Alcohol and drug abuse in burn injuries

Bums Vol. 21, No. 3, pp. 194-199.1995 Copyright 0 1995 Elsevier Science Ltd for ISBI Printed in Great Britain. All rights reserved 0305-4179/95 $10.00 + 0.00

Alcohol and drug abuse in burn injuries A. Hauml, W. Perbix’, H. J. Hick’, G. B. Stark’, G. Spilker’ and M. DoehnZ ‘Department of Plastic and Reconstructive Cologne-Merheim, Koeln, Germany

Surgery with Bum Unit and 2Department

Two studies are described in this paper. In the first study 225 acutely, severely burned patients were retrospectively investigated as to admission blood alcohol level and history of chronic alcohol abuse. The influence of further risk factors, circumstances and therapeutic data was studied, in particular the influence of gender, full-thickness burns, smoke inhalation injury, smoking, length of total and KU stay, and suicide attempt. The 70 patients with positive blood alcohol levels on admission had a significantly higher fatality rate (31.5 per cent) in comparison with the 18.1 per cent fatality rate of patients with a negative blood alcohol level. Both groups had nearly identical mean TBSA and mean age. Chronic alcohol abuse was noted in 59 patients. These patients were found to have a higher fatality rate (31.4 per cent, Z/TO) compared with that of patients without a history of chronic alcohol abuse who had an overall fatality rate of 18.1 per cent

(28/155). No sign$cant differencewas found between non-intoxicated and acutely intoxicated alcoholics (31.4 us 29.3 per cent). Our conclusion is that intake of alcohol before burn injury represents an independent risk factor. The second study was a prospective study of 16 consecutively admitted burn patients, who were evaluated for both drug and alcohol intake. Five patients had positive drug levels andfive had positive alcohol levels. Five patients had a history of chronic drug and/or alcohol abuse. This incidence of alcohol and drug abuse supports the jindings of our retrospective study.

Bums, Vol. 21, No. 3,194-199,1995

Introduction The abuse of psychotropic drugs including alcohol is a growing problem in western society1*2. It has been shown that drug abuse may significantly increase the risk of being involved in severe trauma, including bums3. For this reason, drug users and alcoholics may be overrepresented in admissions to trauma centres and bum units. This has been documented in a previous study, in which alcohol abuse was found to be involved in 80 per cent of bums with a fatal outcome4’5. This also reflects a possible role of alcohol as a negative prognostic factor. To evaluate the incidence of alcohol and drug involvement in bum injuries admitted to a bum centre integrated in a national emergency network for severe bums, we performed two studies. In the first study we retrospectively reviewed all the admissions to our bum unit over a period of 4 years for elevated admission blood alcohol levels. In the second

of Anaesthesiology,

City Hospital

study we prospectively analysed 16 consecutive admissions to our bum unit, whereby toxicological screening for alcohol and other substances of abuse was performed and the patients later questioned abouf their intake of these substances.

Materials and methods Retrospective study Over the &year period between 1989 and 1992 blood alcohol levels were determined in 225 patients admitted directly to our bum unit. Fourteen additional patients were excluded from the study because their bums were so extensive that only basic supportive therapy was administered. Two of these patients had positive blood alcohol levels, four of them were known alcoholics. A positive blood alcohol level and acute intoxication, considered to be synonymous, were defined as greater than 10 mg/lOO ml. Alcoholism has been defined by WHO as: ‘an alcoholic is someone who drinks large amounts of alcohol for more than one year and has lost control over the amount consumed in combination with personal or social problems’. Smoke inhalation injury was diagnosed bronchoscopically and considered present if the trachea or the lower aimays showed soot or signs of inhalation injury. Nicotine abuse was defined as regular smoking of more than five cigarettes per day. The severity of burns was estimated using the abbreviated bum severity index (ABSI)6. This index utilizes coded values for five predictive variables: TBSA, age, sex, full-thickness bums and smoke inhalation. Significance was calculated by Fisher’s exact test. Median values were compared with the Student’s t test, length’s of stay were compared with the U test of Mann-Whitney. Prospective study Sixteen consecutive admissions to our Burn Unit between 27 October 1992 and 31 December 1992 were included. The epidemiological data of this cohort are shown in Table I.

