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Influence of alcohol
Forensic Science International 103 (1999) S25–S29
Influence of alcohol 114 hospitalised victims of traffic accidents a, a b T. Varga *, E. Jeszenszky , J.A. Simonka a
¨ ¨ , Kossuth Lajos sugarut 40, Department of Forensic Medicine of Albert-Szent-Gyorgyi med. Universitat H-6724 Szeged, Hungary b ¨ Medical University Szeged, Szeged, Hungary Department of Traumatology, Albert Szent-Gyorgyi
Abstract The blood-alcohol concentration and the biochemical (GGT, methanol, acetone, isopropanol blood concentrations) as well as the psychological markers (MAST, CAGE tests) of chronic alcoholism have been examined in 619 injured persons admitted to the Department of Traumatolo¨ gy, Albert Szent-Gyorgyi Medical University, Szeged, Hungary in the interval of 1st January 1996–31st December 1997. At the time of their hospitalisation 37.9% of the injured persons in traffic accidents were under moderate influence of alcohol. The frequency of the alcoholic intoxication is 46.8% of drivers, 29% of passengers and 43.6% of pedestrians and cyclists respectively. Habitual consumption of alcohol was diagnosed in 22.9% of injured persons according to at least two positive markers of alcoholism (27% of drivers, 21% of passengers, 20% of pedestrians and cyclists). Attention is called to the necessity of regular examination of alcoholic intoxication and the markers of chronic alcoholism at the time of the hospitalisation of accident victims. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Traffic accidents; Alcohol; Chronic alcoholism; Biochemical markers
1. Introduction Similarly to a number of other countries, alcohol consumption is a prime contributor to traffic accidents in Hungary. The great majority of available data reveal different levels of intoxication in fatally injured victims. Our investigations concluded in recent years in Csongrad county (South-East Hungary) pointed out that 56% of drivers, 32% of passengers, 78% of pedestrians and 60% of cyclists who suffer fatal road accidents are under the influence of alcohol [1]. While the frequency of intoxication among drivers has *Corresponding author. Tel.: 136-62-31-4229; fax: 136-62-31-4229. 0379-0738 / 99 / $ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0379-0738( 99 )00068-7
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somewhat diminished over the past 5 years it remained unchanged among pedestrians and cyclists [2]. Much less data are available regarding the level of intoxication of persons hospitalised with injuries sustained in traffic accidents. Surveys report a frequency of about 20% [3,4]. No representative survey has been made in Hungary of the influence of alcohol in victims. In addition to actual intoxication, psycho-pathological changes consequent to chronic alcoholism are an additional source of danger. In several countries (Germany, Sweden, etc.) chronic alcoholics causing traffic crimes are liable to specific sanctions [5]. In order to promote objective assessment, biochemical markers of chronic alcoholism have been developed [6]. The authors examined the level of intoxication as well as the prevalence of biochemical and psychological markers of chronic alcoholism in persons injured in ¨ traffic accidents and hospitalised at the Traumatological Clinic of Albert Szent-Gyorgyi University of Medicine (Szeged, Hungary).
2. Material and methods In 619 patients hospitalised with injury at the Traumatological Clinic of Albert ¨ SzentGyorgyi University of Medicine between January 1 1996 and December 31, 1997 concentrations of ethyl alcohol, methanol, acetone and isopropanol, as well as the GGT level in the blood were determined. Among the psychological tests, MAST [7] and Ewing’s Questionnaire, CAGE were completed [8]. Blood methyl and ethyl alcohol, acetone and isopropanol were determined by headspace gaschromatographic analysis. Kinetic method was used for the determination of the GGT level. In accordance with literature, blood alcohol level exceeding 2.0 g / l, methanol exceeding 10 mg / l, aggregate acetone and isopropanol concentration exceeding 9 mg / l and GGT level exceeding 60 U / l were considered pathological. In the case of the MAST test the limit indicative of regular alcohol consumption was 5 points and for the CAGE or Ewing’s tests, 3 points. A persons whose markers exceeded the limit on at least two markers were considered regular drinkers.
