National Institute on Alcohol Abuse and Alcoholism No. 3 January 1989

Alcohol and Trauma

Trauma is a major cause of mortality and morbidity in the United States. Each year, more than 140,000 Americans die from injuries, and almost one person in three suffers a nonfatal injury serious enough to require medical attention or to cause temporary disability (Committee on Trauma Research 1985). Injuries, both unintentional and intertional, rank as the fourth leading cause of death for the total population and as the leading cause of death for persons aged 1 to 44 years (Baker et al. 1984). In 1983, unintentional injuries resulted in 2.3 million years of potential life lost (YPLL) while suicide and homicide resulted in 1.2 million YPLL (CDC 1986). Injuries accounted for 31.9 percent of all YPLL in 1986, the most recent year of complete vital statistics (CDC 1988).

Alcohol plays a significant role in trauma. According to Lowenfels and Miller (1984), alcohol intoxication (BAC 100 mg/dL) is associated with 40 to 50 percent of traffic fatalities; 25 to 35 percent of nonfatal motor vehicle injuries; up to 64 percent of fires and burns; 48 percent of hypothermia and frostbite cases; and about 20 percent of completed suicides. Although not necessarily at the level of intoxication, alcohol also has been estimated to be present in 40 percent or more of falls and nearly 50 percent of homicides (victim or perpetrator). More recently, Goodman and colleagues (1986) found that 30 percent of victims of criminal homicide in Los Angeles had a BAC > 100 mg/dL. Haberman (1987) reviewed 4 years of medical examiner cases in a New Jersey county and found positive BACs in 53 percent of traffic accident fatalities and 47 percent of nontraffic accident fatalities.

Because of definitional and methodological differences across alcohol and trauma studies, it is difficult to obtain precise estimates of alcohol's role in trauma events. However, Roizen (1988) reviewed emergency room studies and found that between 20 and 37 percent of all emergency room trauma cases involved alcohol use. Moreover, Waller (1988) estimates that between 20 and 25 percent of all persons hospitalized with an injury have identifiable problem drinking or alcoholism. Some physicians view trauma as an indicator of alcohol abuse and alcoholism (Abrams 1986; Clark et al. 1985; Maull et al. 1986; Skinner et al.1984).

In the context of trauma, alcohol users increase their risk in two ways: likelihood of injury and seriousness of injury. First, alcohol abusers are more likely than sober persons to be involved in a trauma event (Maull 1982; Perrine 1975), i.e., heavy drinkers have a higher risk for accidents than nondrinkers (e.g., Anda et al.1988).

Second, given similar traumatic circumstances, a drinker is likely to be hurt more seriously than a nondrinker. Although there are some exceptions (e.g., Huth et al. 1983; Ward et al. 1982), most research findings support this positive relationship between alcohol use and severity of injury (Roizen 1988). The exact mechanisms of the alcohol-severity relationship are not known (Maull 1982), but the relationship has been further supported by experimental studies that controlled for blood alcohol level, type of injury, and severity of trauma (e.g.. Albin et al. 1986; Anderson 1986). In addition, Waller and colleagues (1986) found potentiating effects of alcohol on driver injury after controlling for several other traffic accident risk factors. It should be noted that at least one researcher (Smith 1986) questions the validity of alcohol-severity effects in trauma events not related to motor vehicle crashes. Nevertheless, the belief that intoxicated persons are less likely to be seriously hurt or killed in an accident because they are so relaxed is probably a myth, as noted by Kirn (1988), Waller and colleagues (1986), and Waller (1987).

The preponderance of data linking alcohol and trauma deserves close scrutiny. Alcohol frequently complicates diagnosis of trauma-related injury (Lowenfels 1982; Soderstrom et al. 1979). For example, emergency room physicians can overdiagnose by interpreting signs of intoxication (e.g., slurred speech or memory lapse) as symptoms of serious head injury, especially if the patient's breath does not smell of alcohol. Conversely, physicians can underdiagnose by attributing most or all injury symptoms to intoxication, thereby missing possible coexisting and life-threatening conditions. Signs of intoxication can mimic other conditions. In the alcohol tolerant drinker, for example, alcohol alone would rarely produce a coma (Knott 1986). Such diagnostic difficulties are especially common with head injuries, which are frequently alcohol related (Brismar et al. 1983; Hillbom and Holm 1986; Jagger et al. 1984; Simonsen 1984).

In addition, alcohol can seriously complicate the management and treatment of the trauma patient. For example, several investigators (Abeloos et al. 1985; Lowenfels 1982; Edwards 1985) emphasize the risk of administering anesthesia to intoxicated patients. Abeloos and colleagues (1985) suggest that--given the extreme risks of anesthesia with highly intoxicated patients--surgery may need to be delayed, if possible, until blood alcohol levels are known and fall below the level of 250 mg/dL. A critical problem with acute intoxication during anesthesia appears to be regurgitation and aspiration of the stomach contents (Abeioos et al. 1985).