On admission we collected 20 ml bf blood and 20 ml of urine from each patient. The chemical and toxicological studies were performed in the Institute of Forensic Medicine of the University of Cologne using high-pressure liquid-solid chromatographic analysis. We evaluated the

Haum et al.: Alcohol and drug abuse in bum injuries

195

Table I. Drug history and positive drug levels

Patient 1. R.N. 2. M.P. 3. K.M. 4. H.C. 5. K.R. 6. L.V. 7. SE. 8. SF. 9. Z.M. 10. A.E. 11. W.O. 12. P.H. 13. T.M. 14. D.A. 15. K.E. 16. W.T.

Sex

Age (yr)

TBSA (%)

F M M M M F M M M F M M M M M M

22 32 16 31 32 23 30 49 30 65 35 23 34 43 23 33

11 10 10 7 44 19 98 55 18 40 7 15 6 41 9

Table II. Non-intoxicated patients

Alcohol (mg/lOOml)

Alcohol history

Morphine/ heroin

Suicide

Dikaliumclorazepat

Flunitrodiazepam

+

Drug addicted

Cannabis

+

+

+

163

+ +

+ +

+ +

46

+ +

67 225 230

and

+ +

+

alcohol-intoxicated

burned

Non-intoxicated

Intoxicated

155 21.3 37.2 27.4 5.9 23.9 6.4 29.0 15.5 18.1

70 20.0 37.5 27.6 9.4 28.3 6.9 50.0 50.0 31.5

Number Female (%) Mean age (vr) Mean TBSA (%) Full thickness burn TBSA, % Mean length ICU stay (days) Mean ABSI Smoke inhalation (%) Alcoholics (%) Fatality rate (%)

specimens for more than 80 substances including soporifics, tranquillizers, analgesics and antidepressants. The urine samples were analysed enzymatically and immunologically for opiates, cannabis, cocaine, amphetamines and methadone. Positive results were confirmed and quantitated using gas-solid chromatography and gas-mass spectrography. Blood alcohol concentration was determined in our own laboratory with an alcohol dehydrogenase test. All the therapeutic drugs that the patient received from the emergency physician were carefully documented so that we could differentiate these from substances of abuse

Results Results of retrospective

Pentobarbital

study

Comparison of fatality rate between non-intoxicated and alcohol-intoxicated patients Seventy of two hundred and twenty-five patients, or 31.1 per cent, had a positive blood alcohol level on admission (Figure I). The overall fatality rate was 22.2 per cent (501225). Patients with positive alcohol levels had an increased fatality rate of 31.4 per cent (22/70). Patients with negative blood alcohol levels had a fatality rate of 18.1 per cent (28/155). This represents a significant difference (P= 0.038, Fisher’s exact test) (Table II). Both groups were similar in age (Figure 2), TBSA (Figure 3) and gender distribution. The extent of the full-thickness bum was two-thirds greater, and smoke inhalation injury was more frequent in patients with

+

+

+

Table III. Non-intoxicated and alcohol-intoxicated: son between survivors and non-survivors

compari-

Survivors

Non -survivors

Negative alcohol concentration

n=127 TBSA= 21.8% Age=35.6yr

n=28 TBSA= 52.1% Age = 44.4 yr

Positive alcohol concentration

n=48 TBSA= 23.6% Age = 36.3 yr

n=22 TBSA= 37.4% Age = 40.1 yr

Table IV. Non-intoxicated alcoholics

Number Female (%) Mean age (vr) Mean TBSA (%) Full-thickness burn TBSA, % Mean length ICU stay (days) Mean ABSI Smoke inhalation (%) Alcoholics (%) Fatality rate (%)

