Original Contribution

The relationship between alcohol consumption and injury in ED trauma patients

Yoonhee Choi MD ^a, Kooyoung Jung MD, PhD ^b,?, Eunkyung Eo MD ^b, Donghoon Lee MD ^c, Junsig Kim MD ^d, Dongwun Shin MD ^d,

Sungeun Kim MD ^e, Mijin Lee MD ^f

^aDepartment of Emergency Medicine, Eulji University, Seoul, South Korea ^bDepartment of Emergency Medicine, Ewha Women’s University, Seoul, South Korea ^cFire Department, Daegu, South Korea

^dDepartment of Emergency Medicine, Inha University, Incheon, South Korea ^eDepartment of Emergency Medicine, Inje University, Gyeonggi-do, South Korea ^fDepartment of Emergency Medicine, Catholic University, Seoul, South Korea

Received 12 December 2007; revised 30 July 2008; accepted 30 July 2008

Abstract

Background: Alcohol-related injuries are significantly more serious than non-alcohol-related injuries. However, there have been few data on the relationship between alcohol consumption and injury in the Korea. This study was designed to determine the absence or Presence of alcohol consumption at the time of injury and the relationship between the quantity of alcohol and the extent of injury.

Materials and Methods: The study subjects consisted of trauma patients aged 15 years or older with the emergency department admission at 5 emergency medical centers. With the informed consent, patients were screened using the questionnaire and blood alcohol concentration. The subjects were divided into 2 groups according to the blood alcohol concentration level: the nonintoxicated and intoxicated groups. The demographic characteristics, cause of injury, injury severity, and length of hospitalization were compared between the 2 groups.

Results: Of a total of 407 cases, there were 123 cases in the intoxicated group and 284 cases in the nonintoxicated group. As to the severity of injury, an Abbreviated Injury Scale was significantly higher in the head and face. Injury Severity Score was higher in intoxicated group with marginal statistical significance. There was no significant difference in the total length of hospitalization, but the length of intensive care unit admission was significantly longer in the intoxicated group than in the nonintoxicated group.

Conclusion: There may be no significant correlation between alcohol consumption and injury severity. However, injury severity may increase with increasing quantity of alcohol and be greater in head injuries.

(C) 2009

* Corresponding author. Ehwa Women’s University Hospital, Jongno 6(yuk)-ga, Jongno-gu, Seoul, 110-783, South Korea. Tel.: +82 2 760 5452, +82 11

9880 5296 (Mobile).

E-mail address: [email protected] (J. Kooyoung).

0735-6757/$ - see front matter (C) 2009 doi:10.1016/j.ajem.2008.07.035

Introduction

Background

Excessive alcohol consumption can cause physical and mental health problems and can lead to traffic accidents, falls, fires, and violence. Alcohol consumption is the leading cause of trauma, which in turn is the leading cause of emergency department visits, accounting for approximately 23% of all of emergency department visits [1,2]. Alcohol- related injuries are serious compared with other diseases and are responsible for economic loss due to lost productivity. Because the risk of traffic accidents, fires, and mortality are significantly higher in intoxicated individuals, screening by blood alcohol concentration measurement and counseling may decrease the incidence of trauma [1].

Drinking heavily or on a weekly basis is strongly associated with alcohol-related injuries. However, these results vary across different countries or regions depending on such factors as drinking patterns and the social acceptance of drinking [3]. In Korea, public attitudes to drinking are strikingly permissive. Because Koreans drink frequently, they do not consider drinking to be a disease. There are no legal regulations on drinking in a public restaurant, and although there is a legal drinking age, there is little vigilance in enforcing the legal drinking age. Thus, a social atmosphere of easy accessibility to alcohol and excessive alcohol consumption is present. In Korea, the percentage of alcohol drinkers was 57% of the general population in 1989 and 64.5% in 1999 [4]. However, although the number of alcohol drinkers increased, there is little data on the causal association between alcohol consumption and injury severity. This assessment may help to establish strategies to prevent alcohol-related injuries.

Goals of this investigation

This study was designed to evaluate the effects of alcohol consumption on injury type and severity in emergency department trauma patients in Korea.

