- Email: [email protected]
Alcohol intoxication in road traffic accidents leads to higher impact speed difference, higher ISS and MAIS, and higher preclinical mortality
Alcohol 46 (2012) 681e686
Contents lists available at SciVerse ScienceDirect
Alcohol journal homepage: http://www.alcoholjournal.org/
Alcohol intoxication in road traffic accidents leads to higher impact speed difference, higher ISS and MAIS, and higher preclinical mortality Timo Stübig*, Maximilian Petri, Christian Zeckey, Stephan Brand, Christian Müller, Dietmar Otte, Christian Krettek, Carl Haasper Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 January 2012 Received in revised form 13 July 2012 Accepted 13 July 2012
Alcohol is one of the most important personal risk factors for serious and fatal injuries, contributing to approximately one third of all deaths from accidents. It is also described that alcohol intoxication leads to a higher mortality in the clinical course. In this study, we hypothesized that alcohol intoxication leads to different accident kinematics, a higher ISS (Injury Severity Score), and higher preclinical mortality compared to sober patients. A technical and medical investigation of alcohol intoxated road users was performed on the scene of the crash and at the primary admitting hospital. Alcohol testing was performed with either breath alcohol tests or measurement of blood alcohol concentration (BAC) in a standard laboratory test. Between 1999 and 2010, 37,635 road traffic accidents were evaluated by the Accident Research Unit. Overall 20,741 patients were injured, 2.3% of the patients were killed. Among the injured patients, 2.2% with negative BAC were killed, compared to 4.6% fatal injuries in patients with a positive BAC (p < 0.0001). Of the patients with a positive BAC, 8.0% were severely injured, compared to 3.6% in the BAC negative group (p < 0.0001). Regarding the relative speed at impact (Dv for motorized drivers, vehicle collision speed for pedestrians and bikers), there was a significant higher difference for BAC positive patients (30 20) compared to the BAC negative patients (25 19, p < 0.0001). Alcohol intoxication in trauma patients leads to higher preclinical mortality, higher impact speed difference, and higher injury severity. The subgroup analysis for different alcohol concentrations shows no difference in ISS, MAIS, and relative speed, but a correlation of increasing age of patients with higher alcohol concentrations. Ó 2012 Elsevier Inc. All rights reserved.
Keywords: Alcohol Trauma Road users Injury severity
Introduction Alcohol use has been well established as one of the most important personal risk factor for serious and fatal injuries, contributing to approximately one third of all deaths from accidents (Li, Keyl, Smith, & Baker, 1997; Maier, 2001; Zeckey et al., 2011). Described prevalence of alcohol intoxication in trauma patients at the time of admission in the hospital is ranging from 18% to 80% in literature depending on study design and inclusion criteria (Centers for Disease and Prevention, 2006; Fabbri et al., 2002; Lowenfels & Miller, 1984; Maier, 2001). Some reports for car drivers indicate that intoxicated drivers are more likely involved in a crash (Chang & Astrachan, 1988), are more likely responsible for crashes (Waller, 1972), and more often sustain fatal injuries than sober drivers (Kim, Nitz, Richardson, & Li, 1995; McCoy, Johnstone, Nelson, & Duthie, 1989; Robertson & Drummer, * Corresponding author. Tel.: þ49 511 532 2026; fax: þ49 511 532 5788. E-mail address: [email protected] (T. Stübig). 0741-8329/$ e see front matter Ó 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.alcohol.2012.07.002
1994). Abuse of alcohol is commonly reported to be associated with more severe injuries and thus a higher mortality in the clinical course (Fabbri et al., 2002; Pories et al., 1992; Tulloh & Collopy, 1994). However, Mann et al. describe that higher blood alcohol concentration (BAC) may lead to less severe injuries, without impacting mortality or length of hospital stay (Mann, Desapriya, Fujiwara, & Pike, 2011). Negative effects of alcohol concerning activities of daily life include retardation of the rate of visual scanning (Moser, Heide, & Kompf, 1998), reduced ability to react to random stimuli (Forchheimer, Cunningham, Gater, , & Maio, 2005), and increased risk-taking behavior (Brismar & Bergman, 1998; Mundt, Ross, & Harrington, 1992). Most of the past and present studies involve the effect of alcohol on the clinical outcome during the hospital stay. Several authors described a depressed posttraumatic immune response, leading to an increased risk for infectious diseases and mortality in alcoholintoxicated patients (Brezel, Kassenbrock, & Stein, 1988; Howland & Hingson, 1987; McGill, Kowal-Vern, Fisher, Kahn, & Gamelli, 1995; Zeckey et al., 2011).
682
T. Stübig et al. / Alcohol 46 (2012) 681e686
Data about the effect of alcohol on patients suffering from traumatic brain injury is inconsistent. While several studies described a beneficial effect of alcohol intoxication on admission regarding mortality (Berry et al., 2011; Salim et al., 2009; Zeckey et al., 2011), other studies could not confirm this effect, but showed a beneficial effect in patients with low dose alcohol intoxication (Mundt et al., 1992; Tien et al., 2006). A prior study of our department did not reveal a prognostic relevance of blood alcohol level at the time of admission in multiple trauma patients in the clinical course. Concerning overall injury severity, there were no ethanol-related differences; however, more severe abdominal injuries were found in alcohol intoxicated patients (Zeckey et al., 2011). Although several studies examined the clinical and mid-range outcome of car drivers, technical information about injury patterns, injury severity, and pre-clinical mortality is sparse. Moreover, patient size of the published reports remains small. We hypothesized that alcohol-intoxicated trauma patients show different accident mechanisms and accident kinematics as well as different injury patterns and injury severity compared to patients with negative blood alcohol levels. Secondly, we hypothesized that there is a dependence of these parameters on the blood alcohol level. The purpose of this study was to analyze the actual injury situation of alcohol-intoxicated injured people in Germany to create a baseline for effective preventive measures in a large retrospective cohort analysis.
clinical injury documentation on site (Otte et al., 2012; Otte et al., 2003; Richter et al., 2005; Richter et al., 2001). The patient relevant case report is carried on in the admitting hospital, with proper documentation of injury type and injury severity, including X-ray and CT diagnostics. The collected data allows an exactly scaled reconstruction of the crash site for later technical analysis of the crash. Vehicles, objects, victims, and any kind of deformation of involved vehicles or objects are measured, including this data in the crash analysis (Richter et al., 2007). Furthermore, data from a database containing technical features of involved vehicles (size, weight, detailed structural data comparable to finite element analysis data) are included in the analysis. The inclusion of the described data allows an exact estimation of parameters (Richter et al., 2007). The monitoring of the crash research unit includes demographic data, type of road user (car/truck occupant, motorcyclist, cyclist, pedestrian, bus and streetcar), relative speed at impact (km/h) (Dv for motorized vehicle user; vehicle collision speed (km/h) for bicyclists/pedestrians), Abbreviated Injury Scale (AIS), Maximum AIS (MAIS) score, Injury Severity Score (ISS), incidence of serious and/or severe multiple injuries, incidence of serious injuries (MAIS 2e4) or severe injuries (MAIS 5 of 6), and mortality. Statistics
The study was approved by the local Ethical Committee of Hannover Medical School, Germany, and follows the ethical standards of the Helsinki Declaration of 1975, as revised in 1983.
Statistical analysis was performed utilizing GraphPad Prism (GraphPad Software, San Diego, CA). The significance level was set to p < 0.05. For statistical analysis, Fishers exact test and students ttest was performed in case of normal distribution, in skew distributed data the ManneWhitney-U- und Wilcoxon-test was used. For contigency analysis, a Chi Square test was performed.
Scoring and group distribution
Results
The injury severity was classified according to the Injury Severity Score (ISS) (Baker, O’Neill, Haddon, & Long, 1974), based on the Abbreviated Injury Scale (AIS) (Greenspan, McLellan, & Greig, 1985). Blood alcohol concentrations (BAC) were measured by order of the police for further examinations in a standard laboratory procedure. If no BAC was available, results of the breath alcohol test were used. Alcohol concentrations (blood alcohol or breath alcohol) equal to or greater than 0.01 g% were defined as BAC positive. As the influence of alcohol on the investigated parameters might be dose dependent, subgroup analyses were performed. As driving is prohibited in Germany with BAC equal to or greater than 0.05 g%, it was another rationale to choose this level. Overall subgroups were calculated for BAC <0.05 g%. <0.15 g%. <0.3 g%, and >0.3 g%. Another subgroup analysis regarding ISS, MAIS, and relative speed was performed for different types of road users (i.e. car drivers, truck drivers, pedestrians, bicyclists).
