CHAPTER 4 THE ROLE OF ALCOHOL AND OTHER DRUGS IN TRAUMA
Injury has been characterized as the neglected disease of modern society.1 However, data suggest that for a significant number of trauma patients, injuries are an unrecognized symptom of an underlying alcohol or other drug use problem. Nearly 50% of injury deaths are alcohol related. Traumatic injury accounts for roughly the same number of alcohol-related deaths as cirrhosis, hepatitis, pancreatitis, and all other medical conditions caused by drinking, combined. A multicenter study that included data on more than 4000 patients admitted to six trauma centers demonstrated that 40% had some level of alcohol in their blood upon admission.2 If drug use is included, up to 60% of patients test positive for one or more intoxicants.2–4
EFFECTS OF ALCOHOL AND DRUGS ON MANAGEMENT AND OUTCOME
The presence of alcohol significantly affects the initial management of trauma patients. Intoxicated patients are more likely to require intubation for airway control, intracranial pressure monitoring for neurological assessment, and more diagnostic tests such as CT scans to evaluate the abdomen.5,6 Alcohol use may also increase the risk of death from serious injury. One study used data from more than 1 million drivers involved in a crash and controlled for the effects of variables such as safety belt use, vehicle deformation, speed, driver age, weather conditions, and vehicle weight, and found that intoxicated drivers were more than twice as likely to suffer serious injury or death compared with nondrinking drivers in a crash of equal severity.7
Patients with a history of chronic alcohol use are more likely to have underlying medical conditions such as cardiomyopathy, liver disease, malnutrition, osteoporosis, and immunosuppression. Acute, in addition to chronic, alcohol use may also affect outcome from trauma. Alcohol causes respiratory depression as well as vasodilatation that limits the ability to compensate for major blood loss. One study measured the amount of hemorrhage required to induce hypotension in dogs, and found that intoxication decreased this volume by one third.8 Acute alcohol intoxication has also been shown to be immunosuppressive. One study analyzed infectious complications in patients with penetrating abdominal trauma and hollow viscus injury.9 A blood alcohol concentration of 200 mg/dl or more was associated with a 2.6-fold increase in abdominal infectious complications, even after controlling for chronic use.
ALCOHOL AND INJURY RECIDIVISM
Traumatic injury is a recurrent disease, especially in patients with alcohol or drug use disorders.10 In a 5-year follow-up study of 263 alcohol intoxicated patients admitted to a level I trauma center, the readmission rate was 44%.11 Although the mean age of the group was only 32 years, the injury-related mortality was 20%, with 70% of deaths attributed to continuing alcohol and other drug use. In a larger, more comprehensive study, over 27,000 patients discharged from a trauma center were followed using death certificate searches to detect postdischarge mortality. Patients who screened positive for an alcohol use disorder had a 35% injury-related mortality rate during the study period, which was significantly higher than patients who screened negative.12
WITHDRAWAL SYNDROMES: PROPHYLAXIS AND TREATMENT
Two main types of alcohol withdrawal prophylactic regimens exist. The first is symptom-triggered therapy, and the second is fixed-schedule dosing with a taper. Symptom-triggered therapy reduces the amount of medication administered, as many patients develop only mild symptoms that do not require therapy.13 Symptoms are measured using a questionnaire such as the Clinical Institute Withdrawal Assessment–Alcohol Revised short form (CIWA–Ar), which measures 10 signs and symptoms of alcohol withdrawal on a 0–7 scale (nausea, tremor, autonomic hyperactivity, anxiety, agitation, tactile, visual and auditory disturbances, headache, and disorientation).14 Treatment is titrated to maintain a score in the mild (8–10) range. Although the CIWA–Ar has been used in general medical settings, it requires training and experience, must be repeated at regular intervals, and is not feasible in critically injured patients. For these reasons, fixed-scheduled dosing is commonly practiced in most trauma intensive care units.
All currently existing guidelines recommend the use of benzodiazepines as a primary therapy for alcohol withdrawal.15 Agents with a short to moderate half-life such as lorazepam are often used when frequent neurological assessments are needed, but may require increased overall dosage and more frequent administration in comparison to the longer-acting benzodiazepines such as diazepam and chlorodiazapoxide. Longer-acting drugs are preferred because slow elimination provides an intrinsic tapering effect.