- Email: [email protected]
Alcohol-Related Injuries Among Adolescents in the Emergency Department
INJURY PREVENTION/ORIGINAL
CONTRIBUTION
Alcohol-Related Injuries Among Adolescents in the Emergency Department From the Departments of Pediatrics*, Family Medicine% and Emergency Medicine~, School of Medicine (student") and BiomedicaZSciences, State University of New York at Buffalo, Buffalo, New York. Receivedfor publication February 24, 1995. Revision received May 9, 1995. Acceptedfor publication May 15, 1995. Presented as a poster exhibit at the 34th Annual Meeting of the Ambulatory Pediatric Association, Seattle, Washington, May 1994. Supported by a grunt from Research for Health in Erie County, Incorporated. Copyright © by the American College of Emergency Physicians.
Sharon B Meropol, MD *~ Ronald M Moscati, MD § Kathleen A Lillis, MD *§ Sarah Ballow, MS" David M Janicke, MD, PhD§
See related editorial, p 221.
Study objective: Todetermine the frequency of positive alcohol readings in adolescent patients presenting for treatment of injury. Design: Patients aged 10 through 21 years were prospectively enrolled in this descriptive study. Demographic data and information about the injury were collected at enrollment. Blood ethanol concentration was measured with a saliva alcohol assay with a lower detection limit of 10 mg/dL (2 mmol/L). Setting: Enrollment was conducted at four emergency departments, an urban trauma center, an urban children's trauma center, a suburban hospital, and a rural hospital. Enrollmentat each facility was conducted during two 24- hour periods for every day of the week (14 days total). Consecutive sampling was used during each enrollment period. Results: We enrolled 295 patients (92% of eligible subjects). Sixty-three percent were male; 74% were white, 19% black, 3% Hispanic, 1% Asian, and 3% from other racial groups. The mean age was 15.6+3.2years. Fifteen patients (5%)tested positive for ethanol (range, 10 to 120 mg/dL [2 to 24 retool/L]). 0nly four of these patients underwent ethanol testing as part of their medical evaluations. Of the 125 subjects aged 17 through 21 years, 14 (11.2%) tested positive for ethanol. Hospital distribution was (number of patients with positive ethanol test results): urban trauma center, 8 of 52; urban children's trauma center, 0 of 91; suburban hospital, 4 of 111; rural hospital, 3 of 41. The highest percentage of positive ethanol test results was found at the urban trauma center, where 15% of total subjects and 22% of subjects aged 17 through 21 tested positive. Injuries related to assaults and motor vehicle crashes were particularly associated with alcohol use.
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Conclusion: Alcohol is associated with injuries in urban, sub-
urban, and rural settings in the older pediatric population. Alcohol use is underrecognized and should be considered in patients presenting with injuries, especially victims of assaults or motor vehicle crashes. [Meropol SB, Moscati RM, Lillis KA, Ballow S, Janicke DM: Alcohol-related injuries among adolescents in the emergency department. Ann EmergMedAugust 1995;26:180-186.] INTRODUCTION Injuries are the leading cause of pediatric mortality in the United States, accounting for one half to three quarters of adolescent deaths. 1 A well-known relationship exists in adults between alcohol and injury mortality. In the United States, 44% of total traffic fatalities in 1993 were related to alcohol 2, and a significant percentage of adults killed in motor vehicle crashes, falls, drownings, fires, assaults, and suicides have blood alcohol concentrations of. 10% (100 mg/dk or 20 mmol/L) or higher. 3,4 Most previous alcohol/ injury studies have involved hospitalized adult trauma victims and have demonstrated that 31% to 53% of such patients have positive alcohol screens s-8 and that the incidence of alcohol abuse or dependence is nine times higher among these patients than in the general population. # Adolescent alcohol use is widespread. In a 1992 national survey, 69% of eighth-graders had used alcohol and 27% of these students had been drunk. Thirteen percent of eighth-graders and 28% of twelfth-graders reported heavy use of alcohol (five or more drinks per occasion in the 2 weeks preceding the survey), lo In the 1990 national school-based Youth Risk Behavior Survey, 44% of US high school seniors reported recent binge drinking, z1 Previous studies of adolescent injuries have focused on fatalities or hospitalized individuals. In 1989, 37% and 53% of traffic fatalities in the United States were related to alcohol in the 15- to 17-year and 18- to 20-year groups, respectively12; in 1993, an estimated 40% of deaths resuiting from motor vehicle crashes in youth aged 15 to 20 years were related to alcohol.2 Alcohol was shown to play a significant role in non-motor vehicle-related unnatural deaths in San Francisco youths. 13 Less is known about the relationship between adolescent alcohol use and nonfatal injuries. Most previous studies have involved patients admitted to trauma or pediatric hospitals. Loiselle et a114 found that 12% of screened adolescents hospitalized for traumatic injury tested positive for alcohol (49% of eligible patients were screened). In a similar study, Rivara et
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al is found that 41% of 18- to 20-year-olds admitted to a trauma center in Seattle tested positive for alcohol (82% of eligible patients screened). Identification of alcohol involvement with injury is important if this recognition plays a role in medical management of injury In addition, any alcohol-related injury in an adolescent, even a minor one, can be an indicator of possible future complications of alcohol use. In a survey of 202 adolescents undergoing treatment for substance abuse, 25% admitted to having needed emergency medical treatment for injuries related to drug or alcohol abuse. 1o We hypothesized that alcohol use in adolescent injury patients is associated with a wide variety of injury types seen in various £D settings but may go unrecognized or unaddressed by the treating physician. The purpose of this study was to examine the prevalence of alcohol use in relation to patient demographics, ED site, and injury type in adolescent patients presenting to the ED for injuries.