Demographic data
Materials and methods
Between 1999 and 2010, 37,635 motor vehicle crashes were evaluated by the Accident Research Unit (Table 1). In total 16,894 patients of the patient collective were not injured, and 20,741 were injured. Of all injured patients, 2.3% were killed, 2.2% of the BAC negative patients and 4.6% of the BAC positive patient group (p < 0.0001). Overall alcohol was tested in 1769 (8.5%) of the patients with a positive result in 823(46.5%) patients and a negative result in 946 (53.5%) cases. The mean alcohol concentration was 0.22 g%. The male to female ratio was 62% male to 38% female overall, with a significant shift toward the male population in the blood alcohol positive patient group (p < 0.0001). The mean age was 38 18 years overall, with no differences between the alcohol intoxicated and the non-intoxicated group (Table 1). Injury characteristics and crash related data ISS, polytrauma, and Dv
Road traffic crash research and investigated parameters Since 1999, a local traffic crash research unit is collecting prospective data in regard to all reported traffic crashes around the area of our hospital (Knobloch et al., 2006; Otte, Jansch, & Haasper, 2012; Otte, Pohlemann, Wiese, & Krettek, 2003 ; Richter, Pape, Otte, & Krettek, 2005; Richter et al., 2001). Specially trained documentation staff is notified by police dispatchers in case of an accident and arrive on scene shortly after and often simultaneously with the rescue teams. Investigation and measurement of the crash is performed by photography, stereophotography, and three dimensional (3D)-laser technique as well as
In the overall patient population, there were statistic differences for the injury severity between the BACþ and BAC patient groups. Overall, 84.4% only had mild injuries with an ISS below 9 (BACþ 73.0%, BAC 84.9%), while 5.5% of the patients sustained injuries with an ISS between 9 and 15 (BACþ 9.5%, BAC 5.3%). Regarding the severely injured patients with an ISS between 16 and 24, there were 1.4% in total with 3.4% for the BACþ and 1.3% for the BAC patients. Even higher injury severity (ISS 25e40) was also found more frequently in BAC þ patients (BACþ 1.9%, BAC 0.6%, total 0.7%), as well as for injury severity with scores above 40 (total patients 2.5%, BACþ 4.7%, BAC 2.4%) (/ Table 1).
T. Stübig et al. / Alcohol 46 (2012) 681e686 Table 1 Demographic data, ISS and subgroup analysis of patients involved in a traffic accident.
Patients (injured) Injured Killed Blood alcohol tested Gender (m:f) Age (years) Injury severity ISS 1e8 ISS 9e15 ISS 16e24 SS 25e40 ISS >40 ISS NA Pedestrians Bike Motorbike Car Motor truck Bus /Street car other Difference of speed (i.e. Delta V) in km/h
Total patients
Positive BAC
Negative BAC/ not tested
Significance
37,635 20,741 2.3% 1769 (8.5%) 62%:38% 38 19
1137 823 4.6% 823 (46.5%) 89%:11% 37 15
36,498 19,918 2.2% 946 (53.5%) 61%:39% 38 19
e
84.4% 5.5% 1.4% 0.7% 2.5% 5.6% 12.7% 26.0% 13.8% 44.6% 2.6% 0.3% 0.1% 25 19
73.0% 9.5% 3.4% 1.9% 4.7% 7.8% 18.2% 25.7% 9.7% 44.7% 1.3% 0.0% 0.0% 30 ± 20
84.9% 5.3% 1.3% 0.6% 2.4% 5.5% 12.5% 26.0% 14.0% 44.6% 2.6% 0.3% 0.1% 25 ± 19
p < 0.0001 e p < 0.0001 ns
p < 0.0001
p< ns p¼ ns p¼ ns ns p<
0.0001 0.0008
683
<0.05 g% <0.15 g%, <0.3 g%, and >0.3 g%) for the patient’s age (p ¼ 0.002) with increasing age for higher BAC. Regarding the difference of speed at impact (Dv for motorized drivers, vehicle collision speed for pedestrians, and bikers), subgroup analysis revealed no significant differences for increasing alcohol levels. Subgroup analysis for different road users showed higher values in each group for BAC positive patients in comparison to BAC negative patients, but only significantly higher speed difference on impact for bike users (p ¼ 0.01), pedestrians (p < 0.0001), truck drivers, and car drivers (p < 0.0001), but not for truck drivers, bus users, and motorbike drivers (Fig. 3). Injury pattern analysis for the subgroups of road users showed for BAC positive patients in comparison to BAC negative patients a significantly higher ISS and MAIS for bike users (ISS p < 0.0001, MAIS p < 0.0001), pedestrians (ISS p ¼ 0.004, MAIS p ¼ 0.0007), and car drivers (ISS p < 0.0001, MAIS p < 0.0001), but not for bus users, motorbike drivers, and truck drivers (Fig. 4).
0.02
Discussion
0.0001
In the present study, we analyzed the effects of alcohol in relation to trauma for road users from 1999 to 2010 by prospectively collected data from our crash traffic research unit, containing data from 20,741 injured traffic participants. Up to date, this is the largest retrospective study focused on this issue in current literature. The most important finding of our study was a doubled mortality rate due to a traffic crash in patients with alcohol use compared to sober patients. Furthermore, the results show that BAC positive vehicle users and pedestrians are more often injured and experience a higher relative speed (i.e. Dv) on impact. Alcohol was tested and documented in 8.5% of the injured patients. Due to this fact, the findings cannot automatically be extrapolated to the all road users, the low BAC sample rate may have affected the results. Of these patients, 46% had positive results with BAC over 0.01 g%. These findings meet the descriptions by Lowenfels et al. (Lowenfels & Miller, 1984) and Maier et al. (Maier, 2001), who described positive BAC in 25%e80%. However, blood or breath alcohol was not tested prospectively for each trauma patient, but only if ordered by the police, depending on the trauma mechanism and clinical symptoms. Of interest Liu et al. described that the mental status as one the predictors for alcohol testing only poorly correlates with blood alcohol levels (Liu et al., 1997). Danielsson et al. described that clinical assessment for alcohol abuse frequently fails to correctly identify acute intoxication or chronic abuse (Danielsson, Rivara, Gentilello, & Maier, 1999), for example, 31% of severely injured patients were acutely intoxicated, as well as 33% of the intubated patients, 37% of the patients in shock, and 38%
The bold printed data indicates statistical significance.
Regarding injury patterns, there was a significantly higher percentage of injured pedestrians (p < 0.0001), but a lower percentage for motorbike (p ¼ 0.0008) and truck drivers (p ¼ 0.02) in the BAC positive group. Other road users like bicyclists, car drivers, and bus occupants showed no difference in the analysis for BAC positive or negative distribution (see Table 1). The relative speed at impact (Dv for motorized drivers, vehicle collision speed for pedestrians and bikers) was significantly higher for BAC positive patients compared to the BAC negative group (p < 0.0001, Table 1). Subgroup analysis The subgroup analysis for alcohol intoxicated patients (BAC <0.05 g% <0.15 g%, <0.3 g% and >0.3 g%) regarding ISS, MAIS, difference of speed (Dv), on impact and age showed no correlation between the level of BAC and the parameters ISS, MAIS, and percentage of killed patients (Fig. 1). There was even a tendency toward lower mean values for ISS and a lower ratio of killed patients with increasing BAC. The percentage distribution of the subgroup analysis for different alcohol levels and age distribution are shown in Fig. 2. There were significant differences between the subgroups (BAC
Fig. 1. ISS, MAIS, and percentage of killed patients in a subgroup analysis for increasing alcohol concentrations. The analysis showed no significant differences.
Fig. 2. Age (black line) and percentage (gray line) distribution in the subgroup analysis. There were significant differences in the age distribution in the subgroup analysis regarding different alcohol levels. Asterisks mark significant difference.
684
T. Stübig et al. / Alcohol 46 (2012) 681e686
Fig. 3. Speed differences on impact for different road user groups. Asterisks marks significant differences.
of the chemically paralyzed patients (Maier, 2001). Nevertheless, it is reported in literature that only some trauma centers consistently scan for alcohol use (Fabbri et al., 2002; Maier, 2001; Nilssen, Ries, Rivara, Gurney, & Jurkovich, 1994). Maier et al. proposed blood alcohol testing for all acutely injured patients because acute interventions may have an impact of the outcome (Maier, 2001). The significant shift of gender distribution from about 2/3 of male patients overall to about 9 from 10 male injured drivers in the alcohol-intoxicated patient group meets the descriptions in other studies from Liu et al. and Fabbri et al. (Fabbri et al., 2002; Liu et al., 1997). Our findings of 37.34 years as the mean age of alcoholized trauma patients corresponds to the findings of Abdel-Aty et al. in their survey about alcohol and driving. In this study and other studies (Abdel-Aty & Abdelwahab, 2000; Liu et al., 1997; McLellan et al., 1990), the highest rate of alcoholized driving with accidents occurred in the group from 25 to 34 years of age. Nevertheless, other authors (Bradbury, 1991; Liu et al., 1997; McLellan et al., 1990) found the average of alcoholized patients to be younger than sober road users, which we could not confirm in our findings. As described later, we only found a significant shift to increasing patients’ age with increasing BAC levels. Increased injury severity in patients with positive BAC levels was already described by Tulloh et al. (Tulloh & Collopy, 1994) and Pories et al. (Pories et al., 1992), moreover, the increased rate of killed patients with alcohol intoxication meets the descriptions of several other studies in the past (Fabbri et al., 2002; Li et al., 1997; Phillips & Brewer, 2011). In our study, we were also able to demonstrate a highly significant increase of ISS and relative speed (i.e Dv) in the alcohol positive group. The higher rate of severely
Fig. 4. ISS and MAIS for different road users. Asterisks mark statistic difference.