Ethanol and other drug reactions or interactions are possible and must be considered in any decisions involving medication, anesthesia, or surgery (Marco and Randels 1981). With the alcoholic, other medical complications also may arise, including electrolyte and fluid imbalance, blood coagulation problems, cardiomyopathy, hepatic dysfunction, and alcohol withdrawal (Edwards 1985).

Proper diagnosis and treatment of trauma patients almost demand routine blood alcohol testing as part of emergency room admissions (Maull et aI. 1986; Soderstrom and Cowley 1987; Zuska 1981). Maull and colleagues (1986) state that physicians should assume alcohol involvement in trauma cases unless blood alcohol tests show otherwise. Without such tests, it is impossible to know a patient's condition with confidence (Waller 1988). Clinical signs of intoxication (e.g., slurred speech, bloodshot eyes, lack of coordination) may be absent and are sometimes unreliable. Waller (1988) stresses the need to actively check for alcohol abuse because it is possible to overlook it in all patients except those with the most flagrant and late-stage alcohol disease patterns. Rockett and Putnam (1986) recommend that hospital personnel routinely document alcohol information for injury cases: 1) to ensure providing appropriate medical care, especially for head injuries; and 2) to detect problem drinking and create potential for early referral of alcohol-troubled persons to treatment.

Despite these data on the relationship of alcohol to trauma, the results of emergency room research indicate that routine testing for alcohol in trauma patients is relatively rare (Maull et al. 1984; Simel and Feussner 1988). Chang and Astrachan (1988) found that house staff assessed only one-quarter of 320 motor vehicle accident patients in an emergency department at an urban hospital. Further, among 47 patients who were BAC positive at 200 mg/dL or more, not one was referred for alcohol abuse evaluation or treatment. In a national survey (Soderstrom and Cowley 1987), only 55.2 percent of trauma centers surveyed reported routine testing for blood alcohol.

Waller (1988) acknowledges barriers that a physician may encounter when trying to diagnose a problem with drinking or alcoholism, but he sugge sts that the physician can make the problem far worse by ignoring it. Physicians who do not test for alcohol abuse risk misdiagnosing and possibly mismanaging a coexisting condition. Finally, they miss the opportunity for referral, an action that may save lives (Maull 1982; Simel and Feussner 1988). Successful use of this opportunity was demonstrated in a recent study (Gentilello et al. 1988) in which planned intervention spurred 17 out of 19 alcoholic trauma patients to accept immediate referral to a treatment program.

Alcohol and Trauma - A Commentary by
NIAAA Director Enoch Gordis, M.D.

In managing traumatic injury, it is essential to obtain accurate information on patient alcohol use and to refer alcohol abusers for appropriate treatment.

Although extensive evaluation of alcohol abuse, especially in busier emergency rooms, may not always be feasible, at a minimum, screening of blood alcohol levels must be done routinely. Doing so provides a quick picture of alcohol as a factor in managing the trauma without compromising emergency room functioning. It also reduces risk for errors that can result from basing diagnoses solely on external signs, such as inebriated behavior or the smell of alcoholic beverages on a patient's breath, rather than basing diagnoses on appropriate medical evaluation.

Bias against treating an inebriated patient who is uncooperative and disruptive may lead to quick disposition of that case in order to free up time for more "deserving" patients. Or, stupor in a patient smelling of alcoholic beverages might be assumed to result only from heavy drinking. In either instance, appropriate medical evaluation could uncover head injuries, such as subdural or epidural hematoma, or other problems that often coexist with alcoholism, such as hypoglycemia, use of drugs other than alcohol, bacterial infections, or meningitis.

Alcoholics who incur trauma but, because of well developed tolerance, show no evidence of intoxication, present a special dilemma due to a variety of unexpected alcohol-related complications that may arise during trauma management. For example, depending on the recency of their drinking, many alcoholics vary in their response to therapeutic drugs, including anesthetics, a critical factor if an operation is required. An alcoholic patient also may enter withdrawal, further complicating management of the traumatic event.

Once patients have been stabilized, practitioners have another responsibility that is all too often ignored--referring alcohol abusers for appropriate alcohol treatment. Doing so is just as medically necessary as managing the traumatic event. In general, patients who should be referred include reasonably coherent persons with a high concentration of alcohol or other drugs of abuse in their body fluids; persons who are inebriated; persons who are in withdrawal; or persons in whom there is evidence of repeated trauma. Treatment needs will vary among victims of alcohol-related trauma, ranging from minimal intervention for episodic abuse to more intensive treatment for alcohol dependency.

Through referral, emergency medical personnel can help alcohol abusers and dependent patients reduce their risk for life-threatening health consequences, including future episodes of alcohol-related injury. Referral is especially critical for the many young victims of alcohol-related trauma for whom early intervention has a great payoff in terms of years of potential life saved.

References

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