3. Findings At the time of admission 30.3% of the injured were under the effect of alcohol. The proportion of males and females in the total group of patients is 1.41:1 and in the group of intoxicated patients, 5.48:1. The average age in the group is 46 whereas the average age in the intoxicated group is 38. Among patients injured in traffic accidents 37.9% were intoxicated at the time of hospitalisation, a rate only surpassed by crime victims (Table 1). The rate of intoxicated drivers was 46.8% followed by pedestrians (43.6%) and motorcyclists (38.7%) (Table 2). At the time of hospitalisation the average level of intoxication of the injured persons
T. Varga et al. / Forensic Science International 103 (1999) S25 –S29
S27
Table 1 Number and rate of hospitalised victims by type of accident (January 1.1996.– December 31. 1997.) (N619) Occurrence
Traffic accident Industrial accident Home accident Crime Others
Intoxication
(No.)
(%)
(No.)
(%)
237 41 208 42 91
38.3 6.6 33.6 6.8 14.7
90 13 37 24 24
37.9 31.7 17.8 57.1 26.4
Table 2 Traffic accident
Occurrence
Intoxication
(No.)
(%)
(No.)
(%)
Driver Passenger Motorcyclist Cyclist Single cyclist Pedestrian Single pedestrian
47 31 31 7 32 39 50
7.6 5 5 1.1 5.2 6.3 8.1
22 9 12 2 11 17 17
46.8 29.0 38.7 28.6 35.5 43.6 34.0
was medium. Intoxication of victims of single pedestrian accidents is particularly high (2.51 g / l, Table 3). Biochemical markers of chronic alcoholism were positive in 13.1 to 25.4% of the cases and psychological tests yielded similar results in 22.2 to 44.4% of the cases. Based on the result of two markers 22.9% of victims injured in traffic accidents are regular drinkers. Their occurrence is highest among drivers (Table 4).
4. Discussion The contribution of intoxication to traffic accidents was revealed a long time ago. More than 50 years have elapsed since the first sanctions were codified. Statistics show Table 3 Traffic accident
Mean blood alcohol conc. (g / l)
Driver Passenger Motorcyclist Cyclist Single cyclist Pedestrian Single pedestrian
1.94 2.00 1.81 2.02 1.79 2.15 2.51
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Table 4 Traffic accident
Drivers (car, motorcyclist) Other (passenger, cyclist, pedestrian) Single cyclist, pedestrian
Occurrence
Intoxication
Chronic
(No.)
(%)
(No.)
(%)
alcoholism (%)
78
12.6
34
43.6
27
77
12.4
28
36.4
21
82
13.2
28
34.1
20
an exponential increase in the frequency of accidents at 0.8 / l blood alcohol concentration. In recent years the former legal limit of 0.8 g / l has been lowered in several countries (to 0.2 g / l in Sweden, 0.5 g / l in Finland etc.) and similar measures are being considered in other countries (Germany). In all of the Central and Eastern European states including Hungary it is forbidden to drive after alcohol consumption. Comparison of statistics is very difficult as it is only occurrences in excess of the legal limit that are reported. Roadside surveys indicate a 0.2 to 19% frequency of drinking and driving [4] with regularly repeated surveys reporting a declining trend [3,9]. As differences among legal regulation systems somewhat distort the data. The blood alcohol concentrations of victims of traffic accidents who died on the spot is the best indicator as to the frequency of intoxication. Hungary’s data in this respect are not outstanding, though they exceed those of the Nordic countries and of most Western European states. On the other hand, Hungary scores extremely high on intoxication among pedestrians and cyclists (60–80%) [1]. Similarly high figures were only reported about the black population of the Republic of South Africa and the native population of the United States [10,11]. Intoxication of hospitalised victims seems to be more favourable compared to fatally injured victims. Frequency indexes of hospitalised victims are significantly lower. In Australia 27.1% of male and 8.7% of female drivers injured in accidents had blood alcohol level exceeding the legal limit [12]. In a London hospital 