injured patients concurs with the prior findings in literature (Fabbri et al., 2002; McCoy et al., 1989; Phillips & Brewer, 2011). Our mean alcohol level of 0.22 g% was slightly higher than described in other studies (Apodaca & Schermer, 2003; McLellan et al., 1990). However, studies by Blondell et al. and Ward et al. described an equal injury severity and even reduced trauma mortality for patients with positive BAC (Blondell, Looney, Krieg, & Spain, 2002; Ward, Flynn, Miller, & Blaisdell, 1982). Berry et al. described a lower mortality for patients with a high BAC and traumatic brain injury (Berry et al., 2011). This corresponds to the findings of a recently published study from our department, which showed no hint for worse or improved outcome in the clinical course (Zeckey et al., 2011). Andersen et al. examined the correlation between alcohol levels and the rate of belted and unbelted car drivers. They found that 51% of unbelted and 21% of belted patients had a positive BAC, concluding that higher injury severity in alcoholized patients may also be related to unbelted car driving (Andersen, McLellan, Pagliarello, & Nelson, 1990). Regarding the relative speed at impact, our findings of significantly higher values in BAC positive patients have also been described analogically by Phillips et al. (Phillips & Brewer, 2011). Furthermore, in our subgroup analysis, we were able to demonstrate a higher percentage of injured pedestrians in the BAC positive group compared to patients with negative alcohol tests, which corresponds to the information in literature so far (Bradbury, 1991; Dultz et al., 2011; Mittmeyer, 1991). For truck and motorbike drivers, bus and streetcar drivers, as well as for bus and streetcars passengers, our findings of a lower rate of injured patients in alcoholized patients is different to the findings in other studies (McCarthy, Sheng, Baker, Rebok, & Li, 2009; Orsay, Doan-Wiggins, Lewis, Lucke, & RamaKrishnan, 1994). There is no literature available about alcohol and truck driving yet, one possible explanation for less injured alcoholized patients compared to the alcohol negative group may be that a lot of truck drivers drive as a profession and not for private matters. The subgroup analysis for different levels of alcohol-intoxicated patients showed no significant differences for the ISS, MAIS, and killed patients, but a tendency toward lower mean values with increasing BAC levels. This meets the findings by Deutch et al. (Deutch et al., 2004), who could also find a positive correlation between ISS and alcohol-positive patients, but no dose-related effects. There may be a protecting effect of alcohol as described by Mann et al. (Mann et al., 2011), Tien et al. (Tien et al., 2006), and Berry et al. (Berry et al., 2011). Nevertheless, patient populations examined in the hospital, as performed by the authors above, already depict a preselected group, as they only focus on the patients that survived the crash (von Oppell, Bautz, & De Groot, 2000). On the other hand, the results are contrary to the findings of Philips et al. (Phillips & Brewer, 2011), who found increasing BAC levels to be associated with more severe injuries. The road user-dependent analysis showed a higher mean relative speed at the moment of impact for alcoholized patients in all road users groups except motorbike users, with significant values for bicyclists, pedestrians, and car occupants. In prior, this has also been mentioned by other authors in literature (Abele, 1958; Phillips & Brewer, 2011), mainly for car drivers. Regarding the ISS and MAIS, we found significant differences in pedestrians, bicyclists and car drivers as already frequently described in studies with smaller patient numbers in literature and mainly for car drivers (Bolhofner, Carmen, Donohue, & Harlen, 1994; Bradbury, 1991; Dultz et al., 2011; Mittmeyer, 1991; Phillips & Brewer, 2011; Tulloh & Collopy, 1994; Ward et al., 1982). Analysis for bus users, motorbike, and truck drivers showed no significant difference and even lower mean values in alcoholized-truck drivers.
T. Stübig et al. / Alcohol 46 (2012) 681e686
Limitations Although this is the largest study analyzing the effect of alcohol on several issues of trauma patients, there are some limitations of this study. First, this is not a randomized controlled study, and the results may therefore be exaggerated by confounders and biases. Second, our study analyzed patients admitted during a time period of 11 years. Pre-hospital emergency medicine has improved during this time, leading to potentially modified results. Moreover, one has to be aware that other drugs than alcohol (i.e. cocaine, benzodiazepines, marihuana) might be consumed by the patients analyzed in our report. The Center of Disease Control of the United States announced in a disclosure that the prevalence for drug intoxication was the same as for alcohol intoxication (Centers for Disease and Prevention, 2006). Other drugs than alcohol may have had an effect on the injury mechanism too, however, this was not tested in our study. Besides, public health efforts against alcohol-intoxicated driving have increased, and the allowed alcohol level in traffic has been reduced from 0.08 g% to 0.05 g% by a law from 2001 in Germany. The alcohol testing was only performed by order of the police, leading to a potential preselection of the tested patients. Legal aspects complicate standardized alcohol testing for trauma patients in Germany, as the patient has to give his consent. If the patient refuses the consent for blood alcohol testing, the analysis can only be performed by the order of a judge. In our study, we only used the results of the BAC that were ordered by police, as alcohol testing for trauma patients was not performed on a regular basis in clinics in Germany, as also reported in other countries (Fabbri et al., 2002; Maier, 2001; Nilssen et al., 1994). The potential ethanol contamination of BAC testing by standard dermal antiseptics in clinics, described by Higuchi et al. (Higuchi et al., 2005), was another reason for us to use the results of the police or judge ordered BAC testing only, as this procedure has to be performed in a standard way without the use of alcoholic antiseptics. Conclusions Alcohol intoxication in trauma patients leads to a higher preclinical mortality. Furthermore, BAC positive vehicle users and pedestrians are more often injured and experience a higher relative speed (i.e. Dv) on impact. The subgroup analysis showed no alcohol dose-related effect on injury severity and relative speed, but a correlation of increasing age of patients age with higher alcohol concentrations. Acknowledgments For the present study, accident data from GIDAS (German In-Depth Accident Study) was used. GIDAS is the largest in-depth accident study in Germany and is funded by the Federal Highway Research Institute (BASt) and the German Research Association for Automotive Technology (FAT), a department of the VDA (German Association of the Automotive Industry). References Abdel-Aty, M. A., & Abdelwahab, H. T. (2000). Exploring the relationship between alcohol and the driver characteristics in motor vehicle accidents. Accident; Analysis and Prevention, 32, 473e482. Abele, G. (1958). [Effect of alcohol on driving speed ability of the operator]. Deutsche Zeitschrift Fur Die Gesamte Gerichtliche Medizin, 47, 447e471. Andersen, J. A., McLellan, B. A., Pagliarello, G., & Nelson, W. R. (1990). The relative influence of alcohol and seatbelt usage on severity of injury from motor vehicle crashes. The Journal of Trauma, 30, 415e417. Apodaca, T. R., & Schermer, C. R. (2003). Readiness to change alcohol use after trauma. The Journal of Trauma, 54, 990e994.
