorrhage from branches of the hypogastric artery.