Department of Neurology, Oulu University Hospital, Finland, 1 Department of Laboratory Medicine, Tampere University and Seinäjoki Central Hospital, Finland
* Author to whom correspondence should be addressed at: Olli Savola, Oulu University Hospital, Box 25, FIN-90029, Oulu, Finland. Tel.: +358 8 315 4137; Fax: +358 8 315 4544; E-mail: olli.savola{at}oulu.fi
(Received 30 September 2004; first review notified 28 October 2004; in revised form 3 January 2005; accepted 6 January 2005)
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ABSTRACT |
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INTRODUCTION |
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Binge drinking is currently a growing problem in most Western countries, and recent surveys in general hospitals have indicated that it may actually be a more prevalent cause of medical hazards than chronic drinking (Chikritzhs et al., 2001; Mäkelä et al., 2001
; Naimi et al., 2003
). Binge drinking has also been linked with an increased prevalence of trauma in several studies (Honkanen et al., 1976
; Cherpitel et al., 1995
; Rivara et al., 1997
; McLeod et al., 1999
; Li et al., 2001
; Borges et al., 2004
). McLeod et al. (1999)
reported that the consumption of
5 drinks on one occasion produces an odds ratio (OR) of 3.4 (95% confidence interval (CI) 1.86.4) for sustaining an injury. Despite the large body of evidence of alcohol abuse as a risk factor for trauma, little attention has been paid to the comparisons of the types and mechanisms of injury that are associated with different patterns of alcohol drinking and to actual blood alcohol levels at the time of injury.
The aim of this study was to examine the types and mechanisms of injury in consecutive trauma patients who underwent detailed interviews on the amount and pattern of drinking preceding the injury.
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SUBJECTS AND METHODS |
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After immediate critical care, all clinical data, including the cause, type and extent of injury were carefully recorded by trained emergency department physicians on a structured checklist designed for this purpose. The causes of injury were classified as follows: motor vehicle crash, fall on the ground, fall from height, assault, sport injury and unspecified injury (Table 1). Motor vehicle crashes (40) included both motor vehicle occupants (32) and motorcycle riders (8). The class of unspecified (113) injuries included both blunt (62) and penetrating/cutting (51) injuries. In each case, the injured body parts were divided into six categories as follows: head, spine, thorax, abdomen and upper and lower extremities. The presence of injury was recorded when there was a distinct physical evidence of trauma as assessed by the emergency room physician. Additionally, the injury severity score (ISS) was used as an index of trauma severity (Baker et al., 1974; Copes et al., 1988
). In the case of patients with head injury, the Glasgow coma scale (GCS) score was also determined, and the patients were graded as having mild (GCS 1315), moderate (GCS 912) or severe (GCS 38) brain injury. The emergency room physician decided the additional examinations (imaging) that were needed, and patients were subsequently treated according to the hospital routine protocols. All patients with head trauma were followed up for possible signs of neurological deterioration. The patients included in this study did not report cancer, multiple sclerosis, stroke, treated epilepsy or any other neurological diseases of known aetiology.
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Laboratory procedures
Venous blood samples were obtained upon admission, and blood alcohol concentrations were determined on a Vitros 250 clinical chemistry analyzer (Johnson & Johnson Clinical Diagnostics, Rochester, NY). ALCO-SENSOR III (Intoximeters, Inc, St Louis, MI) was used for the breath analyses.
Statistical methods
Continuous variables were compared between the groups by using Student's t-test with SPSS, version 10.0, for Windows. OR and 95% CI and differences between proportions and 95% CIs were calculated by using the CIA statistical software version 1.0. OR estimates and 95% CIs after adjustments for age and sex were calculated by logistic regression with SPSS.
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RESULTS |
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DISCUSSION |
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These findings emphasize the adverse consequences of binge drinking, which may also manifest as severe intoxications in individuals who are not regular drinkers and who do not have increased tolerance to alcohol. Naimi et al. (2003) reported recently that the overall prevalence of binge drinking is 14% among US adults and found that 73% of all binge drinkers can be classified as moderate drinkers in terms of their total alcohol consumption. The number and proportion of binge drinkers in Finland is known to be relatively high. Mäkelä et al. (2001)
found that the mean frequency of binging in Finland is
11 times a year. At the time of the present study the total amount of drinking in the area (Northern Finland), in which the study was conducted (7.9 l of pure ethanol/capita) has been somewhat lower than the average in Finland (8.8 l). Recent national statistics have, however, shown that only 8% of adult men and 9% of women are abstainers, whereas a total of 51, 31, 20 and 15% of men between 1519, 2029, 3049 and 5069 years report binge drinking at least once a month, respectively. The corresponding percentages for women are 23, 12, 5 and 3%, respectively (Metso et al., 2000
). The high binging rate among the trauma patients in our study supports previous findings, indicating that the incidence of trauma is concentrated particularly in this type of population (Cherpitel et al., 1995
; McLeod et al., 1999
; Borges et al., 2004
). Future studies should also address the possibility whether there is an impact of weekend drinking and the time of day on the occurrence of alcohol-related traumas.