685
Baker, S. P., O’Neill, B., Haddon, W., Jr., & Long, W. B. (1974). The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. The Journal of Trauma, 14, 187e196. Berry, C., Ley, E. J., Margulies, D. R., Mirocha, J., Bukur, M., Malinoski, D., et al. (2011). Correlating the blood alcohol concentration with outcome after traumatic brain injury: too much is not a bad thing. The American Surgeon, 77, 1416e1419. Blondell, R. D., Looney, S. W., Krieg, C. L., & Spain, D. A. (2002). A comparison of alcohol-positive and alcohol-negative trauma patients. Journal Studies on Alcohol, 63, 380e383. Bolhofner, B., Carmen, B. A., Donohue, S. D., & Harlen, K. (1994). Motorcycle accident injury severity, blood alcohol levels, insurance status, and hospital costs: a 4-year study in St. Petersburg, Florida. Journal of Orthopaedic Trauma, 8, 228e232. Bradbury, A. (1991). Pattern and severity of injury sustained by pedestrians in road traffic accidents with particular reference to the effect of alcohol. Injury, 22, 132e134. Brezel, B. S., Kassenbrock, J. M., & Stein, J. M. (1988). Burns in substance abusers and in neurologically and mentally impaired patients. The Journal of Burn Care & Rehabilitation, 9, 169e171. Brismar, B., & Bergman, B. (1998). The significance of alcohol for violence and accidents. Alcoholism, Clinical and Experimental Research, 22, 299Se306S. Centers for Disease and Prevention. (2006). Alcohol and other drug use among victims of motor-vehicle crasheseWest Virginia, 2004-2005. MMWR. Morbidity and Mortality Weekly Report, 55, 1293e1296. Chang, G., & Astrachan, B. M. (1988). The emergency department surveillance of alcohol intoxication after motor vehicle accidents. JAMA: The Journal of American Medical Association, 260, 2533e2536. Danielsson, P. E., Rivara, F. P., Gentilello, L. M., & Maier, R. V. (1999). Reasons why trauma surgeons fail to screen for alcohol problems. Archives of Surgery, 134, 564e568. Deutch, S. R., Christian, C., Hoyer, S., Christensen, E. F., Dragsholt, C., Hansen, A. C., et al. (2004). Drug and alcohol use among patients admitted to a Danish trauma centre: a prospective study from a regional trauma centre in Scandinavia. European Journal of Emergency Medicine, 11, 318e322. Dultz, L. A., Frangos, S., Foltin, G., Marr, M., Simon, R., Bholat, O., et al. (2011). Alcohol use by pedestrians who are struck by motor vehicles: how drinking influences behaviors, medical management, and outcomes. The Journal of Trauma, 71, 1252e1257. Fabbri, A., Marchesini, G., Morselli-Labate, A. M., Rossi, F., Cicognani, A., Dente, M., et al. (2002). Positive blood alcohol concentration and road accidents. A prospective study in an Italian emergency department. Emergency Medicine Journal: EMJ, 19, 210e214. Forchheimer, M., Cunningham, R. M., Gater, D. R., Jr., & Maio, R. F. (2005). The relationship of blood alcohol concentration to impairment severity in spinal cord injury. The Journal of Spinal Cord Medicine, 28, 303e307. Greenspan, L., McLellan, B. A., & Greig, H. (1985). Abbreviated injury scale and injury severity score: a scoring chart. The Journal of Trauma, 25, 60e64. Higuchi, A., Kurihara, R., Yoshimoto, T., Sano, T., Katsumata, K., Ishii, A., et al. (2005). Problems in blood alcohol testing of severely injured drivers brought to emergency departments in Japan. Legal Medicine, 7, 299e305. Howland, J., & Hingson, R. (1987). Alcohol as a risk factor for injuries or death due to fires and burns: review of the literature. Public Health Reports, 102, 475e483. Kim, K., Nitz, L., Richardson, J., & Li, L. (1995). Personal and behavioral predictors of automobile crash and injury severity. Accident; Analysis & Prevention, 27, 469e481. Knobloch, K., Wagner, S., Haasper, C., Probst, C., Krettek, C., Otte, D., et al. (2006). Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. The Annals of Thoracic Surgery, 82, 444e450. Li, G., Keyl, P. M., Smith, G. S., & Baker, S. P. (1997). Alcohol and injury severity: reappraisal of the continuing controversy. The Journal of Trauma, 42, 562e569. Liu, S., Siegel, P. Z., Brewer, R. D., Mokdad, A. H., Sleet, D. A., & Serdula, M. (1997). Prevalence of alcohol-impaired driving. Results from a national self-reported survey of health behaviors. JAMA: The Journal of American Medical Association, 277, 122e125. Lowenfels, A. B., & Miller, T. T. (1984). Alcohol and trauma. Annals of Emergency Medicine, 13, 1056e1060. Maier, R. V. (2001). Ethanol abuse and the trauma patient. Surgical Infections (Larchmt.), 2, 133e141, discussion 141e134. Mann, B., Desapriya, E., Fujiwara, T., & Pike, I. (2011). Is blood alcohol level a good predictor for injury severity outcomes in motor vehicle crash victims? Emergency Medicine International, 2011, 616323. McCarthy, M. L., Sheng, P., Baker, S. P., Rebok, G. W., & Li, G. (2009). Validity of policereported alcohol involvement in fatal motor carrier crashes in the United States between 1982 and 2005. Journal of Safety Research, 40, 227e232. McCoy, G. F., Johnstone, R. A., Nelson, I. W., & Duthie, R. B. (1989). A review of fatal road accidents in Oxfordshire over a 2-year period. Injury, 20, 65e68. McGill, V., Kowal-Vern, A., Fisher, S. G., Kahn, S., & Gamelli, R. L. (1995). The impact of substance use on mortality and morbidity from thermal injury. The Journal of Trauma, 38, 931e934. McLellan, B. A., Vingilis, E., Liban, C. B., Stoduto, G., McMurtry, R. Y., & Nelson, W. R. (1990). Blood alcohol testing of motor vehicle crash admissions at a regional trauma unit. The Journal of Trauma, 30, 418e421. Mittmeyer, H. J. (1991). [Severity of injury of alcohol intoxicated pedestrians in street traffic]. Beitrage Zur Gerichtlichen Medizin, 49, 247e251.
686
T. Stübig et al. / Alcohol 46 (2012) 681e686
Moser, A., Heide, W., & Kompf, D. (1998). The effect of oral ethanol consumption on eye movements in healthy volunteers. Journal of Neurology, 245, 542e550. Mundt, J. C., Ross, L. E., & Harrington, H. L. (1992). A modeling analysis of young drivers’ judgments of accident risk due to alcohol use and other driving conditions. Journal of Studies on Alcohol, 53, 239e248. Nilssen, O., Ries, R. K., Rivara, F. P., Gurney, J. G., & Jurkovich, G. J. (1994). The CAGE questionnaire and the short Michigan alcohol screening test in trauma patients: comparison of their correlations with biological alcohol markers. The Journal of Trauma, 36, 784e788. Orsay, E. M., Doan-Wiggins, L., Lewis, R., Lucke, R., & RamaKrishnan, V. (1994). The impaired driver: hospital and police detection of alcohol and other drugs of abuse in motor vehicle crashes. Annals of Emergency Medicine, 24, 51e55. Otte, D., Jansch, M., & Haasper, C. (2012). Injury protection and accident causation parameters for vulnerable road users based on German in-depth accident study GIDAS. Accident; Analysis & Prevention, 44, 149e153. Otte, D., Pohlemann, T., Wiese, B., & Krettek, C. (2003). [Changes in the injury pattern of polytraumatized patients over the last 30 years]. Der Unfallchirurg, 106, 448e455. Phillips, D. P., & Brewer, K. M. (2011). The relationship between serious injury and blood alcohol concentration (BAC) in fatal motor vehicle accidents: BAC ¼ 0.01% is associated with significantly more dangerous accidents than BAC ¼ 0.00%. Addiction, 106, 1614e1622. Pories, S. E., Gamelli, R. L., Vacek, P., Goodwin, G., Shinozaki, T., & Harris, F. (1992). Intoxication and injury. The Journal of Trauma, 32, 60e64. Richter, M., Otte, D., Haasper, C., Knobloch, K., Probst, C., Westhoff, J., et al. (2007). The current injury situation of bicyclistsea medical and technical crash analysis. The Journal of Trauma, 62, 1118e1122.
Richter, M., Pape, H. C., Otte, D., & Krettek, C. (2005). The current status of road user injuries among the elderly in Germany: a medical and technical accident analysis. The Journal of Trauma, 58, 591e595. Richter, M., Thermann, H., Wippermann, B., Otte, D., Schratt, H. E., & Tscherne, H. (2001). Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years. Journal of Orthopaedic Trauma, 15, 287e293. Robertson, M. D., & Drummer, O. H. (1994). Responsibility analysis: a methodology to study the effects of drugs in driving. Accident; Analysis & Prevention, 26, 243e247. Salim, A., Ley, E. J., Cryer, H. G., Margulies, D. R., Ramicone, E., & Tillou, A. (2009). Positive serum ethanol level and mortality in moderate to severe traumatic brain injury. Archives of Surgery, 144, 865e871. Tien, H. C., Tremblay, L. N., Rizoli, S. B., Gelberg, J., Chughtai, T., Tikuisis, P., et al. (2006). Association between alcohol and mortality in patients with severe traumatic head injury. Archives of Surgery, 141, 1185e1191, discussion 1192. Tulloh, B. R., & Collopy, B. T. (1994). Positive correlation between blood alcohol level and ISS in road trauma. Injury, 25, 539e543. von Oppell, U. O., Bautz, P., & De Groot, M. (2000). Penetrating thoracic injuries: what we have learnt. The Thoracic and Cardiovascular Surgeon, 48, 55e61. Waller, J. A. (1972). Factors associated with alcohol and responsibility for fatal highway crashes. Quarterly Journal of Studies on Alcohol, 33, 160e170. Ward, R. E., Flynn, T. C., Miller, P. W., & Blaisdell, W. F. (1982). Effects of ethanol ingestion on the severity and outcome of trauma. American Journal of Surgery, 144, 153e157. Zeckey, C., Dannecker, S., Hildebrand, F., Mommsen, P., Scherer, R., Probst, C., et al. (2011). Alcohol and multiple trauma-is there an influence on the outcome? Alcohol, 45, 245e251.