MATERIALS AND METHODS Patients aged 10 through 21 years presenting to the ED for treatment of any type of injury were prospectively
Figure. Age distribution of the study population at the four ED sites (N=295). ]
No. of patients
10
11
12
13
14
15
16
17
18
19
Trauma
20
21
Age (years)
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ADOLESCENTS AND ALCOHOL Meropol et al
enrolled from four local hospitals: an urban Level I trauma center, urban Level I children's trauma center, a suburban hospital, and a rural hospital. Enrollment at each facility was conducted during two 24-hour periods for every day of the week (14 days total). In the first enrollment cycle, data were collected during a 24-hour study period for every day of the week from each hospital from July 6, 1993, through August 2, 1993. The second enrollment cycle was conducted from November 1993 through January 1994. Patients were excluded from the study if they had sustained injury more than 24 hours before the ED visit or if injuries were related to alleged sexual abuse. Medical student research assistants approached eligible patients for study enrollment. Informed consent was obtained from the subject and from the parent or guardian when appropriate. The number of eligible subjects who declined participation in the study was recorded. Demographic data and information about the injury were collected at enrollment. Medications used in the preceding 24 hours were noted. Blood ethanol concentration was measured with the Q.E.D. A-150 Saliva Alcohol Test (Enzymatics, Incorporated) with a lower detection limit of 10 mg/dL (2 mmol/L) and a correlation with blood alcohol concentration of .98. it,is Each research assistant was taught to use the saliva alcohol test and was required to demonstrate correct use of the test before enrolling any patients. If the subject underwent
serum or breath alcohol testing as part of the emergency care ordered by the emergency physician, this result was also recorded. We used standard descriptive statistics to calculate means and percentages for demographic data. Multiple logistic-regression analysis was used to examine the possible relationship between the dichotomous dependent variable ethanol concentration (present or absent) and the independent variables: age (less than 17 years or 17 years or older), ED site (urban trauma center, suburban hospital, urban children's trauma center, rural hospital), sex, and race (black, Hispanic, Asian, white, other). We used a stepwise model-computed method to include variables with significance levels less than .05 as calculated with X2 analysis. We also performed analysis of the odds ratio (OR) for each independent variable and used the HosmerLemeshow test to assess goodness of fit (True Epistat statistical software; Epistat Services). This study was approved by the State University of New York School of Medicine and Biomedical Sciences Institutional Review Board, the Institutional Review Board of the Children's Hospital of Buffalo, and the Human Research Committee of Millard Fillmore Hospitals. Subjects were protected from the use of data for criminal prosecution under conditions set forth in a National Institute on Alcohol Abuse and Alcoholism Certificate of Confidentiality.
Table 1.
Patients with positive ethanol test results. Ethanol Concentration (mg/dL) Site
Sex
Urban trauma center F Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Suburban hospital M Suburban hospital M Suburban hospital F Suburban hospital F Rural hospital F Rural hospital M Rural hospital M *Valuesnot obtainedsimultaneously. tPatientadmittedto hospital. tNot determined;patientwas intubated.
1 82
Age (yr)
19 20 21 21 20 20 17 19 19 19 18 19 18 10 20
Most Severe Injury
Laceration, wrist Contusion, leg Gunshot wound, knee Laceration, scalp and face Gunshot wound, buttockt Central nervous system bleedingt Contusion, knee Contusions, back and shoulder Laceration, lip Laceration, finger Contusion, scalp Contusion, leg Contusion, arm Bee sting, face Abrasion, neck
Saliva
10 45 45 Less than 10" 70 Not determined* 110 50* lO 25 120 135 20 3O 5O
Blood
Breath
45* 93 130"
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85*
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RESULTS
received a dose of diphenhydramine elixir (5.6% ethanol content) at an unknown time before presentation, which may have contributed to his measured ethanol concentration of 30 rag/alL (6 retool/L). However, on the basis of a 10-mL dose of elixir, body weight of 45 kg, and a reported volume of distribution for ethanol of .54 L/kg 19 and assuming that the ethanol was measured immediately after ingestion, with complete and instantaneous oral absorption, the maximum estimated ethanol concentration would be 2.3 mg/dL (.46 mmol/L), less than one tenth the measured level. Therefore it seems unlikely that the reported dose of diphenhydramine elixir accounted for the ethanol concentration measured. The highest percentage of positive alcohol test results was found at the urban trauma center, where 15% of total subjects and 22% of subjects aged 17 through 21 tested positive; there were no positive alcohol tests at the urban children's trauma center (Table 2). The race distribution of patients with positive ethanol test results (10 white, 4 black, 1 Hispanic) was similar to that of the total study population. Multiple logistic-regression analysis revealed that age and ED site were significant predictors of positive ethanol test results (P<.0001). No significant predictive value was found for sex or race. In the stepwise model-computed analysis, age accounted for the most variability (P<.0001) and ED site was the second most predictive variable (P=.01). The OR analysis indicated that age 17 years or older increased the likelihood of a positive ethanol test result 14.4 times (95% confidence interval, 1.79 to 116) compared with the lower age group. When ED sites were compared individually with the urban trauma center, the only one for which site approached statistical significance as a predictor was the suburban hospital (at the P=.06 level), with an OR of .3:1 compared with the urban trauma center. The value of ED site as a predictor was revealed only when the power of the analysis was increased with data from all the hospitals combined.
Ninety-two percent of eligible patients (295 of 321) were enrolled in the study. In 24 cases enrollment was declined: by the parent or guardian in 11 cases, by the patient in 9 cases, and by the patient and the parent in 4 cases. Two patients were not enrolled for technical reasons: in one, saliva could not be obtained for ethanol testing, and in the other, the ethanol saliva test kit control indicated an invalid test. Enrolled patients ranged in age from 10 to 21 years (mean, 15.6_+3.2 years). Sixty-three percent of subjects were male. The racial/ethnic mix was 74% white, 19% black, 3% Hispanic, 1% Asian, and 3% other. Forty-six percent of the study patients were from the trauma centers (urban and urban children's), and 54% were from the community hospitals (suburban and rural). The urban children's trauma center showed a trend toward younger patients--24% of the patients were 17 years or younger--and the urban trauma center showed a trend toward older patients--71% of the patients were 17 years or older. Forty-seven percent and 34% of patients at the suburban hospital and the rural hospital, respectively, were 17 years or older. When data from all hospitals were combined, however, the distribution of ages was not skewed toward either extreme of age (Figure). The most common mechanisms of injury were athletics-related (23%), falls (19%), assaults (11%), injuries caused by sharp objects (11%), motor vehicle crashes (9%), and bicycle accidents (6%). The most common injuries were lacerations (28%), sprains/strains (22%), contusions (18%), and fractures (13%). Five percent of the study patients tested positive for ethanol, with saliva ethanol concentrations ranging from 10 to 135 mg/dL (2 to 27 mmolFL) (Table 1 ). Fourteen of the 15 positive results were in patients aged 17 through 21 years; 11.2% of subjects 17 through 21 years old (14 of 125) tested positive. The youngest patient with a positive alcohol test result was 10 years old. This patient Table 2.