26.2% of male and 18.4% of female accident victims had alcohol in their blood [13]. The findings of our survey underpin reports whereby the frequency of intoxication is lower among survivors than among fatally injured victims. However, 37.9% frequency is very high in international comparison. Higher frequency was found only among victims of crime (57.1%). It is hard to explain why almost half of the car drivers injured in accidents are intoxicated – a finding somewhat contradictory to the previous statement. Similarly, in their case the level of intoxication is essentially identical with that of the fatally injured victims [1]. At the same time there is a notable decline in the frequency and level of intoxication among passengers and other victims suffering less severe injuries. Specificity of biochemical and psychological markers of chronic alcoholism is 85–91%. This means that based on at least two positive markers, chronic alcoholism is a probable diagnosis. Per capita alcohol consumption in Hungary is around 1 l pure alcohol per year and despite the decreasing trend in recent years, it is still one of the
T. Varga et al. / Forensic Science International 103 (1999) S25 –S29
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highest in Europe. The increase in the frequency of alcohol related hepatic cirrhosis as cause of death is another indicator of high alcohol consumption. According to estimates, ´ 5 to 8% of the adult population are chronic alcoholics but in a survey, Jozan indicated that a quarter of the adult male population can be considered as regular drinkers [14]. The 22.0% frequency of intoxication the authors found, and specifically the 27% frequency of intoxication among drivers, are certainly above the average and point at the hazards alcoholism imposes on traffic.
References ´ [1] T. Varga (Ed.), Traffic Accidents and Their Main Risk Factors in Hungary, Pediatria, Szeged, 1997. ´ ´ The occurrence frequency of alcohol, medicine and drug and its [2] J. Szendrenyi, E. Jerszenszky, I. Kovacs, role in the traffic (in Hungarian). Dissertation Hungarian Academy of Sciences, 1996. [3] R. Voas, J. Wells, D. Lestina, A. Williams, M. Greene (Eds.), Drinking and Driving in the US: The 1996 National Roadside Survey. Alcohol, Drugs and Traffic Safety-T97, Ed. C. Mercier-Guyon, CERMT, Annecy, 1997, 1159–1166 [4] A.F. Williams, The 1996 U.S. Roadside Survey and its Implication. Alcohol, Drugs and Traffic Safety T-97, Ed. C. Mercier-Guyon, CERMT, Annecy, 1997, pp. 37–40. [5] R. Iffland, Evolution of an increased blood level of GGT, CDT, methanol, acetone and isoropanol in alcohol intoxicated automobile drivers. Alcoholism indicators instead of medical-psychological examination., Blutalkohol 31 (1994) 273–314. [6] R. Iffland, M. Staak, Methanol and isopropanol as markers of alcoholism, Beitr. Gerichl. Med. 48 (1990) 173–177. [7] M. SeIzer L, The Michigan alcoholism screening test: the quest for a new diagnostic instrument, Am. J. Psychiatry 127 (1971) 1653–1658. [8] F.J. Alvarez, Screening for problem drinkers in a general population survey in spain by use of the CAGE scale, J. Stud. Alcohol 55 (1994) 471–474. [9] J. Pikkarainen, A. Penttila, Drinking, Driving, and Road Side Studies – The Finnish Experience. Alcohol, Drugs, and Traffic Safety-T92, Cologne, Verlag TUV Rheinland, 1993, pp. 1582–1602. [10] L. Lerer, The social epidemology of transport injury in South Africa – some brief comments, in: T. Varga ´ (Ed.), Traffic Accidents, Perdiatria, Szeged, 1996, pp. 115–122. [11] M. Levy, Identification of the Alcohol-Pedestrian Crash Problem Among Culturally Diverse Groups. Office of Research and Traffic Records, NHTSA, NTS-31, 1998. [12] S. McDermott, Compulsory blood alcohol testing of road crash casualties in Victoria: the first three years, Med. J. Aust. 2 (1978) 612–615. [13] I. Ghodse, Treatment of drug and addiction in London. Lancet i (1997) 636–639. ´ [14] P. Jozan, Health Behaviour Survey, 1994, CSO, Budapest, 1996.