Contents lists available at SciVerse ScienceDirect
Alcohol journal homepage: http://www.alcoholjournal.org/
Alcohol intoxication in road traffic accidents leads to higher impact speed difference, higher ISS and MAIS, and higher preclinical mortality Timo Stübig*, Maximilian Petri, Christian Zeckey, Stephan Brand, Christian Müller, Dietmar Otte, Christian Krettek, Carl Haasper Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 January 2012 Received in revised form 13 July 2012 Accepted 13 July 2012
Alcohol is one of the most important personal risk factors for serious and fatal injuries, contributing to approximately one third of all deaths from accidents. It is also described that alcohol intoxication leads to a higher mortality in the clinical course. In this study, we hypothesized that alcohol intoxication leads to different accident kinematics, a higher ISS (Injury Severity Score), and higher preclinical mortality compared to sober patients. A technical and medical investigation of alcohol intoxated road users was performed on the scene of the crash and at the primary admitting hospital. Alcohol testing was performed with either breath alcohol tests or measurement of blood alcohol concentration (BAC) in a standard laboratory test. Between 1999 and 2010, 37,635 road traffic accidents were evaluated by the Accident Research Unit. Overall 20,741 patients were injured, 2.3% of the patients were killed. Among the injured patients, 2.2% with negative BAC were killed, compared to 4.6% fatal injuries in patients with a positive BAC (p < 0.0001). Of the patients with a positive BAC, 8.0% were severely injured, compared to 3.6% in the BAC negative group (p < 0.0001). Regarding the relative speed at impact (Dv for motorized drivers, vehicle collision speed for pedestrians and bikers), there was a significant higher difference for BAC positive patients (30 20) compared to the BAC negative patients (25 19, p < 0.0001). Alcohol intoxication in trauma patients leads to higher preclinical mortality, higher impact speed difference, and higher injury severity. The subgroup analysis for different alcohol concentrations shows no difference in ISS, MAIS, and relative speed, but a correlation of increasing age of patients with higher alcohol concentrations. Ó 2012 Elsevier Inc. All rights reserved.
Keywords: Alcohol Trauma Road users Injury severity
Introduction Alcohol use has been well established as one of the most important personal risk factor for serious and fatal injuries, contributing to approximately one third of all deaths from accidents (Li, Keyl, Smith, & Baker, 1997; Maier, 2001; Zeckey et al., 2011). Described prevalence of alcohol intoxication in trauma patients at the time of admission in the hospital is ranging from 18% to 80% in literature depending on study design and inclusion criteria (Centers for Disease and Prevention, 2006; Fabbri et al., 2002; Lowenfels & Miller, 1984; Maier, 2001). Some reports for car drivers indicate that intoxicated drivers are more likely involved in a crash (Chang & Astrachan, 1988), are more likely responsible for crashes (Waller, 1972), and more often sustain fatal injuries than sober drivers (Kim, Nitz, Richardson, & Li, 1995; McCoy, Johnstone, Nelson, & Duthie, 1989; Robertson & Drummer, * Corresponding author. Tel.: þ49 511 532 2026; fax: þ49 511 532 5788. E-mail address: [email protected] (T. Stübig). 0741-8329/$ e see front matter Ó 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.alcohol.2012.07.002
1994). Abuse of alcohol is commonly reported to be associated with more severe injuries and thus a higher mortality in the clinical course (Fabbri et al., 2002; Pories et al., 1992; Tulloh & Collopy, 1994). However, Mann et al. describe that higher blood alcohol concentration (BAC) may lead to less severe injuries, without impacting mortality or length of hospital stay (Mann, Desapriya, Fujiwara, & Pike, 2011). Negative effects of alcohol concerning activities of daily life include retardation of the rate of visual scanning (Moser, Heide, & Kompf, 1998), reduced ability to react to random stimuli (Forchheimer, Cunningham, Gater, , & Maio, 2005), and increased risk-taking behavior (Brismar & Bergman, 1998; Mundt, Ross, & Harrington, 1992). Most of the past and present studies involve the effect of alcohol on the clinical outcome during the hospital stay. Several authors described a depressed posttraumatic immune response, leading to an increased risk for infectious diseases and mortality in alcoholintoxicated patients (Brezel, Kassenbrock, & Stein, 1988; Howland & Hingson, 1987; McGill, Kowal-Vern, Fisher, Kahn, & Gamelli, 1995; Zeckey et al., 2011).
682
T. Stübig et al. / Alcohol 46 (2012) 681e686
Data about the effect of alcohol on patients suffering from traumatic brain injury is inconsistent. While several studies described a beneficial effect of alcohol intoxication on admission regarding mortality (Berry et al., 2011; Salim et al., 2009; Zeckey et al., 2011), other studies could not confirm this effect, but showed a beneficial effect in patients with low dose alcohol intoxication (Mundt et al., 1992; Tien et al., 2006). A prior study of our department did not reveal a prognostic relevance of blood alcohol level at the time of admission in multiple trauma patients in the clinical course. Concerning overall injury severity, there were no ethanol-related differences; however, more severe abdominal injuries were found in alcohol intoxicated patients (Zeckey et al., 2011). Although several studies examined the clinical and mid-range outcome of car drivers, technical information about injury patterns, injury severity, and pre-clinical mortality is sparse. Moreover, patient size of the published reports remains small. We hypothesized that alcohol-intoxicated trauma patients show different accident mechanisms and accident kinematics as well as different injury patterns and injury severity compared to patients with negative blood alcohol levels. Secondly, we hypothesized that there is a dependence of these parameters on the blood alcohol level. The purpose of this study was to analyze the actual injury situation of alcohol-intoxicated injured people in Germany to create a baseline for effective preventive measures in a large retrospective cohort analysis.
clinical injury documentation on site (Otte et al., 2012; Otte et al., 2003; Richter et al., 2005; Richter et al., 2001). The patient relevant case report is carried on in the admitting hospital, with proper documentation of injury type and injury severity, including X-ray and CT diagnostics. The collected data allows an exactly scaled reconstruction of the crash site for later technical analysis of the crash. Vehicles, objects, victims, and any kind of deformation of involved vehicles or objects are measured, including this data in the crash analysis (Richter et al., 2007). Furthermore, data from a database containing technical features of involved vehicles (size, weight, detailed structural data comparable to finite element analysis data) are included in the analysis. The inclusion of the described data allows an exact estimation of parameters (Richter et al., 2007). The monitoring of the crash research unit includes demographic data, type of road user (car/truck occupant, motorcyclist, cyclist, pedestrian, bus and streetcar), relative speed at impact (km/h) (Dv for motorized vehicle user; vehicle collision speed (km/h) for bicyclists/pedestrians), Abbreviated Injury Scale (AIS), Maximum AIS (MAIS) score, Injury Severity Score (ISS), incidence of serious and/or severe multiple injuries, incidence of serious injuries (MAIS 2e4) or severe injuries (MAIS 5 of 6), and mortality. Statistics
The study was approved by the local Ethical Committee of Hannover Medical School, Germany, and follows the ethical standards of the Helsinki Declaration of 1975, as revised in 1983.
Statistical analysis was performed utilizing GraphPad Prism (GraphPad Software, San Diego, CA). The significance level was set to p < 0.05. For statistical analysis, Fishers exact test and students ttest was performed in case of normal distribution, in skew distributed data the ManneWhitney-U- und Wilcoxon-test was used. For contigency analysis, a Chi Square test was performed.
Scoring and group distribution
Results
The injury severity was classified according to the Injury Severity Score (ISS) (Baker, O’Neill, Haddon, & Long, 1974), based on the Abbreviated Injury Scale (AIS) (Greenspan, McLellan, & Greig, 1985). Blood alcohol concentrations (BAC) were measured by order of the police for further examinations in a standard laboratory procedure. If no BAC was available, results of the breath alcohol test were used. Alcohol concentrations (blood alcohol or breath alcohol) equal to or greater than 0.01 g% were defined as BAC positive. As the influence of alcohol on the investigated parameters might be dose dependent, subgroup analyses were performed. As driving is prohibited in Germany with BAC equal to or greater than 0.05 g%, it was another rationale to choose this level. Overall subgroups were calculated for BAC <0.05 g%. <0.15 g%. <0.3 g%, and >0.3 g%. Another subgroup analysis regarding ISS, MAIS, and relative speed was performed for different types of road users (i.e. car drivers, truck drivers, pedestrians, bicyclists).