Materials and methods

Study design and selection of participants

Study subjects consisted of trauma patients admitted to 1 of 5 emergency medical centers located in the metropolitan area between July 20, 2005, and October 20, 2005. Of 47 578 patients, 7536 were trauma patients. Of these, 1188 were 15 years or older and required admission. Excluding 827 patients who did not consent to the questionnaire survey and BAC measurements, we enrolled 361 patients (30.4%) in this study. With informed consent, patients were screened using a questionnaire and BAC measurements. In cases of life-

threatening trauma, head trauma with altered mentality, and emergency surgery, in which responding to a questionnaire was unfeasible, injury extent and BAC were determined before acquiring informed consent. If there was no improve- ment in the clinical course of these Severe trauma patients, informed consent was obtained from the patient’s family. In cases of death on arrival, only BAC was measured. Subjects who arrived beyond 6 hours after trauma or who continued to drink after trauma were excluded from the study.

Data collection and processing

The subjects were divided into 2 groups according to BAC. Intoxicated patients had a BAC above 10 mg/dL, whereas sober patients had a BAC below this level. The 2 groups were compared in terms of age, sex, time of injury, hospital arrival time, vital signs (blood pressure, pulse rate, respiration rate, and body temperature), consciousness level (Glasgow Coma Scale [GCS]), cause of injury, anatomical diagnosis based on the international disease classification, length of hospitalization, and injury severity. To compare injury severity, we obtained the Abbreviated Injury Scale and the Injury Severity Score (ISS). An ISS of 15 or greater or an AIS of 3 or greater was defined as a “severe injury” [5,6].

All statistical analyses were performed using SPSS version 12.0 (SPSS Inc, Chicago, Ill). Comparison of categorical data was made using the ?2 test, and comparison of continuous variables was made using Student t test. P b.05 was considered significant.

Results

Demographic characteristics

The number of male patients (265 patients, 73.4%) was larger than the number of female patients (96 patients, 26.6%). The mean age of the intoxicated patients was significantly lower than that of sober ones (P b.001, Table 1). Sixty-two patients (17.2%) were admitted to the intensive care unit (ICU), 2 patients (0.6%) died in the emergency department, and 4 patients (1.1%) died on arrival.

Table 1 Demographic characteristics according to BAC levels

BAC positive (n = 105)		BAC negative (n = 256)	P
Mean age (y)	39.0 +- 13.7	45.6 +- 19.0	b.001
Sex (%)
M/F	7.1:1	2.1:1	b.001
Male (n = 265)	92 (87.6)	173 (67.6)
Female (n = 96)	13 (12.4)	83 (32.4)

BAC positive (n = 105)		BAC negative (n = 256)	P
ISS >=15 (%)	22 (21.0)	30 (11.7)	.023
Head AIS >=3	27 (25.7)	34 (13.3)	.004
Thorax AIS >=3	13 (12.4)	19 (7.4)	.132
Abdomen AIS >=3	6 (5.7)	8 (3.1)	.247
Extremity AIS >=3	12 (11.4)	50 (19.5)	.064

Causes of injury

Table 2 Causes of injury in BAC-positive and BAC-negative groups

Table 4 Comparisons of injury severity between severe injury patients in BAC-positive and BAC-negative groups

BAC positive BAC negative			P
	(n = 105)	(n = 256)
Traffic accidents (%)	31 (29.5)	81 (31.6)	.001
Slips (%)	26 (24.8)	67 (26.2)
Falls (%)	9 (8.6)	33 (12.9)
Penetrating trauma (%)	17 (16.2)	23 (9.0)
Blunt trauma (%)	5 (4.8)	30 (11.7)
Violence (%)	14 (13.3)	10 (3.9)
Others (%)	3 (2.9)	12 (4.7)

The causes of injury were, in decreasing order of frequency, traffic accidents (112 patients, 31.0%), slips (93

patients, 25.8%), falls (42 patients, 11.6%), penetrating trauma by sharp objects (40 patients, 11.1%), blunt trauma (35 patients, 9.7%), violence (24 patients, 6.6%), and others (14 patients, 3.9%). Injury by violence was more frequent in intoxicated patients than in sober ones (Table 2).