Relationship of care site, age, and positive alcohol test result. Urban Trauma Center Age (yr) 10-16 17-21 Total
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Urban Children's Trauma Center
Suburban Hospital
Rural Hospital
Totals
Positive
Total
Positive
Total
Positive
Total
Positive
Total
Positive
Total
0 8 8
15 37 52
0 0 0
69 22 91
0 4 4
59 52 111
1 2 3
27 14 41
1 14 15
170 125 295
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Meropol ¢t al
The relationship between alcohol use and mechanism of injury is shown in Table 3. Six of 34 (18%) of subjects who presented with injuries related to assault and 4 of 28 (14%) of those who presented with injuries related to motor vehicle crashes tested positive. The severity of injuries ranged from gunshot wounds to an insect sting (Table 1). In only 4 out of 15 patients with positive ethanol test results was ethanol screening ordered by the treating physician as part of the ED evaluation. DISCUSSION
Injuries account for more years of potential life lost in the United States than cancer and heart disease combined. 2° Nevertheless, little is known about the factors that contribute to injuries and about interventions to avoid consequent mortality and morbidity. We know that many adolescents regularly consume alcoholic beverages, often heavily. However, we do not know how their injuries are related to alcohol use. It is important to understand the origins and context of injuries so that effective interventions can be targeted to reduce the potentially serious consequences of injuries for young people. This multicenter study was designed to examine the prevalence of alcohol use in adolescent injury patients presenting to four different types of EDs: a children's hospital, an urban trauma hospital, a suburban hospital, and a rural hospital. By enrolling a diverse population with good representation at each hospital, we aimed for results more generalizable to the young patients seen by many practitioners than if we involved only an urban trauma center or a children's hospital. Our subjects represented a wide variety of mechanisms, types, and severities of injury. Although some of our subjects could be described as young adults, almost all (279 of 295) were under the age of legal alcohol consumption. Table 3.
Mechanisms of injury related to positive alcohol test results.
Mechanism of Injury Assault
Motor vehicle crash Suicide attempt Fall Sharp object (knife)
Bee sting
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No, Positive/ No. Presenting (%)
6/34 (18) 4/28 (14) 1/3 (33) 2/57 (4) 1/34 (3) 1/7 (14)
Five percent of all subjects had been drinking alcohol, 11% at the higher age range of 17 through 21 years. Multiple logistic-regression analysis revealed that age (17 through 21 years versus 10 through 16 years) and, to a lesser extent, ED site were significant predictors of positive ethanol test results in pediatric patients presenting to the ED with injuries. No significant predictive value was found for sex or race. OR analysis showed that the risk of a positive ethanol test result was increased 14.4 times in the older patients compared with the younger patients studied. This finding is in accordance with results from the 1990 National Household Survey on Drug Abuse, which examined age-related alcohol use (down to age 12) and found that habitual drinking behavior increased by a factor of 4.8 between ages 12 and 17 yearsY 1 By restricting the comparison to injured patients, we may have selected for those using alcohol. The data revealed a higher percentage of positive ethanol test results at the urban trauma hospital than at the other three sites (Table 2). It might be anticipated that more injuries would be related to alcohol at an urban trauma center (the urban trauma center and the urban children's trauma center), to which serious injury cases are referred than at a suburban or rural hospital. Other factors such as socioeconomic status may play a role in the differences m results among different enrollment sites. The urban children's trauma center had no positive ethanol test results in the patient sample studied. This may be partially explained by random variability with a relatively low number (n=22) of patients seen at the urban children's trauma center in the group of patients 17 years or older. The proximity of the urban trauma center and the urban children's trauma center in this study also raises the possibility that ambulance-routing practices could differentially affect the types of patients and injuries seen at these two hospitals, both in the younger and in the older adolescent age ranges. Results from research performed only at children's hospitals may not be generalizable to adolescent populations from other settings. In two previous adult studies, injured patients were approximately twice as likely to have positive blood ethanol test results as patients who presented to the ED for other reasons. 22,23 Because we have no data on the incidence of alcohol use by uninjured adolescents in the populations served by the hospitals in our study, we did not address the question of whether alcohol use is more common in injured than in uninjured adolescents. Other investigators have demonstrated a relationship between
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Meropol et aI
ethanol abuse and other problem behaviors and risktaking among adolescents. 24-26 Certain mechanisms of injury seemed to be particularly associated with alcohol use. Positive alcohol test results were found for 6 of 34 (18%) of subjects who presented with injuries related to assault and in 4 of 28 (14%) of those who presented with injuries related to motor vehicle crashes. These 10 patients accounted for two thirds (10 of 15) of the patients found to have positive alcohol test results in this study. Differences in the rates of certain high-risk mechanisms of injury between hospitals could affect the proportions of patients who tested positive for alcohol at each facility Although the proportions of assaults and motor vehicle crashes at the urban children's trauma center (both 10%) differ considerably from those at the urban trauma center (27% and 21%, respectively), they are not substantially different from those of the suburban hospital (8% and 5%, respectively) and the rural hospital (both 5%) to enable us to fully explain the differences between hospitals. Other investigators have shown an association between alcohol and other substance use and suicide attempts in young people. 27-29 Because of limited data, we cannot draw conclusions about any association between alcohol use and suicide attempts in this population. Most subjects who tested positive for alcohol in our study (11 of 15 [73%]) had not been tested for ethanol by their treating emergency physicians. Other investigators have demonstrated that alcohol use is often missed by medical providers. Rutherford3° showed that although 42% of patients who presented to an ED with mild head injuries had positive blood alcohol test results, clinical signs such as breath smell, slurred speech, red eyes, and poor coordination were found to be unreliable for physician identification of alcohol use. Identification of alcohol consumption by any patient may be important for medical management. Also, subjects with alcohol-associated injuries may be at high risk for subsequent complications related to alcohol use. Studies on adults have shown that although alcoholism is common among trauma patients, caregivers in the ED and hospital settings often fail to recognize this pattern, and patients frequently do not get referrals for treatment of substance abuse and dependence. 2<3t-33
settings. Alcohol use often goes unrecognized or unaddressed in the ED. Alcohol use should be considered in adolescents presenting with injuries, especially older youths and victims of assaults or motor vehicle crashes, for whom we found the greatest prevalence of positive alcohol test results. Future studies are needed with regard to effective interventions for this population. Ameliorating a high rate of injury-related mortality is particularly important for young people. We also can hope to curtail long-term complications of alcohol abuse, including those involving health, finances, and family relationships. Recognizing possible alcohol involvement in adolescent injury is only the first step.