Demographic data
Materials and methods
Between 1999 and 2010, 37,635 motor vehicle crashes were evaluated by the Accident Research Unit (Table 1). In total 16,894 patients of the patient collective were not injured, and 20,741 were injured. Of all injured patients, 2.3% were killed, 2.2% of the BAC negative patients and 4.6% of the BAC positive patient group (p < 0.0001). Overall alcohol was tested in 1769 (8.5%) of the patients with a positive result in 823(46.5%) patients and a negative result in 946 (53.5%) cases. The mean alcohol concentration was 0.22 g%. The male to female ratio was 62% male to 38% female overall, with a significant shift toward the male population in the blood alcohol positive patient group (p < 0.0001). The mean age was 38 18 years overall, with no differences between the alcohol intoxicated and the non-intoxicated group (Table 1). Injury characteristics and crash related data ISS, polytrauma, and Dv
Road traffic crash research and investigated parameters Since 1999, a local traffic crash research unit is collecting prospective data in regard to all reported traffic crashes around the area of our hospital (Knobloch et al., 2006; Otte, Jansch, & Haasper, 2012; Otte, Pohlemann, Wiese, & Krettek, 2003 ; Richter, Pape, Otte, & Krettek, 2005; Richter et al., 2001). Specially trained documentation staff is notified by police dispatchers in case of an accident and arrive on scene shortly after and often simultaneously with the rescue teams. Investigation and measurement of the crash is performed by photography, stereophotography, and three dimensional (3D)-laser technique as well as
In the overall patient population, there were statistic differences for the injury severity between the BACþ and BAC patient groups. Overall, 84.4% only had mild injuries with an ISS below 9 (BACþ 73.0%, BAC 84.9%), while 5.5% of the patients sustained injuries with an ISS between 9 and 15 (BACþ 9.5%, BAC 5.3%). Regarding the severely injured patients with an ISS between 16 and 24, there were 1.4% in total with 3.4% for the BACþ and 1.3% for the BAC patients. Even higher injury severity (ISS 25e40) was also found more frequently in BAC þ patients (BACþ 1.9%, BAC 0.6%, total 0.7%), as well as for injury severity with scores above 40 (total patients 2.5%, BACþ 4.7%, BAC 2.4%) (/ Table 1).
T. Stübig et al. / Alcohol 46 (2012) 681e686 Table 1 Demographic data, ISS and subgroup analysis of patients involved in a traffic accident.
Patients (injured) Injured Killed Blood alcohol tested Gender (m:f) Age (years) Injury severity ISS 1e8 ISS 9e15 ISS 16e24 SS 25e40 ISS >40 ISS NA Pedestrians Bike Motorbike Car Motor truck Bus /Street car other Difference of speed (i.e. Delta V) in km/h
Total patients
Positive BAC
Negative BAC/ not tested
Significance
37,635 20,741 2.3% 1769 (8.5%) 62%:38% 38 19
1137 823 4.6% 823 (46.5%) 89%:11% 37 15
36,498 19,918 2.2% 946 (53.5%) 61%:39% 38 19
e
84.4% 5.5% 1.4% 0.7% 2.5% 5.6% 12.7% 26.0% 13.8% 44.6% 2.6% 0.3% 0.1% 25 19
73.0% 9.5% 3.4% 1.9% 4.7% 7.8% 18.2% 25.7% 9.7% 44.7% 1.3% 0.0% 0.0% 30 ± 20
84.9% 5.3% 1.3% 0.6% 2.4% 5.5% 12.5% 26.0% 14.0% 44.6% 2.6% 0.3% 0.1% 25 ± 19
p < 0.0001 e p < 0.0001 ns
p < 0.0001
p< ns p¼ ns p¼ ns ns p<
0.0001 0.0008
683
<0.05 g% <0.15 g%, <0.3 g%, and >0.3 g%) for the patient’s age (p ¼ 0.002) with increasing age for higher BAC. Regarding the difference of speed at impact (Dv for motorized drivers, vehicle collision speed for pedestrians, and bikers), subgroup analysis revealed no significant differences for increasing alcohol levels. Subgroup analysis for different road users showed higher values in each group for BAC positive patients in comparison to BAC negative patients, but only significantly higher speed difference on impact for bike users (p ¼ 0.01), pedestrians (p < 0.0001), truck drivers, and car drivers (p < 0.0001), but not for truck drivers, bus users, and motorbike drivers (Fig. 3). Injury pattern analysis for the subgroups of road users showed for BAC positive patients in comparison to BAC negative patients a significantly higher ISS and MAIS for bike users (ISS p < 0.0001, MAIS p < 0.0001), pedestrians (ISS p ¼ 0.004, MAIS p ¼ 0.0007), and car drivers (ISS p < 0.0001, MAIS p < 0.0001), but not for bus users, motorbike drivers, and truck drivers (Fig. 4).
0.02
Discussion
0.0001
In the present study, we analyzed the effects of alcohol in relation to trauma for road users from 1999 to 2010 by prospectively collected data from our crash traffic research unit, containing data from 20,741 injured traffic participants. Up to date, this is the largest retrospective study focused on this issue in current literature. The most important finding of our study was a doubled mortality rate due to a traffic crash in patients with alcohol use compared to sober patients. Furthermore, the results show that BAC positive vehicle users and pedestrians are more often injured and experience a higher relative speed (i.e. Dv) on impact. Alcohol was tested and documented in 8.5% of the injured patients. Due to this fact, the findings cannot automatically be extrapolated to the all road users, the low BAC sample rate may have affected the results. Of these patients, 46% had positive results with BAC over 0.01 g%. These findings meet the descriptions by Lowenfels et al. (Lowenfels & Miller, 1984) and Maier et al. (Maier, 2001), who described positive BAC in 25%e80%. However, blood or breath alcohol was not tested prospectively for each trauma patient, but only if ordered by the police, depending on the trauma mechanism and clinical symptoms. Of interest Liu et al. described that the mental status as one the predictors for alcohol testing only poorly correlates with blood alcohol levels (Liu et al., 1997). Danielsson et al. described that clinical assessment for alcohol abuse frequently fails to correctly identify acute intoxication or chronic abuse (Danielsson, Rivara, Gentilello, & Maier, 1999), for example, 31% of severely injured patients were acutely intoxicated, as well as 33% of the intubated patients, 37% of the patients in shock, and 38%
The bold printed data indicates statistical significance.
Regarding injury patterns, there was a significantly higher percentage of injured pedestrians (p < 0.0001), but a lower percentage for motorbike (p ¼ 0.0008) and truck drivers (p ¼ 0.02) in the BAC positive group. Other road users like bicyclists, car drivers, and bus occupants showed no difference in the analysis for BAC positive or negative distribution (see Table 1). The relative speed at impact (Dv for motorized drivers, vehicle collision speed for pedestrians and bikers) was significantly higher for BAC positive patients compared to the BAC negative group (p < 0.0001, Table 1). Subgroup analysis The subgroup analysis for alcohol intoxicated patients (BAC <0.05 g% <0.15 g%, <0.3 g% and >0.3 g%) regarding ISS, MAIS, difference of speed (Dv), on impact and age showed no correlation between the level of BAC and the parameters ISS, MAIS, and percentage of killed patients (Fig. 1). There was even a tendency toward lower mean values for ISS and a lower ratio of killed patients with increasing BAC. The percentage distribution of the subgroup analysis for different alcohol levels and age distribution are shown in Fig. 2. There were significant differences between the subgroups (BAC
Fig. 1. ISS, MAIS, and percentage of killed patients in a subgroup analysis for increasing alcohol concentrations. The analysis showed no significant differences.
Fig. 2. Age (black line) and percentage (gray line) distribution in the subgroup analysis. There were significant differences in the age distribution in the subgroup analysis regarding different alcohol levels. Asterisks mark significant difference.
684
T. Stübig et al. / Alcohol 46 (2012) 681e686
Fig. 3. Speed differences on impact for different road user groups. Asterisks marks significant differences.
of the chemically paralyzed patients (Maier, 2001). Nevertheless, it is reported in literature that only some trauma centers consistently scan for alcohol use (Fabbri et al., 2002; Maier, 2001; Nilssen, Ries, Rivara, Gurney, & Jurkovich, 1994). Maier et al. proposed blood alcohol testing for all acutely injured patients because acute interventions may have an impact of the outcome (Maier, 2001). The significant shift of gender distribution from about 2/3 of male patients overall to about 9 from 10 male injured drivers in the alcohol-intoxicated patient group meets the descriptions in other studies from Liu et al. and Fabbri et al. (Fabbri et al., 2002; Liu et al., 1997). Our findings of 37.34 years as the mean age of alcoholized trauma patients corresponds to the findings of Abdel-Aty et al. in their survey about alcohol and driving. In this study and other studies (Abdel-Aty & Abdelwahab, 2000; Liu et al., 1997; McLellan et al., 1990), the highest rate of alcoholized driving with accidents occurred in the group from 25 to 34 years of age. Nevertheless, other authors (Bradbury, 1991; Liu et al., 1997; McLellan et al., 1990) found the average of alcoholized patients to be younger than sober road users, which we could not confirm in our findings. As described later, we only found a significant shift to increasing patients’ age with increasing BAC levels. Increased injury severity in patients with positive BAC levels was already described by Tulloh et al. (Tulloh & Collopy, 1994) and Pories et al. (Pories et al., 1992), moreover, the increased rate of killed patients with alcohol intoxication meets the descriptions of several other studies in the past (Fabbri et al., 2002; Li et al., 1997; Phillips & Brewer, 2011). In our study, we were also able to demonstrate a highly significant increase of ISS and relative speed (i.e Dv) in the alcohol positive group. The higher rate of severely
Fig. 4. ISS and MAIS for different road users. Asterisks mark statistic difference.