and

alcohol-intoxicated

burned

Non-intoxicated

Intoxicated

23 32.9 44.7 32.0 6.1 36.6 7.5 45.8 0 29.2

35 31.4 41.3 26.8 9.1 32.0 7.1 64.3 1.29 31.4

positive alcohol levels (50.0 vs 29.0 per cent). The comparison of age and TBSA in non-survivors reveals that non-survivors with positive alcohol levels were 4.3 years younger and had significantly (P= 0.019) lower TBSAs (11.7 per cent) than non-survivors with negative alcohol levels (Table III). Comparison of chronic alcoholics with nonalcoholics Fifty-nine patients (26.1 per cent, 591226) had a history of chronic alcohol abuse. The fatality rate of the alcoholics was 30.5 per cent, compared with that of non-alcoholics 19.2 per cent (321166). This difference was significant with P~0.10 (Fisher’s exact test) There was no significant difference in the fatality rates of acutely intoxicated (31.4 per cent) and non-intoxicated alcoholics (29.2 per cent) (TableIV).

Burns: Vol. 21, No. 3, 1995

196

225 (50) patients

I

I 155

”

70 (48) intoxicated

(28) non-intoxicated

All Positive alcohol

&IO

0 0

IO-20

20-30

3a-40

40-30

3o-60

60-70

70-80

19 6

12 22

40 14

45 15

26 9

8 3

4 0

80-9090-IM)

1 0

1 0

Age (year) I 24 (7) alcoholics

I

1 131 (21) non dcoholics

I

35 (I 1) dmholin

Figure 1. Evaluation of 225 burned parentheses indicate non-survivors.

Figure 2. Distribution of age in burned patients. patients; a, patients with positive alcohol level.

35 (II) non-alcoholics

patients.

Numbers

Forty-seven patients (20.9 per Influence of gender cent) were female. They contributed equally to the composition of the intoxicated group (20.0 per cent) and the non-intoxicated group (21.3 per cent) (‘TkbleII). They were, however, proportionately overrepresented among chronic alcoholics (17/59 or 28.8 per cent vs. 301166 or 18.1 per cent). The fatality rate of female patients was generally higher than that of male patients, but was not significantly different (Figured). In the general cohort 23.4 per cent (11/47) women vs. 21.9 per cent (39/178) men died. In the intoxicated group 35.7 per cent (5/14) women vs. 30.3 per cent (17/56) men and in the alcoholic group 47.1 per cent (8/17) vs 23.8 per cent (10/42) died. Even this apparently large difference was not significant (P= 0.118). Although the TBSAs Influence of full-thickness burns in intoxicated and non-intoxicated patients were almost identical (27.4 vs. 27.6 per cent), the TBSA of full thickness bums was more than one-third greater (9.4 versus 5.9 per cent, P= 0.072) in patients with positive blood alcohol levels (TubleII). A causal relation between greater bum depth and the known analgesic effect of alcohol remains hypothetical at this time. The mean ICU stay was Length of stay and alcohol 25.3 (s.d. = 27.1) days, the mean total stay was 36.9

x

P .s k

ii; O-10

All Positivealcohol

52 15

IO-20 20-30

53 13

44 15

30-m

40-30

so-60

23 10

20 7

11 4

60-70 70-W

10 4

5 1

80-90 90-100

4 1

3 0

TBSA (%) Figure 3. Distribution of TBSA. with positive alcohol level.

n,

All patients;