REFERENCES 1. Baker SP, O'Neill BO, Oinsburg M J, et al: Injuries in relation to other health problems, in The Injury FactBook,2nd ed. New York: Oxford University Press, 1992, pp 8-16. 2. Centers for Disease Control: Alcohol involvement in fatal motor-vehicle crashes, United States, 1992-1993. MMWR 1994;43:878-879. 3. Waller J: Alcohol and unintentional injury, in Kissis B, Begleiter H (ads): TheBielegyof Alcoholism,vol 4. New York: Plenum, 1976, pp 307-349. 4. Centers for Disease Control: Alcohol involvement in pedestrian fatalities, United States, 19821992. MMWR 1993;42:716-719. 5. McLetlan BA, Vingilis E, Liban CB, at al: Blood alcohol testing of motor vehicle crash admissions at a regional trauma unit. J Trauma1990;30:418-421. 6. Jurkovich GJ, Rivara FP, Gurney JG, et al: Effects of alcohol intoxication on the initial assessment of trauma patients. Ann EmergMad 1992;21:704-708. 7. Sloan EP, Zalenski RJ, Smithe RF, et al: Toxicology screening in urban trauma patients: Drug prevalence and its relationship to trauma severity and management. J Trauma1989;29:16471653. 8. Lindenbaum GA, Carroll SF, Daskal I, et ah Patterns of alcohol and drug abuse in an urban trauma center: The increasing role of cocaine abuse. J Trauma1989;29:1654-1658. 9. Soderstrom CA, Dischinger PC, Smith GS, et al: Psychoactive substance dependence among trauma center patients. JAMA 1992;267:2756-2759. 10. Johnston LD, O'Malley PM, Bachman JG: NationalSurveyResultson DrugUseFrom Monitoring the FutureStudy, 1975-1992.Washington DO: National Institute on Drug Abuse, 1993. NIH publication no. 93-3597. 11. Centers for Disease Control: Alcohol and other drug use among high school students, United States, 1990. MMWR 1991;40:776-784. 12. Centers for Disease Control: Alcohol related traffic fatalities among youth and young adults, United States, 1982-1989. MMWR 1991;40:178-187. 13. Friedman IM: Alcohol and unnatural deaths in San Francisco youths. Pediatrics1985;76:191193. 14. Loiselle JM, Baker MD, Templeton JM, et ah Substance abuse in adolescent trauma. Ann EmergMed 1993;22:1530-1534. 15. Rivara FP, Gurney JG, Ries RK, et al: A descriptive study of trauma, alcohol and alcoholism in young adults. JAdolesc Health 1992;13:663-667. 16. Schwartz RH: Alcohol, drugs and head injury (letter). Pediatrics1986;78:1169. 17. Christopher TA, Zeccardi JA: Evaluation of the Q.E.D.TM saliva alcohol test; A new, rapid, accurate device for measuring ethanol in saliva. Ann EmergMed 1992;21:1135-1137.
CONCLUSION
Our results show that measurable alcohol concentrations are found in male and female adolescents presenting for treatment of injuries in urban, suburban, and rural
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18. Jones AW: Inter- and intra-individual variations in the saliva/blood alcohol ratio during ethanol metabolism in man. Clio Chem1979;25:1394-1398. 19. Tillman AG, Rail TW, Nies AS, et al: Goodmanand Gilman's ThePharmacologicalBasis of Therapeutics,ed 8. Elmsford, New York: Pergamon Press, 1990, p 1679.
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20. National Committee for Injury Prevention and Control: A history of injury prevention, in Injury Prevention:Meeting the Challenge.New York: Oxford University Press, 1989, p 5.
Reprint no. 47/1/66457 Address for reprints:
21. National Institute on Drug Abuse, Division of Epidemiologyand Prevention Research: NationaIHouseholdSurveyon DrugAbuse: Highlights 1990.Washington DC: US Department of Health and Human Services, 1990, p 91.
Sharon B Meropol, MD
22. Stephens Cherpitel CJ, RosovskyH: Alcohol consumption and casualties: A comparison of emergencyroom populations in the United States and Mexico. J StudAIceho11990;51:319-326.
Children's Hospital of Buffalo
23. StephensCherpitel CJ: Breath analysis and self-reports as measuresof alcohol-related emergency room admissions. J StudAlcohol1989;50:155-161. 24. Jessor R, Jessor S: Problem.behavior:Prevalenceand interrelations, in ProblemBehavioranfl PsychosocialDevelopment,A LongitudinalStudyof Youth.New York: Academic Press, 1977, pp 71-93. 25. Jessor R, ChaseJA, DonovanJE: Psychosocia[correlates of marijuana use and problem drinking in a national sample of adolescents.Am J Public Health1980;70:604-613.
PACT Program
219 Bryant Street Buffalo, New York 14222 716-878-7624 Fax 716-878-7914 E-mail smeropol @ H52.buffalo.edu
26. Lowenstein SR, Weissberg MP, Terry B: Alcohol intoxication, injuries and dangerous behaviors-and the revolving emergencydepartment door. J Trauma1990;30:1252-1257. 27. Garrison CZ, McKeown RE, Valois BF: Aggression, substance use and suicidal behaviors in high school students. Am J Public Health 1993;83:179-184. 28. GrossmanDC, Milligan BC, OeyoRA: Risk factors for suicide attempts among Navajo adolescents. Am J Public Health1991;81:870-874. 29. Adcock AG, Nagy S, Simpson JA: Selected risk factors in adolescent suicide attempts. Adolescence1991;26:817-828. 30. RutherfordWH: Diagnosis of alcohol ingestion in mild head injuries. Lancet1977;1:10211023. 31. SoderstromCA, Dischinger PC, Smith GS, et al: Psychoactivesubstance dependenceamong trauma center patients. JAMA 1992;267:2756-2759. 32. Yates BW, Hadfield JM, Peters K: The detection of problem drinkers in the accident and emergencydepartment. Br J Addiction 1987;82:163-167. 33. SoderstromCA, Cowley RA: A national alcohol and trauma center survey: Missed opportunities, failures of responsibility. Arch Surg1987;122:1067-1071.