injured patients concurs with the prior findings in literature (Fabbri et al., 2002; McCoy et al., 1989; Phillips & Brewer, 2011). Our mean alcohol level of 0.22 g% was slightly higher than described in other studies (Apodaca & Schermer, 2003; McLellan et al., 1990). However, studies by Blondell et al. and Ward et al. described an equal injury severity and even reduced trauma mortality for patients with positive BAC (Blondell, Looney, Krieg, & Spain, 2002; Ward, Flynn, Miller, & Blaisdell, 1982). Berry et al. described a lower mortality for patients with a high BAC and traumatic brain injury (Berry et al., 2011). This corresponds to the findings of a recently published study from our department, which showed no hint for worse or improved outcome in the clinical course (Zeckey et al., 2011). Andersen et al. examined the correlation between alcohol levels and the rate of belted and unbelted car drivers. They found that 51% of unbelted and 21% of belted patients had a positive BAC, concluding that higher injury severity in alcoholized patients may also be related to unbelted car driving (Andersen, McLellan, Pagliarello, & Nelson, 1990). Regarding the relative speed at impact, our findings of significantly higher values in BAC positive patients have also been described analogically by Phillips et al. (Phillips & Brewer, 2011). Furthermore, in our subgroup analysis, we were able to demonstrate a higher percentage of injured pedestrians in the BAC positive group compared to patients with negative alcohol tests, which corresponds to the information in literature so far (Bradbury, 1991; Dultz et al., 2011; Mittmeyer, 1991). For truck and motorbike drivers, bus and streetcar drivers, as well as for bus and streetcars passengers, our findings of a lower rate of injured patients in alcoholized patients is different to the findings in other studies (McCarthy, Sheng, Baker, Rebok, & Li, 2009; Orsay, Doan-Wiggins, Lewis, Lucke, & RamaKrishnan, 1994). There is no literature available about alcohol and truck driving yet, one possible explanation for less injured alcoholized patients compared to the alcohol negative group may be that a lot of truck drivers drive as a profession and not for private matters. The subgroup analysis for different levels of alcohol-intoxicated patients showed no significant differences for the ISS, MAIS, and killed patients, but a tendency toward lower mean values with increasing BAC levels. This meets the findings by Deutch et al. (Deutch et al., 2004), who could also find a positive correlation between ISS and alcohol-positive patients, but no dose-related effects. There may be a protecting effect of alcohol as described by Mann et al. (Mann et al., 2011), Tien et al. (Tien et al., 2006), and Berry et al. (Berry et al., 2011). Nevertheless, patient populations examined in the hospital, as performed by the authors above, already depict a preselected group, as they only focus on the patients that survived the crash (von Oppell, Bautz, & De Groot, 2000). On the other hand, the results are contrary to the findings of Philips et al. (Phillips & Brewer, 2011), who found increasing BAC levels to be associated with more severe injuries. The road user-dependent analysis showed a higher mean relative speed at the moment of impact for alcoholized patients in all road users groups except motorbike users, with significant values for bicyclists, pedestrians, and car occupants. In prior, this has also been mentioned by other authors in literature (Abele, 1958; Phillips & Brewer, 2011), mainly for car drivers. Regarding the ISS and MAIS, we found significant differences in pedestrians, bicyclists and car drivers as already frequently described in studies with smaller patient numbers in literature and mainly for car drivers (Bolhofner, Carmen, Donohue, & Harlen, 1994; Bradbury, 1991; Dultz et al., 2011; Mittmeyer, 1991; Phillips & Brewer, 2011; Tulloh & Collopy, 1994; Ward et al., 1982). Analysis for bus users, motorbike, and truck drivers showed no significant difference and even lower mean values in alcoholized-truck drivers.
T. Stübig et al. / Alcohol 46 (2012) 681e686
Limitations Although this is the largest study analyzing the effect of alcohol on several issues of trauma patients, there are some limitations of this study. First, this is not a randomized controlled study, and the results may therefore be exaggerated by confounders and biases. Second, our study analyzed patients admitted during a time period of 11 years. Pre-hospital emergency medicine has improved during this time, leading to potentially modified results. Moreover, one has to be aware that other drugs than alcohol (i.e. cocaine, benzodiazepines, marihuana) might be consumed by the patients analyzed in our report. The Center of Disease Control of the United States announced in a disclosure that the prevalence for drug intoxication was the same as for alcohol intoxication (Centers for Disease and Prevention, 2006). Other drugs than alcohol may have had an effect on the injury mechanism too, however, this was not tested in our study. Besides, public health efforts against alcohol-intoxicated driving have increased, and the allowed alcohol level in traffic has been reduced from 0.08 g% to 0.05 g% by a law from 2001 in Germany. The alcohol testing was only performed by order of the police, leading to a potential preselection of the tested patients. Legal aspects complicate standardized alcohol testing for trauma patients in Germany, as the patient has to give his consent. If the patient refuses the consent for blood alcohol testing, the analysis can only be performed by the order of a judge. In our study, we only used the results of the BAC that were ordered by police, as alcohol testing for trauma patients was not performed on a regular basis in clinics in Germany, as also reported in other countries (Fabbri et al., 2002; Maier, 2001; Nilssen et al., 1994). The potential ethanol contamination of BAC testing by standard dermal antiseptics in clinics, described by Higuchi et al. (Higuchi et al., 2005), was another reason for us to use the results of the police or judge ordered BAC testing only, as this procedure has to be performed in a standard way without the use of alcoholic antiseptics. Conclusions Alcohol intoxication in trauma patients leads to a higher preclinical mortality. Furthermore, BAC positive vehicle users and pedestrians are more often injured and experience a higher relative speed (i.e. Dv) on impact. The subgroup analysis showed no alcohol dose-related effect on injury severity and relative speed, but a correlation of increasing age of patients age with higher alcohol concentrations. Acknowledgments For the present study, accident data from GIDAS (German In-Depth Accident Study) was used. GIDAS is the largest in-depth accident study in Germany and is funded by the Federal Highway Research Institute (BASt) and the German Research Association for Automotive Technology (FAT), a department of the VDA (German Association of the Automotive Industry). References Abdel-Aty, M. A., & Abdelwahab, H. T. (2000). Exploring the relationship between alcohol and the driver characteristics in motor vehicle accidents. Accident; Analysis and Prevention, 32, 473e482. Abele, G. (1958). [Effect of alcohol on driving speed ability of the operator]. Deutsche Zeitschrift Fur Die Gesamte Gerichtliche Medizin, 47, 447e471. Andersen, J. A., McLellan, B. A., Pagliarello, G., & Nelson, W. R. (1990). The relative influence of alcohol and seatbelt usage on severity of injury from motor vehicle crashes. The Journal of Trauma, 30, 415e417. Apodaca, T. R., & Schermer, C. R. (2003). Readiness to change alcohol use after trauma. The Journal of Trauma, 54, 990e994.