1,

patients

(s.d= 30.8) days for the 225 patients. Patients with positive blood alcohol levels on admission had increased KU (mean= 28.3, s.d. = 25.3 days) and total stays (mean = 41.3, s.d. = 30.2 days) compared with those without positive blood alcohol levels (ICU stay: mean = 23.9, s.d. = 25.3; total stay: mean= 41.3, s.d. = 30.2 days). This difference was not significant with P= 0.0968 for ICU stay and P=O.1053 (U-test Mann-Whitney) for total stay. In alcoholics ICU stay was even more prolonged (ICU stay: meanc33.9, s.d.= 28.7 days; total stay: mean = 44.2, s.d. = 3 1.2 days) compared to non-alcoholics (ICU s.d. = 25.8 days; total stay: stay: mean = 22.2, mean = 34.3, s.d. = 30.2 days) (see Tables II, IV). This difference was significant with P=O.OOOT for length of ICU stay and P= 0.0135 for total stay.

Female 22%

Female 21%

Figure 4. Distribution

All

in

”

Survivors

m,

Non-survivors

of gender in survivors and non-survivors.

Haum et al.: Alcohol and drug abuse in bum injuries

197

of inhalation injury of 29.0 per cent (45/155) in alcoholics or 30.1 per cent (501166) in non-alcoholics (Figure 6). Both differences were significant, for intoxicated patients P= 0.003, for alcoholics P= 0.007 (Fisher’s exact test). We conclude that bums both in alcohol-intoxicated patients and alcoholics are more frequently combined with inhalation injury.

Survivor Non-survivor

147 31

28 19

Blood alcohol concentration (mg/lOOml)

blood alcohol level and fatality rate. n , m, survivor.

Figure 5. Admission

Non-survivor;

When the median was used to determine the length of stay, both intoxicated patients and alcoholics had increased lengths of stay; the population median was 17 days (range: l-184), that for intoxicated patients 21.5 days (range: 2-1x2), and that for chronic alcoholics 26 days (range: 2-157) and for intoxicated, chronic alcoholics, 30 days (range: 2-83). Influence of blood alcohol concentration on fatality rate The mean alcohol level was significantly higher in (129 mg/lOO ml) than in non-alcoholics alcoholics (87 mg/lOO ml), P= 0.0087 (Fisher’s exact test). Patients with a blood alcohol level below 60 mg/lOO ml had a fatality rate of 17.4 per cent. A blood alcohol level above 60 mg/lOO ml corresponded with an increased risk of fatality, a rate of 40.4 per cent (Figure 5). This difference was greatest at alcohol levels between 60 and 150mg/ 100 ml. This difference was significant (PC 0.0012). The proportion of alcoholics was greater in the groups with higher blood alcohol levels. Eighteen per cent of the patients with an alcohol level below 60 mg/lOO ml were alcoholics, 44.4 per cent of those with a level between 60 and 150 mg/IOOml were alcoholics and 75 per cent of those with levels greater than 150mg/lOOml were alcoholics. We conclude that alcohol levels above 60 mg/lOO ml mean a greater risk for a fatal outcome. Influence of inhalation injury In 35.6 per cent of patients (80/225) an inhalation injury was diagnosed using bronchoscopy. The incidence of inhalation injury was much higher in both intoxicated patients and in chronic alcoholics. In alcoholics, inhalation injury was documented in 50.8 per cent (30/59), and in alchol-intoxicated patients in 50.0 per cent (35/70). This compares with an incidence