Comparison of injury severity between intoxi- cated and sober patients

The average GCS was 13.5 +- 6.8 in the group of intoxicated patients and 14.6 +- 1.9 in the group of sober patients; this difference was not statistically significant. The average systolic blood pressure was 113.2 +- 32.1 mm Hg in intoxicated patients and 130.2 +- 27.4 mm Hg in sober patients, with a significant difference between the 2 groups (P b.001). The average head AIS was 1.1 +- 1.7 in intoxicated patients and 0.6 +- 1.2 in sober patients, with a significantly higher head AIS in intoxicated patients (P = .008, Table 3). The average ISS was 9.3 +- 8.1 in intoxicated patients and

7.7 +- 6.2 in sober patients; however, this difference was not statistically significant (P = .066). Mortality was signifi- cantly higher in intoxicated patients than in sober ones (6 deaths, 5.7%, vs 5 deaths, 2.0%; P = .003) (Table 3).

Table 3 Comparison of Injury severity between BAC- positive and BAC-negative groups

Comparison of injury severity between severely injured patients

There was a significantly higher number of intoxicated patients with severe injuries and specifically with Severe head injuries (head AIS >=3). Twenty-two (21.0%) intoxi- cated patients and 30 (11.7%) sober patients were severely injured (P = .023), as defined by an ISS of 15 or greater. Twenty-seven (25.7%) intoxicated patients and 34 (13.3%) sober patients had severe head injuries (P = .004, Table 4). There was no significant difference in thorax or abdomen injuries between the 2 groups (Table 4).

Comparison of the length of hospitalization

The total length of ICU admission was significantly higher in intoxicated patients than in sober ones (P = .024, Table 5); the duration of ICU admission was 1.9 +- 4.6 days in intoxicated patients and 0.7 +- 2.6 days in sober patients. The total length of hospitalization did not differ significantly between the 2 groups.

Comparison of injury severity according to BAC

There was no significant correlation between BAC and injury severity. However, injury severity tended to increase in patients with BAC levels less than 200 mg/dL, decrease in patients with BAC levels between 200 and 250 mg/dL, and increase again in patients with BAC levels 250 mg/dL or higher (Fig. 1).

Discussion

Alcohol consumption is an important risk factor for disease and injury, and it may decrease adaptation, work

BAC positive (n = 105)		BAC negative (n = 256)	P
GCS score	13.5 +- 6.8	14.6 +- 1.9	.105
Mean SBP (mm Hg)	113.2 +- 32.1	130.2 +- 27.4	b.001
ISS	9.3 +- 8.1	7.7 +- 6.2	.066
Head AIS	1.1 +- 1.7	0.6 +- 1.2	.008
Thorax AIS	0.5 +- 1.1	0.4 +- 1.0	.360
Abdomen AIS	0.4 +- 0.9	0.3 +- 0.7	.360
Extremity AIS	1.0 +- 1.1	1.5 +- 1.1	b.001
Mortality (%)	6 (5.7)	5 (2.0)	.003
SBP indicates systolic blood pressure.

Table 5 Comparisons of length of hospitalization (day) between BAC-positive and BAC-negative groups
	BAC positive (n = 105)	BAC negative	P
ICU	1.9 +- 4.6	0.7 +- 2.6	.024
General ward	14.9 +- 19.6	18.1 +- 19.0	.147
Total	16.7 +- 20.1	20.4 +- 24.3	.178

(n = 256)

Fig. 1 The relationship between BAC and ISS. N indicates the number of patients.

performance, and risk awareness [7-9]. In addition, alcohol consumption has been known to increase the incidence of injuries from home accidents, fires, driver, pedestrian accidents, and the like [10,11]. Specifically, mortality is 8 times higher, traffic accidents are 5 times higher, and burns or fires are approximately 10 times higher in heavy drinkers than in the general population [12]. Based on the Emergency Room Collaborative Alcohol Analysis Project from 31 emergency departments covering 7 countries, BAC and self-reported alcohol consumption are predictive of an injury compared with a noninjury, with odds ratios of 1.51 and 1.58, respectively [3,13]. In addition, alcohol consumption can lead to suicide, gunshot accidents, falls, drowning, traffic accidents, and violence [14]. In the present study, the incidence of injuries from violence and penetrating trauma was significantly higher in intoxicated patients than in sober ones; however, in contrast to previous reports, there was no significant difference in the incidence of injuries sustained from traffic accidents and falls.