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CONTRIBUTION
Alcohol-Related Injuries Among Adolescents in the Emergency Department From the Departments of Pediatrics*, Family Medicine% and Emergency Medicine~, School of Medicine (student") and BiomedicaZSciences, State University of New York at Buffalo, Buffalo, New York. Receivedfor publication February 24, 1995. Revision received May 9, 1995. Acceptedfor publication May 15, 1995. Presented as a poster exhibit at the 34th Annual Meeting of the Ambulatory Pediatric Association, Seattle, Washington, May 1994. Supported by a grunt from Research for Health in Erie County, Incorporated. Copyright © by the American College of Emergency Physicians.
Sharon B Meropol, MD *~ Ronald M Moscati, MD § Kathleen A Lillis, MD *§ Sarah Ballow, MS" David M Janicke, MD, PhD§
See related editorial, p 221.
Study objective: Todetermine the frequency of positive alcohol readings in adolescent patients presenting for treatment of injury. Design: Patients aged 10 through 21 years were prospectively enrolled in this descriptive study. Demographic data and information about the injury were collected at enrollment. Blood ethanol concentration was measured with a saliva alcohol assay with a lower detection limit of 10 mg/dL (2 mmol/L). Setting: Enrollment was conducted at four emergency departments, an urban trauma center, an urban children's trauma center, a suburban hospital, and a rural hospital. Enrollmentat each facility was conducted during two 24- hour periods for every day of the week (14 days total). Consecutive sampling was used during each enrollment period. Results: We enrolled 295 patients (92% of eligible subjects). Sixty-three percent were male; 74% were white, 19% black, 3% Hispanic, 1% Asian, and 3% from other racial groups. The mean age was 15.6+3.2years. Fifteen patients (5%)tested positive for ethanol (range, 10 to 120 mg/dL [2 to 24 retool/L]). 0nly four of these patients underwent ethanol testing as part of their medical evaluations. Of the 125 subjects aged 17 through 21 years, 14 (11.2%) tested positive for ethanol. Hospital distribution was (number of patients with positive ethanol test results): urban trauma center, 8 of 52; urban children's trauma center, 0 of 91; suburban hospital, 4 of 111; rural hospital, 3 of 41. The highest percentage of positive ethanol test results was found at the urban trauma center, where 15% of total subjects and 22% of subjects aged 17 through 21 tested positive. Injuries related to assaults and motor vehicle crashes were particularly associated with alcohol use.
1 80
ANNALS OF EMERGENCY MEDICINE 26:2 AUGUST 1995
ADOLESCENTS AND ALCOHOL Meropol et al
Conclusion: Alcohol is associated with injuries in urban, sub-
urban, and rural settings in the older pediatric population. Alcohol use is underrecognized and should be considered in patients presenting with injuries, especially victims of assaults or motor vehicle crashes. [Meropol SB, Moscati RM, Lillis KA, Ballow S, Janicke DM: Alcohol-related injuries among adolescents in the emergency department. Ann EmergMedAugust 1995;26:180-186.] INTRODUCTION Injuries are the leading cause of pediatric mortality in the United States, accounting for one half to three quarters of adolescent deaths. 1 A well-known relationship exists in adults between alcohol and injury mortality. In the United States, 44% of total traffic fatalities in 1993 were related to alcohol 2, and a significant percentage of adults killed in motor vehicle crashes, falls, drownings, fires, assaults, and suicides have blood alcohol concentrations of. 10% (100 mg/dk or 20 mmol/L) or higher. 3,4 Most previous alcohol/ injury studies have involved hospitalized adult trauma victims and have demonstrated that 31% to 53% of such patients have positive alcohol screens s-8 and that the incidence of alcohol abuse or dependence is nine times higher among these patients than in the general population. # Adolescent alcohol use is widespread. In a 1992 national survey, 69% of eighth-graders had used alcohol and 27% of these students had been drunk. Thirteen percent of eighth-graders and 28% of twelfth-graders reported heavy use of alcohol (five or more drinks per occasion in the 2 weeks preceding the survey), lo In the 1990 national school-based Youth Risk Behavior Survey, 44% of US high school seniors reported recent binge drinking, z1 Previous studies of adolescent injuries have focused on fatalities or hospitalized individuals. In 1989, 37% and 53% of traffic fatalities in the United States were related to alcohol in the 15- to 17-year and 18- to 20-year groups, respectively12; in 1993, an estimated 40% of deaths resuiting from motor vehicle crashes in youth aged 15 to 20 years were related to alcohol.2 Alcohol was shown to play a significant role in non-motor vehicle-related unnatural deaths in San Francisco youths. 13 Less is known about the relationship between adolescent alcohol use and nonfatal injuries. Most previous studies have involved patients admitted to trauma or pediatric hospitals. Loiselle et a114 found that 12% of screened adolescents hospitalized for traumatic injury tested positive for alcohol (49% of eligible patients were screened). In a similar study, Rivara et
AUGUST 1995
26:2
ANNALS OF EMERGENCY MEDICINE
al is found that 41% of 18- to 20-year-olds admitted to a trauma center in Seattle tested positive for alcohol (82% of eligible patients screened). Identification of alcohol involvement with injury is important if this recognition plays a role in medical management of injury In addition, any alcohol-related injury in an adolescent, even a minor one, can be an indicator of possible future complications of alcohol use. In a survey of 202 adolescents undergoing treatment for substance abuse, 25% admitted to having needed emergency medical treatment for injuries related to drug or alcohol abuse. 1o We hypothesized that alcohol use in adolescent injury patients is associated with a wide variety of injury types seen in various £D settings but may go unrecognized or unaddressed by the treating physician. The purpose of this study was to examine the prevalence of alcohol use in relation to patient demographics, ED site, and injury type in adolescent patients presenting to the ED for injuries.