Inhalation 80

Non-inhal

All Figure 6. Inhalation

injury: comparison

Nicotine abuse was present in Influence of smoking 28.0 per cent (63/225) of patients. Alcoholics had a significantly higher incidence of nicotine abuse (54.2 per cent, 32159) than non-alcoholics (18.7 per cent, 311166); (PC 0.0001 Fisher’s exact test). In patients with a positive alcohol level the incidence was 34.3 per cent (24/70), higher than that in non-alcoholics where the incidence was 25.2 per cent (39/155), the difference was remarkable but none the less significant with PC 0.0001 Fisher’s exact test. We conclude that bums in intoxicated patients and alcoholics are very frequently combined with a history of smoking when compared with non-intoxicated patients or non-alcoholic patients. No significant relationAlcohol and attempted suicide ship between alcohol and attempted suicide was recognized. Twenty-four patients (10.7 per cent; 241225) were burned while attempting suicide. Among the alcoholics 13.6 per cent (B/59) attempted suicide, in intoxicated patients 12.9 per cent (9/70) attempted suicide. Four of the suicidal patients died, none of whom was an alcoholic and only one of whom had an elevated alcohol level. Results of prospedive study Among the 16 patients prospectively screened for multiple substances of abuse, five (31 per cent showed positive toxicology (drug levels) and five patients had positive alcohol levels. The distribution of single and combined substances may be seen in Tablel. Two patients had consumed both drugs and alcohol. The area of body surface burned ranwd between 6 and 98 per cent with a mean bum area of 16.5 per cent. Seven patients had predominantly full-thickness bums, the rest had partial thickness bums. Historical information obtained from interview of patients’ and/or patients’ relatives revealed that chronic alcohol abuse was present in four patients. Three of the bum admissions were the result of suicidal self-immolation with petrol. Five patients suffered from psychological disorders, including psychosis, schizophrenia and major depressive illnesses, and had a history of current or prior

Inhalation

Inhalation

Non-inhalation 35

Non-inhalation 29

Intoxicated patients

Alcoholics

between

alcohol inioxicated

and alcoholics.

Burns: Vol. 21, No. 3, 1995

198

treatment with psychopharmaceutical agents. Two patients were known drug addicts who had curtailed drug abuse 3 years prior to injury. Toxicological screening, meaning the detection of morphine, heroin, pentabarbital, dikaliumclorazepat or cannabis, was positive in five of seven patients with predominately full-thickness burns. Four of these patients subsequently died. The fatality rate was not significantly different from patients not showing drug or alcohol ingestion.

Discussion It is well known that substance abusers make up a large proportion of bum victims. We investigated whether alcohol and drug intake has an influence on the bum patient’s hospital course and survival. Several other factors thought to influence postbum survival were also analysed. We did a retrospective study of 225 patients consecutively admitted to our Bum Unit. We found that patients acutely intoxicated with alcohol had a significantly higher fatality rate when compared with non-intoxicated patients (31.4 vs. 18.1 per cent). Based on historical information obtained from either patients, their relatives or both, we elicited a history of chronic alcoholism in 59 of these patients. These patients had a significantly higher fatality rate than patients without a history of chronic alcoholism. This correlates with a study of 108 bum patients by Jones et al.‘, in which a significantly higher fatality rate among alcoholics was demonstrated. This study documented the incidence of acute alcohol intoxication among bum patients and found that 27 per cent of the patients were intoxicated. This corresponds to the intoxication rate of 31 per cent which we noted in our study. Interestingly there was a relationship between blood alcohol concentration and fatality rate. A blood alcohol level greater than 60 mg/lOO ml correlated with an increased fatality rate. Barillo and Rush4 established that the higher the alcohol level the less was the tendency to flee from the accident site. This may explain the increased fatality rate. The fact that the proportion of chronic alcoholics was proportionately greater in the groups with higher alcohol levels was not surprising. That the fatality rate does not increase linearly with increasing blood alcohol concentration may be explained by taking into account the increasing representation of alcoholics in the groups with higher blood alcohol levels, and adding to this our knowledge of the tolerance a chronic alcoholic develops to an increased blood alcohol. In other words, we found that the group with blood alcohol levels greater than 150mg/100 ml contained a larger number of alcoholics who probably were less totally impaired as a group at this alcohol level than either the first group, having fewer alcohol-tolerant members, or the third group, although being made up of a greater proportion of alcoholics, had a respective alcohol level obviating the effect of, tolerance and therefore resulting in greater impairment of its members. Tobiasen et a1.6 found that female gender was an independent risk factor for burn fatality. Although there was a slightly higher rate of death among our female patients, this was not significant. The results of our analysis of length of stay in the ICU revealed a significantly increased length of stay among chronic alcoholics. The stays among the patients acutely intoxicated was not significantly lengthened. Kelly et a1.8 Brezel et a1.9 and Swenson et al.‘O have established in several studies that among bum patients who were