In our study, we found that BACs >150 mg/dl markedly increase the relative risk of sustaining head trauma. To our knowledge, this is the first study to report how the risk for head trauma specifically increases upon increasing BAC, even though high proportions of BAC-positive patients with head trauma have also been reported earlier (Rimel et al., 1982; Brismar et al., 1983
; Corrigan 1995
; Dikmen et al., 1995
). Our finding that 51% of all trauma patients had alcohol in their blood on admission is in good agreement with previous studies (Rivara et al., 1993
). However, in studies that included only patients with head trauma, the estimated frequencies of BAC-positives have varied from 32 to 73% (Rimel et al., 1982
; Brismar et al., 1983
; Kraus et al., 1989
; Sparadeo and Gill, 1989
; Ruff et al., 1990
; Porter, 2000
). In our series, the corresponding percentage was high (65%), whereas the subjects with other types of injury showed a lower percentage (32%). It should be noted that in previous studies, only part of the patients have been tested for BAC, and the characteristics of study design may also have differed from ours (Rimel et al., 1982
; Brismar et al., 1983
; Kraus et al., 1989
; Sparadeo and Gill, 1989
; Ruff et al., 1990
; Porter, 2000
).
The causes of head trauma under the influence of alcohol were typically assaults, falls and biking accidents. Not surprisingly, nearly all those who were injured by violence were BAC-positive on admission, and all the assault victims were dependent drinkers or frequent binge drinkers. The high prevalence of hazardous alcohol drinking among assault victims has also been noted earlier (Brismar et al., 1983). In accordance with recent findings by Li et al. (2001)
, the risk for bicycling injury was also found to be increased among patients who were BAC-positive. In this study, bicycling under the influence of alcohol also increased the risk for head traumas, whereas the bicyclists without any alcohol in blood more often avoided head trauma and injured their extremities upon accidents. This probably reflects the deleterious effects of alcohol on psychomotor skills and the lack of preventive mechanisms to respond to situational hazards, which, in turn, may favour the occurrence of head trauma. This view was further supported by the finding that those who were also injured owing to falls and were BAC-positive were more frequently injured on the head than their sober counterparts.
Here, we did not find any association between the severity of head trauma and positive blood alcohol levels. Although some trials have indicated that alcohol could even protect from the consequences of injury, it is currently known that alcohol intoxication is associated with the occurrence of serious injuries and death from a wide variety of causes (Ward et al., 1982; Waller et al., 1986
; Li et al., 2001
). Our series did not include the victims who died immediately on the scene. Obviously, many accidental deaths occur before hospital admission (Waller et al., 1986
) and thus, future population-based studies appear warranted to specifically address this issue. In this work, we also excluded children and those who were at the age of
50 years. In these groups, the occurrence of excessive alcohol consumption and injuries may be different from those observed here (Luukinen et al., 1999
; Porter, 2000
). Indeed, traumas are known to be major causes of morbidity, mortality and persistent functional impairment, particularly among young adults and working aged individuals (Kraus, 1993
; Levin, 1993
).
Interestingly, in this series of trauma patients we found a relatively low percentage of dependent drinkers (8%) compared with frequent binge drinkers (61%). Previously, the methods used to detect alcohol problems have varied greatly (Rimel et al., 1982; Brismar et al., 1983
; Sparadeo and Gill, 1989
; Kreutzer et al., 1990
; Ruff et al., 1990
; Kreutzer et al., 1991
; Drubach et al., 1993
; Wong et al., 1993
). The lowest incidences of alcohol-related accidents, such as 16% (Rimel et al., 1982
), 25% (Sparadeo and Gill, 1989
) and 36% (Wong et al., 1993
) have been reported in studies in which the assessments have been based on retrospective chart reviews. The highest incidences i.e. 66% (Kreutzer et al., 1991
) and 58% (Kreutzer et al., 1990
) have been reported from series drawn from rehabilitation centers. Approximately 45% of trauma patients have previously reported alcohol misuse based on screenings with the CAGE and SMAST questionnaires (Nilssen et al., 1994
).
In conclusion, this study shows that binge drinking is the characteristic pattern of drinking among trauma patients, and that the injuries of such patients typically result from assaults, falls and biking accidents. Excessive alcohol consumption appears to specifically increase the risk for head trauma as a function of increasing BACs.
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ACKNOWLEDGEMENTS |
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