Many recent studies have reported that the risk for injury increases with increasing BAC, but the association between alcohol and both injury severity and Treatment outcome is still controversial [15-17]. According to Jurkovich et al [18], trauma in acute or chronic alcohol intoxication has no significant correlation with BAC and GCS, suggesting that alcohol does not adversely affect injury severity. Brickley and Shepherd [19] compared the ISS between intoxicated and sober patients (n = 1957) and found no significant difference between the 2 groups but high correlation between BAC and GCS. Other studies suggested that the presence of positive BAC dose not result in a clinically significant reduction in GCS [20]. In body region prevalence of injury in alcohol-related injury, more injuries to the head and facial areas compared with other body parts were found in intoxicated patients [21]. Fuller [22] has demonstrated that the ISS and mortality were not affected in acute alcohol intoxication, but length of hospital stay was significantly short for intoxicated patients. Conversely, Spaite et al [23] documented that the mean ISS (n = 350) and the mean length of hospitalization were both higher in intoxicated patients as compared with sober ones. In addition, Cherpitel [24] and

Deutch et al [25] advocate that alcohol increases injury severity and mortality.

In the present study, the ISS was higher in intoxicated patients, though this was not statistically significant. Abbreviated Injury Scale was significantly higher in cases of head injury. In addition, higher mortality and longer hospitalization were noted in intoxicated patients. In cases of head injury, continued intoxication induces metabolic acidosis, a decrease in consciousness level with dyspnea, and vasodilation with hypotension, ultimately leading to a decrease in cerebral perfusion. Through this mechanism, the brain tissue sustains secondary injuries with neurologic deficits, and the mortality in patients with traumatic brain injury increases when associated with these secondary injuries [26].

Many recent studies on BAC indicate that alcohol consumption increases the risk for injury, regardless of BAC. The risk for injury and injury severity are not always proportional to BAC. A study on the association between alcohol and traffic accidents demonstrates that overall injury severity is higher in intoxicated patients than in sober ones. However, overall severity is significantly higher in patients with a BAC of 2 to 32.3 mmol/L (10-150 mg/dL, low alcohol concentration group), similar in patients with a BAC of 32.3 to 43.2 mmol/L (150-200 mg/dL), and lower in patients with a BAC of 54 mmol/L or higher (>=250 mg/dL, high alcohol concentration group) [11]. In the present study, injury severity tended to increase in patients with a BAC of up to

43.2 mmol/L (20 mg/dL), was similar in patients with a BAC of 43.2 to 54 mmol/L (200-250 mg/dL), and, unlike the findings in the international reports, increased again in patients with a BAC of 54 mmol/L or higher (250 mg/dL). The findings in this study are subject to several limitations. First, although this study included patients with severe injuries, the 5 emergency medical centers involved in this study had different criteria for admission. To control for these factors, we determined the correlation between alcohol consumption and injury severity only in patients with an ISS of 15 or higher. Second, we attempted to obtain informed consent for blood samples and questionnaires, but 827 (69%) of 1188 patients did not consent to the questionnaire survey and blood sampling. Because BAC measurement can produce more legal and ethical problems than self-reported alcohol consumption, patients refused to give consent. In this study, there were 14 (5.5%) BAC-negative cases that reported alcohol consumption, which is similar to interna- tional reports. However, there were 14 patient (13.3%) cases that were BAC-positive and denied alcohol consumption, which is much higher than in the international reports. Self- reported alcohol consumption and BAC measurement may

show social, cultural, and individual differences.

Only trauma patients with an emergency department visit within 6 hours after injury were included in this study. Because the time of BAC measurement does not always accurately reflect the patient’s mental status at the time of injury, and tolerance to alcohol differs between individuals,

data on the association between BAC and injury might be inaccurate, even after controlling for the time of injury.

In conclusion, based on the results of this study on the effects of alcohol consumption on injury severity, we suggest that the ISS tends to increase in the intoxicated group with marginal statistical significance, and head injury severity is significantly higher in intoxicated patients than in sober ones. This study demonstrates significantly higher mortality and longer admission to the ICU stay.

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