MATERIALS AND METHODS Patients aged 10 through 21 years presenting to the ED for treatment of any type of injury were prospectively
Figure. Age distribution of the study population at the four ED sites (N=295). ]
No. of patients
10
11
12
13
14
15
16
17
18
19
Trauma
20
21
Age (years)
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ADOLESCENTS AND ALCOHOL Meropol et al
enrolled from four local hospitals: an urban Level I trauma center, urban Level I children's trauma center, a suburban hospital, and a rural hospital. Enrollment at each facility was conducted during two 24-hour periods for every day of the week (14 days total). In the first enrollment cycle, data were collected during a 24-hour study period for every day of the week from each hospital from July 6, 1993, through August 2, 1993. The second enrollment cycle was conducted from November 1993 through January 1994. Patients were excluded from the study if they had sustained injury more than 24 hours before the ED visit or if injuries were related to alleged sexual abuse. Medical student research assistants approached eligible patients for study enrollment. Informed consent was obtained from the subject and from the parent or guardian when appropriate. The number of eligible subjects who declined participation in the study was recorded. Demographic data and information about the injury were collected at enrollment. Medications used in the preceding 24 hours were noted. Blood ethanol concentration was measured with the Q.E.D. A-150 Saliva Alcohol Test (Enzymatics, Incorporated) with a lower detection limit of 10 mg/dL (2 mmol/L) and a correlation with blood alcohol concentration of .98. it,is Each research assistant was taught to use the saliva alcohol test and was required to demonstrate correct use of the test before enrolling any patients. If the subject underwent
serum or breath alcohol testing as part of the emergency care ordered by the emergency physician, this result was also recorded. We used standard descriptive statistics to calculate means and percentages for demographic data. Multiple logistic-regression analysis was used to examine the possible relationship between the dichotomous dependent variable ethanol concentration (present or absent) and the independent variables: age (less than 17 years or 17 years or older), ED site (urban trauma center, suburban hospital, urban children's trauma center, rural hospital), sex, and race (black, Hispanic, Asian, white, other). We used a stepwise model-computed method to include variables with significance levels less than .05 as calculated with X2 analysis. We also performed analysis of the odds ratio (OR) for each independent variable and used the HosmerLemeshow test to assess goodness of fit (True Epistat statistical software; Epistat Services). This study was approved by the State University of New York School of Medicine and Biomedical Sciences Institutional Review Board, the Institutional Review Board of the Children's Hospital of Buffalo, and the Human Research Committee of Millard Fillmore Hospitals. Subjects were protected from the use of data for criminal prosecution under conditions set forth in a National Institute on Alcohol Abuse and Alcoholism Certificate of Confidentiality.
Table 1.
Patients with positive ethanol test results. Ethanol Concentration (mg/dL) Site
Sex
Urban trauma center F Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Urban trauma center M Suburban hospital M Suburban hospital M Suburban hospital F Suburban hospital F Rural hospital F Rural hospital M Rural hospital M *Valuesnot obtainedsimultaneously. tPatientadmittedto hospital. tNot determined;patientwas intubated.
1 82
Age (yr)
19 20 21 21 20 20 17 19 19 19 18 19 18 10 20
Most Severe Injury
Laceration, wrist Contusion, leg Gunshot wound, knee Laceration, scalp and face Gunshot wound, buttockt Central nervous system bleedingt Contusion, knee Contusions, back and shoulder Laceration, lip Laceration, finger Contusion, scalp Contusion, leg Contusion, arm Bee sting, face Abrasion, neck
Saliva
10 45 45 Less than 10" 70 Not determined* 110 50* lO 25 120 135 20 3O 5O
Blood
Breath
45* 93 130"
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85*
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ADOLESCENTS AND ALCOHOL Meropol et al
RESULTS
received a dose of diphenhydramine elixir (5.6% ethanol content) at an unknown time before presentation, which may have contributed to his measured ethanol concentration of 30 rag/alL (6 retool/L). However, on the basis of a 10-mL dose of elixir, body weight of 45 kg, and a reported volume of distribution for ethanol of .54 L/kg 19 and assuming that the ethanol was measured immediately after ingestion, with complete and instantaneous oral absorption, the maximum estimated ethanol concentration would be 2.3 mg/dL (.46 mmol/L), less than one tenth the measured level. Therefore it seems unlikely that the reported dose of diphenhydramine elixir accounted for the ethanol concentration measured. The highest percentage of positive alcohol test results was found at the urban trauma center, where 15% of total subjects and 22% of subjects aged 17 through 21 tested positive; there were no positive alcohol tests at the urban children's trauma center (Table 2). The race distribution of patients with positive ethanol test results (10 white, 4 black, 1 Hispanic) was similar to that of the total study population. Multiple logistic-regression analysis revealed that age and ED site were significant predictors of positive ethanol test results (P<.0001). No significant predictive value was found for sex or race. In the stepwise model-computed analysis, age accounted for the most variability (P<.0001) and ED site was the second most predictive variable (P=.01). The OR analysis indicated that age 17 years or older increased the likelihood of a positive ethanol test result 14.4 times (95% confidence interval, 1.79 to 116) compared with the lower age group. When ED sites were compared individually with the urban trauma center, the only one for which site approached statistical significance as a predictor was the suburban hospital (at the P=.06 level), with an OR of .3:1 compared with the urban trauma center. The value of ED site as a predictor was revealed only when the power of the analysis was increased with data from all the hospitals combined.
Ninety-two percent of eligible patients (295 of 321) were enrolled in the study. In 24 cases enrollment was declined: by the parent or guardian in 11 cases, by the patient in 9 cases, and by the patient and the parent in 4 cases. Two patients were not enrolled for technical reasons: in one, saliva could not be obtained for ethanol testing, and in the other, the ethanol saliva test kit control indicated an invalid test. Enrolled patients ranged in age from 10 to 21 years (mean, 15.6_+3.2 years). Sixty-three percent of subjects were male. The racial/ethnic mix was 74% white, 19% black, 3% Hispanic, 1% Asian, and 3% other. Forty-six percent of the study patients were from the trauma centers (urban and urban children's), and 54% were from the community hospitals (suburban and rural). The urban children's trauma center showed a trend toward younger patients--24% of the patients were 17 years or younger--and the urban trauma center showed a trend toward older patients--71% of the patients were 17 years or older. Forty-seven percent and 34% of patients at the suburban hospital and the rural hospital, respectively, were 17 years or older. When data from all hospitals were combined, however, the distribution of ages was not skewed toward either extreme of age (Figure). The most common mechanisms of injury were athletics-related (23%), falls (19%), assaults (11%), injuries caused by sharp objects (11%), motor vehicle crashes (9%), and bicycle accidents (6%). The most common injuries were lacerations (28%), sprains/strains (22%), contusions (18%), and fractures (13%). Five percent of the study patients tested positive for ethanol, with saliva ethanol concentrations ranging from 10 to 135 mg/dL (2 to 27 mmolFL) (Table 1 ). Fourteen of the 15 positive results were in patients aged 17 through 21 years; 11.2% of subjects 17 through 21 years old (14 of 125) tested positive. The youngest patient with a positive alcohol test result was 10 years old. This patient Table 2.