substance abusers or neurologically impaired, the hospital stay was prolonged. Jones et al.’ found no difference in the length of stay among alcoholics in the ICU but an overall increased length of hospital stay among these patients. The risk of fatality is doubled by the simultaneous occurrence of a bum injury and an inhalation injury5. We found in our study that there was significantly more inhalation injury among both the acutely intoxicated and chronic alcoholics. This may be accounted for by the assumption that the generalized neurological depression of alcohol intoxication decreases awareness of the irritating stimuli of smoke and other substances noxious to the respiratory tract. The rate of nicotine abuse was higher among both chronic alcoholics and the acutely intoxicated. No significant relation between alcohol ingestion or history and bum injury secondary to attempted suicide was seen. In our prospective study we investigated drug and alcohol intake in 16 patients. Thirty-one per cent of patients had a positive alcohol level, which corresponds to the rate seen in our retrospective study (30.1 per cent). We found it remarkable that as many as 31 per cent of the patients had positive toxicology screens and that 31 per cent of them had a history of psychological illness. We were not able to establish a significant difference in the fatality rate of those patients who had ingested drugs or alcohol and those who had not. However, our sample size was small. It has been established that alcohol and drug abuse is higher in bum and trauma patients2”1’12. We carried out two studies, one retrospective, one prospective, to evaluate further the influence of drugs and alcohol on the burned patient and his/her course. We were able to demonstrate an increased rate of fatality in both the acutely intoxicated and chronically alcoholic bum patients. Alcoholics had an increased length of ICU stay and a greater incidence of inhalation injury. The subgroups of alcoholics and alcoholintoxicated bum patients represent a population manifesting a more complex injury spectrum, a costly and prolonged medical management and increased risk of death.

References German Government Crime Defense Office (1991) Bundeskriminalamt. Elisabeth AM. Preanaesthetic assessment of the drug abuse patient. Anesthesia1 C/in North Am 1990;18: 829-844. Lowenfels AB, Miller TT. Alcohol and trauma. Ann Emerg Med 1984;13:1056. Barillo DJ, Rush BF. Is ethanol the unknown toxin in smoke inhalation injury?. Am Surgeon 1986;52: 641. Heimbach DM, Waeckerle JF. Inhalation injuries. Ann Emerg Med 1988;17:1316. Tobiasen J, Hiebert JM, Edlich RF. A practical bum severity index. ] Burn Care Rehabil 1982; 3: 229. Jones JD, Barber B, Engrav L, Heimbach D. Alcohol use and bum injury. J Bum Care Rehabil 1991;12: 148. Kelley D, Lynch JB. Burns in alcohol and drug users result in longer treatment times with more complications. ] Bum Care Rehabil 1992; 13: 218.

199

Haum et al.: Alcohol and drug abuse in bum injuries

9 Brezel BS, Kassenbrock JM, Stein JM. Bums in substance abusers and in neurologically and mentally impaired patients. J Burn Cure Rehabil 1988; 9: 169. 10 Swenson JR, Dimsdale JE, Rockwell E, Carroll W, Hansbrough J. Drug and alcohol abuse in patients with acute bum injuries. Psychosomatics 1991; 32: 287. 11 Rivara FP, Mueller BA, Flinger CI et al. Drug use in trauma victims. ] Trauma 1989; 29: 462.

12 Thal ER, Bost RO. Effects of ,alcohol and other drugs on traumatized patients. Arch Surg 198.5; 120:708. Paper

accepted

after revision

18 July 1994.

Correspondence should be addressed to: Dr Anette Haum, Starenweg 11, 50226 Frechen, Germany.