685
Baker, S. P., O’Neill, B., Haddon, W., Jr., & Long, W. B. (1974). The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. The Journal of Trauma, 14, 187e196. Berry, C., Ley, E. J., Margulies, D. R., Mirocha, J., Bukur, M., Malinoski, D., et al. (2011). Correlating the blood alcohol concentration with outcome after traumatic brain injury: too much is not a bad thing. The American Surgeon, 77, 1416e1419. Blondell, R. D., Looney, S. W., Krieg, C. L., & Spain, D. A. (2002). A comparison of alcohol-positive and alcohol-negative trauma patients. Journal Studies on Alcohol, 63, 380e383. Bolhofner, B., Carmen, B. A., Donohue, S. D., & Harlen, K. (1994). Motorcycle accident injury severity, blood alcohol levels, insurance status, and hospital costs: a 4-year study in St. Petersburg, Florida. Journal of Orthopaedic Trauma, 8, 228e232. Bradbury, A. (1991). Pattern and severity of injury sustained by pedestrians in road traffic accidents with particular reference to the effect of alcohol. Injury, 22, 132e134. Brezel, B. S., Kassenbrock, J. M., & Stein, J. M. (1988). Burns in substance abusers and in neurologically and mentally impaired patients. The Journal of Burn Care & Rehabilitation, 9, 169e171. Brismar, B., & Bergman, B. (1998). The significance of alcohol for violence and accidents. Alcoholism, Clinical and Experimental Research, 22, 299Se306S. Centers for Disease and Prevention. (2006). Alcohol and other drug use among victims of motor-vehicle crasheseWest Virginia, 2004-2005. MMWR. Morbidity and Mortality Weekly Report, 55, 1293e1296. Chang, G., & Astrachan, B. M. (1988). The emergency department surveillance of alcohol intoxication after motor vehicle accidents. JAMA: The Journal of American Medical Association, 260, 2533e2536. Danielsson, P. E., Rivara, F. P., Gentilello, L. M., & Maier, R. V. (1999). Reasons why trauma surgeons fail to screen for alcohol problems. Archives of Surgery, 134, 564e568. Deutch, S. R., Christian, C., Hoyer, S., Christensen, E. F., Dragsholt, C., Hansen, A. C., et al. (2004). Drug and alcohol use among patients admitted to a Danish trauma centre: a prospective study from a regional trauma centre in Scandinavia. European Journal of Emergency Medicine, 11, 318e322. Dultz, L. A., Frangos, S., Foltin, G., Marr, M., Simon, R., Bholat, O., et al. (2011). Alcohol use by pedestrians who are struck by motor vehicles: how drinking influences behaviors, medical management, and outcomes. The Journal of Trauma, 71, 1252e1257. Fabbri, A., Marchesini, G., Morselli-Labate, A. M., Rossi, F., Cicognani, A., Dente, M., et al. (2002). Positive blood alcohol concentration and road accidents. A prospective study in an Italian emergency department. Emergency Medicine Journal: EMJ, 19, 210e214. Forchheimer, M., Cunningham, R. M., Gater, D. R., Jr., & Maio, R. F. (2005). The relationship of blood alcohol concentration to impairment severity in spinal cord injury. The Journal of Spinal Cord Medicine, 28, 303e307. Greenspan, L., McLellan, B. A., & Greig, H. (1985). Abbreviated injury scale and injury severity score: a scoring chart. The Journal of Trauma, 25, 60e64. Higuchi, A., Kurihara, R., Yoshimoto, T., Sano, T., Katsumata, K., Ishii, A., et al. (2005). Problems in blood alcohol testing of severely injured drivers brought to emergency departments in Japan. Legal Medicine, 7, 299e305. Howland, J., & Hingson, R. (1987). Alcohol as a risk factor for injuries or death due to fires and burns: review of the literature. Public Health Reports, 102, 475e483. Kim, K., Nitz, L., Richardson, J., & Li, L. (1995). Personal and behavioral predictors of automobile crash and injury severity. Accident; Analysis & Prevention, 27, 469e481. Knobloch, K., Wagner, S., Haasper, C., Probst, C., Krettek, C., Otte, D., et al. (2006). Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. The Annals of Thoracic Surgery, 82, 444e450. Li, G., Keyl, P. M., Smith, G. S., & Baker, S. P. (1997). Alcohol and injury severity: reappraisal of the continuing controversy. The Journal of Trauma, 42, 562e569. Liu, S., Siegel, P. Z., Brewer, R. D., Mokdad, A. H., Sleet, D. A., & Serdula, M. (1997). Prevalence of alcohol-impaired driving. Results from a national self-reported survey of health behaviors. JAMA: The Journal of American Medical Association, 277, 122e125. Lowenfels, A. B., & Miller, T. T. (1984). Alcohol and trauma. Annals of Emergency Medicine, 13, 1056e1060. Maier, R. V. (2001). Ethanol abuse and the trauma patient. Surgical Infections (Larchmt.), 2, 133e141, discussion 141e134. Mann, B., Desapriya, E., Fujiwara, T., & Pike, I. (2011). Is blood alcohol level a good predictor for injury severity outcomes in motor vehicle crash victims? Emergency Medicine International, 2011, 616323. McCarthy, M. L., Sheng, P., Baker, S. P., Rebok, G. W., & Li, G. (2009). Validity of policereported alcohol involvement in fatal motor carrier crashes in the United States between 1982 and 2005. Journal of Safety Research, 40, 227e232. McCoy, G. F., Johnstone, R. A., Nelson, I. W., & Duthie, R. B. (1989). A review of fatal road accidents in Oxfordshire over a 2-year period. Injury, 20, 65e68. McGill, V., Kowal-Vern, A., Fisher, S. G., Kahn, S., & Gamelli, R. L. (1995). The impact of substance use on mortality and morbidity from thermal injury. The Journal of Trauma, 38, 931e934. McLellan, B. A., Vingilis, E., Liban, C. B., Stoduto, G., McMurtry, R. Y., & Nelson, W. R. (1990). Blood alcohol testing of motor vehicle crash admissions at a regional trauma unit. The Journal of Trauma, 30, 418e421. Mittmeyer, H. J. (1991). [Severity of injury of alcohol intoxicated pedestrians in street traffic]. Beitrage Zur Gerichtlichen Medizin, 49, 247e251.
686
T. Stübig et al. / Alcohol 46 (2012) 681e686
Moser, A., Heide, W., & Kompf, D. (1998). The effect of oral ethanol consumption on eye movements in healthy volunteers. Journal of Neurology, 245, 542e550. Mundt, J. C., Ross, L. E., & Harrington, H. L. (1992). A modeling analysis of young drivers’ judgments of accident risk due to alcohol use and other driving conditions. Journal of Studies on Alcohol, 53, 239e248. Nilssen, O., Ries, R. K., Rivara, F. P., Gurney, J. G., & Jurkovich, G. J. (1994). The CAGE questionnaire and the short Michigan alcohol screening test in trauma patients: comparison of their correlations with biological alcohol markers. The Journal of Trauma, 36, 784e788. Orsay, E. M., Doan-Wiggins, L., Lewis, R., Lucke, R., & RamaKrishnan, V. (1994). The impaired driver: hospital and police detection of alcohol and other drugs of abuse in motor vehicle crashes. Annals of Emergency Medicine, 24, 51e55. Otte, D., Jansch, M., & Haasper, C. (2012). Injury protection and accident causation parameters for vulnerable road users based on German in-depth accident study GIDAS. Accident; Analysis & Prevention, 44, 149e153. Otte, D., Pohlemann, T., Wiese, B., & Krettek, C. (2003). [Changes in the injury pattern of polytraumatized patients over the last 30 years]. Der Unfallchirurg, 106, 448e455. Phillips, D. P., & Brewer, K. M. (2011). The relationship between serious injury and blood alcohol concentration (BAC) in fatal motor vehicle accidents: BAC ¼ 0.01% is associated with significantly more dangerous accidents than BAC ¼ 0.00%. Addiction, 106, 1614e1622. Pories, S. E., Gamelli, R. L., Vacek, P., Goodwin, G., Shinozaki, T., & Harris, F. (1992). Intoxication and injury. The Journal of Trauma, 32, 60e64. Richter, M., Otte, D., Haasper, C., Knobloch, K., Probst, C., Westhoff, J., et al. (2007). The current injury situation of bicyclistsea medical and technical crash analysis. The Journal of Trauma, 62, 1118e1122.
Richter, M., Pape, H. C., Otte, D., & Krettek, C. (2005). The current status of road user injuries among the elderly in Germany: a medical and technical accident analysis. The Journal of Trauma, 58, 591e595. Richter, M., Thermann, H., Wippermann, B., Otte, D., Schratt, H. E., & Tscherne, H. (2001). Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years. Journal of Orthopaedic Trauma, 15, 287e293. Robertson, M. D., & Drummer, O. H. (1994). Responsibility analysis: a methodology to study the effects of drugs in driving. Accident; Analysis & Prevention, 26, 243e247. Salim, A., Ley, E. J., Cryer, H. G., Margulies, D. R., Ramicone, E., & Tillou, A. (2009). Positive serum ethanol level and mortality in moderate to severe traumatic brain injury. Archives of Surgery, 144, 865e871. Tien, H. C., Tremblay, L. N., Rizoli, S. B., Gelberg, J., Chughtai, T., Tikuisis, P., et al. (2006). Association between alcohol and mortality in patients with severe traumatic head injury. Archives of Surgery, 141, 1185e1191, discussion 1192. Tulloh, B. R., & Collopy, B. T. (1994). Positive correlation between blood alcohol level and ISS in road trauma. Injury, 25, 539e543. von Oppell, U. O., Bautz, P., & De Groot, M. (2000). Penetrating thoracic injuries: what we have learnt. The Thoracic and Cardiovascular Surgeon, 48, 55e61. Waller, J. A. (1972). Factors associated with alcohol and responsibility for fatal highway crashes. Quarterly Journal of Studies on Alcohol, 33, 160e170. Ward, R. E., Flynn, T. C., Miller, P. W., & Blaisdell, W. F. (1982). Effects of ethanol ingestion on the severity and outcome of trauma. American Journal of Surgery, 144, 153e157. Zeckey, C., Dannecker, S., Hildebrand, F., Mommsen, P., Scherer, R., Probst, C., et al. (2011). Alcohol and multiple trauma-is there an influence on the outcome? Alcohol, 45, 245e251.