Relationship of care site, age, and positive alcohol test result. Urban Trauma Center Age (yr) 10-16 17-21 Total
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Urban Children's Trauma Center
Suburban Hospital
Rural Hospital
Totals
Positive
Total
Positive
Total
Positive
Total
Positive
Total
Positive
Total
0 8 8
15 37 52
0 0 0
69 22 91
0 4 4
59 52 111
1 2 3
27 14 41
1 14 15
170 125 295
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The relationship between alcohol use and mechanism of injury is shown in Table 3. Six of 34 (18%) of subjects who presented with injuries related to assault and 4 of 28 (14%) of those who presented with injuries related to motor vehicle crashes tested positive. The severity of injuries ranged from gunshot wounds to an insect sting (Table 1). In only 4 out of 15 patients with positive ethanol test results was ethanol screening ordered by the treating physician as part of the ED evaluation. DISCUSSION
Injuries account for more years of potential life lost in the United States than cancer and heart disease combined. 2° Nevertheless, little is known about the factors that contribute to injuries and about interventions to avoid consequent mortality and morbidity. We know that many adolescents regularly consume alcoholic beverages, often heavily. However, we do not know how their injuries are related to alcohol use. It is important to understand the origins and context of injuries so that effective interventions can be targeted to reduce the potentially serious consequences of injuries for young people. This multicenter study was designed to examine the prevalence of alcohol use in adolescent injury patients presenting to four different types of EDs: a children's hospital, an urban trauma hospital, a suburban hospital, and a rural hospital. By enrolling a diverse population with good representation at each hospital, we aimed for results more generalizable to the young patients seen by many practitioners than if we involved only an urban trauma center or a children's hospital. Our subjects represented a wide variety of mechanisms, types, and severities of injury. Although some of our subjects could be described as young adults, almost all (279 of 295) were under the age of legal alcohol consumption. Table 3.
Mechanisms of injury related to positive alcohol test results.
Mechanism of Injury Assault
Motor vehicle crash Suicide attempt Fall Sharp object (knife)
Bee sting
1 84
No, Positive/ No. Presenting (%)
6/34 (18) 4/28 (14) 1/3 (33) 2/57 (4) 1/34 (3) 1/7 (14)
Five percent of all subjects had been drinking alcohol, 11% at the higher age range of 17 through 21 years. Multiple logistic-regression analysis revealed that age (17 through 21 years versus 10 through 16 years) and, to a lesser extent, ED site were significant predictors of positive ethanol test results in pediatric patients presenting to the ED with injuries. No significant predictive value was found for sex or race. OR analysis showed that the risk of a positive ethanol test result was increased 14.4 times in the older patients compared with the younger patients studied. This finding is in accordance with results from the 1990 National Household Survey on Drug Abuse, which examined age-related alcohol use (down to age 12) and found that habitual drinking behavior increased by a factor of 4.8 between ages 12 and 17 yearsY 1 By restricting the comparison to injured patients, we may have selected for those using alcohol. The data revealed a higher percentage of positive ethanol test results at the urban trauma hospital than at the other three sites (Table 2). It might be anticipated that more injuries would be related to alcohol at an urban trauma center (the urban trauma center and the urban children's trauma center), to which serious injury cases are referred than at a suburban or rural hospital. Other factors such as socioeconomic status may play a role in the differences m results among different enrollment sites. The urban children's trauma center had no positive ethanol test results in the patient sample studied. This may be partially explained by random variability with a relatively low number (n=22) of patients seen at the urban children's trauma center in the group of patients 17 years or older. The proximity of the urban trauma center and the urban children's trauma center in this study also raises the possibility that ambulance-routing practices could differentially affect the types of patients and injuries seen at these two hospitals, both in the younger and in the older adolescent age ranges. Results from research performed only at children's hospitals may not be generalizable to adolescent populations from other settings. In two previous adult studies, injured patients were approximately twice as likely to have positive blood ethanol test results as patients who presented to the ED for other reasons. 22,23 Because we have no data on the incidence of alcohol use by uninjured adolescents in the populations served by the hospitals in our study, we did not address the question of whether alcohol use is more common in injured than in uninjured adolescents. Other investigators have demonstrated a relationship between
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Meropol et aI
ethanol abuse and other problem behaviors and risktaking among adolescents. 24-26 Certain mechanisms of injury seemed to be particularly associated with alcohol use. Positive alcohol test results were found for 6 of 34 (18%) of subjects who presented with injuries related to assault and in 4 of 28 (14%) of those who presented with injuries related to motor vehicle crashes. These 10 patients accounted for two thirds (10 of 15) of the patients found to have positive alcohol test results in this study. Differences in the rates of certain high-risk mechanisms of injury between hospitals could affect the proportions of patients who tested positive for alcohol at each facility Although the proportions of assaults and motor vehicle crashes at the urban children's trauma center (both 10%) differ considerably from those at the urban trauma center (27% and 21%, respectively), they are not substantially different from those of the suburban hospital (8% and 5%, respectively) and the rural hospital (both 5%) to enable us to fully explain the differences between hospitals. Other investigators have shown an association between alcohol and other substance use and suicide attempts in young people. 27-29 Because of limited data, we cannot draw conclusions about any association between alcohol use and suicide attempts in this population. Most subjects who tested positive for alcohol in our study (11 of 15 [73%]) had not been tested for ethanol by their treating emergency physicians. Other investigators have demonstrated that alcohol use is often missed by medical providers. Rutherford3° showed that although 42% of patients who presented to an ED with mild head injuries had positive blood alcohol test results, clinical signs such as breath smell, slurred speech, red eyes, and poor coordination were found to be unreliable for physician identification of alcohol use. Identification of alcohol consumption by any patient may be important for medical management. Also, subjects with alcohol-associated injuries may be at high risk for subsequent complications related to alcohol use. Studies on adults have shown that although alcoholism is common among trauma patients, caregivers in the ED and hospital settings often fail to recognize this pattern, and patients frequently do not get referrals for treatment of substance abuse and dependence. 2<3t-33
settings. Alcohol use often goes unrecognized or unaddressed in the ED. Alcohol use should be considered in adolescents presenting with injuries, especially older youths and victims of assaults or motor vehicle crashes, for whom we found the greatest prevalence of positive alcohol test results. Future studies are needed with regard to effective interventions for this population. Ameliorating a high rate of injury-related mortality is particularly important for young people. We also can hope to curtail long-term complications of alcohol abuse, including those involving health, finances, and family relationships. Recognizing possible alcohol involvement in adolescent injury is only the first step.
REFERENCES 1. Baker SP, O'Neill BO, Oinsburg M J, et al: Injuries in relation to other health problems, in The Injury FactBook,2nd ed. New York: Oxford University Press, 1992, pp 8-16. 2. Centers for Disease Control: Alcohol involvement in fatal motor-vehicle crashes, United States, 1992-1993. MMWR 1994;43:878-879. 3. Waller J: Alcohol and unintentional injury, in Kissis B, Begleiter H (ads): TheBielegyof Alcoholism,vol 4. New York: Plenum, 1976, pp 307-349. 4. Centers for Disease Control: Alcohol involvement in pedestrian fatalities, United States, 19821992. MMWR 1993;42:716-719. 5. McLetlan BA, Vingilis E, Liban CB, at al: Blood alcohol testing of motor vehicle crash admissions at a regional trauma unit. J Trauma1990;30:418-421. 6. Jurkovich GJ, Rivara FP, Gurney JG, et al: Effects of alcohol intoxication on the initial assessment of trauma patients. Ann EmergMad 1992;21:704-708. 7. Sloan EP, Zalenski RJ, Smithe RF, et al: Toxicology screening in urban trauma patients: Drug prevalence and its relationship to trauma severity and management. J Trauma1989;29:16471653. 8. Lindenbaum GA, Carroll SF, Daskal I, et ah Patterns of alcohol and drug abuse in an urban trauma center: The increasing role of cocaine abuse. J Trauma1989;29:1654-1658. 9. Soderstrom CA, Dischinger PC, Smith GS, et al: Psychoactive substance dependence among trauma center patients. JAMA 1992;267:2756-2759. 10. Johnston LD, O'Malley PM, Bachman JG: NationalSurveyResultson DrugUseFrom Monitoring the FutureStudy, 1975-1992.Washington DO: National Institute on Drug Abuse, 1993. NIH publication no. 93-3597. 11. Centers for Disease Control: Alcohol and other drug use among high school students, United States, 1990. MMWR 1991;40:776-784. 12. Centers for Disease Control: Alcohol related traffic fatalities among youth and young adults, United States, 1982-1989. MMWR 1991;40:178-187. 13. Friedman IM: Alcohol and unnatural deaths in San Francisco youths. Pediatrics1985;76:191193. 14. Loiselle JM, Baker MD, Templeton JM, et ah Substance abuse in adolescent trauma. Ann EmergMed 1993;22:1530-1534. 15. Rivara FP, Gurney JG, Ries RK, et al: A descriptive study of trauma, alcohol and alcoholism in young adults. JAdolesc Health 1992;13:663-667. 16. Schwartz RH: Alcohol, drugs and head injury (letter). Pediatrics1986;78:1169. 17. Christopher TA, Zeccardi JA: Evaluation of the Q.E.D.TM saliva alcohol test; A new, rapid, accurate device for measuring ethanol in saliva. Ann EmergMed 1992;21:1135-1137.
CONCLUSION
Our results show that measurable alcohol concentrations are found in male and female adolescents presenting for treatment of injuries in urban, suburban, and rural
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18. Jones AW: Inter- and intra-individual variations in the saliva/blood alcohol ratio during ethanol metabolism in man. Clio Chem1979;25:1394-1398. 19. Tillman AG, Rail TW, Nies AS, et al: Goodmanand Gilman's ThePharmacologicalBasis of Therapeutics,ed 8. Elmsford, New York: Pergamon Press, 1990, p 1679.
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20. National Committee for Injury Prevention and Control: A history of injury prevention, in Injury Prevention:Meeting the Challenge.New York: Oxford University Press, 1989, p 5.
Reprint no. 47/1/66457 Address for reprints:
21. National Institute on Drug Abuse, Division of Epidemiologyand Prevention Research: NationaIHouseholdSurveyon DrugAbuse: Highlights 1990.Washington DC: US Department of Health and Human Services, 1990, p 91.
Sharon B Meropol, MD
22. Stephens Cherpitel CJ, RosovskyH: Alcohol consumption and casualties: A comparison of emergencyroom populations in the United States and Mexico. J StudAIceho11990;51:319-326.
Children's Hospital of Buffalo
23. StephensCherpitel CJ: Breath analysis and self-reports as measuresof alcohol-related emergency room admissions. J StudAlcohol1989;50:155-161. 24. Jessor R, Jessor S: Problem.behavior:Prevalenceand interrelations, in ProblemBehavioranfl PsychosocialDevelopment,A LongitudinalStudyof Youth.New York: Academic Press, 1977, pp 71-93. 25. Jessor R, ChaseJA, DonovanJE: Psychosocia[correlates of marijuana use and problem drinking in a national sample of adolescents.Am J Public Health1980;70:604-613.
PACT Program
219 Bryant Street Buffalo, New York 14222 716-878-7624 Fax 716-878-7914 E-mail smeropol @ H52.buffalo.edu
26. Lowenstein SR, Weissberg MP, Terry B: Alcohol intoxication, injuries and dangerous behaviors-and the revolving emergencydepartment door. J Trauma1990;30:1252-1257. 27. Garrison CZ, McKeown RE, Valois BF: Aggression, substance use and suicidal behaviors in high school students. Am J Public Health 1993;83:179-184. 28. GrossmanDC, Milligan BC, OeyoRA: Risk factors for suicide attempts among Navajo adolescents. Am J Public Health1991;81:870-874. 29. Adcock AG, Nagy S, Simpson JA: Selected risk factors in adolescent suicide attempts. Adolescence1991;26:817-828. 30. RutherfordWH: Diagnosis of alcohol ingestion in mild head injuries. Lancet1977;1:10211023. 31. SoderstromCA, Dischinger PC, Smith GS, et al: Psychoactivesubstance dependenceamong trauma center patients. JAMA 1992;267:2756-2759. 32. Yates BW, Hadfield JM, Peters K: The detection of problem drinkers in the accident and emergencydepartment. Br J Addiction 1987;82:163-167. 33. SoderstromCA, Cowley RA: A national alcohol and trauma center survey: Missed opportunities, failures of responsibility. Arch Surg1987;122:1067-1071.
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