Influence of alcohol 114 hospitalised victims of traffic accidents a, a b T. Varga *, E. Jeszenszky , J.A. Simonka a
¨ ¨ , Kossuth Lajos sugarut 40, Department of Forensic Medicine of Albert-Szent-Gyorgyi med. Universitat H-6724 Szeged, Hungary b ¨ Medical University Szeged, Szeged, Hungary Department of Traumatology, Albert Szent-Gyorgyi
Abstract The blood-alcohol concentration and the biochemical (GGT, methanol, acetone, isopropanol blood concentrations) as well as the psychological markers (MAST, CAGE tests) of chronic alcoholism have been examined in 619 injured persons admitted to the Department of Traumatolo¨ gy, Albert Szent-Gyorgyi Medical University, Szeged, Hungary in the interval of 1st January 1996–31st December 1997. At the time of their hospitalisation 37.9% of the injured persons in traffic accidents were under moderate influence of alcohol. The frequency of the alcoholic intoxication is 46.8% of drivers, 29% of passengers and 43.6% of pedestrians and cyclists respectively. Habitual consumption of alcohol was diagnosed in 22.9% of injured persons according to at least two positive markers of alcoholism (27% of drivers, 21% of passengers, 20% of pedestrians and cyclists). Attention is called to the necessity of regular examination of alcoholic intoxication and the markers of chronic alcoholism at the time of the hospitalisation of accident victims. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Traffic accidents; Alcohol; Chronic alcoholism; Biochemical markers
1. Introduction Similarly to a number of other countries, alcohol consumption is a prime contributor to traffic accidents in Hungary. The great majority of available data reveal different levels of intoxication in fatally injured victims. Our investigations concluded in recent years in Csongrad county (South-East Hungary) pointed out that 56% of drivers, 32% of passengers, 78% of pedestrians and 60% of cyclists who suffer fatal road accidents are under the influence of alcohol [1]. While the frequency of intoxication among drivers has *Corresponding author. Tel.: 136-62-31-4229; fax: 136-62-31-4229. 0379-0738 / 99 / $ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0379-0738( 99 )00068-7
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T. Varga et al. / Forensic Science International 103 (1999) S25 –S29
somewhat diminished over the past 5 years it remained unchanged among pedestrians and cyclists [2]. Much less data are available regarding the level of intoxication of persons hospitalised with injuries sustained in traffic accidents. Surveys report a frequency of about 20% [3,4]. No representative survey has been made in Hungary of the influence of alcohol in victims. In addition to actual intoxication, psycho-pathological changes consequent to chronic alcoholism are an additional source of danger. In several countries (Germany, Sweden, etc.) chronic alcoholics causing traffic crimes are liable to specific sanctions [5]. In order to promote objective assessment, biochemical markers of chronic alcoholism have been developed [6]. The authors examined the level of intoxication as well as the prevalence of biochemical and psychological markers of chronic alcoholism in persons injured in ¨ traffic accidents and hospitalised at the Traumatological Clinic of Albert Szent-Gyorgyi University of Medicine (Szeged, Hungary).
2. Material and methods In 619 patients hospitalised with injury at the Traumatological Clinic of Albert ¨ SzentGyorgyi University of Medicine between January 1 1996 and December 31, 1997 concentrations of ethyl alcohol, methanol, acetone and isopropanol, as well as the GGT level in the blood were determined. Among the psychological tests, MAST [7] and Ewing’s Questionnaire, CAGE were completed [8]. Blood methyl and ethyl alcohol, acetone and isopropanol were determined by headspace gaschromatographic analysis. Kinetic method was used for the determination of the GGT level. In accordance with literature, blood alcohol level exceeding 2.0 g / l, methanol exceeding 10 mg / l, aggregate acetone and isopropanol concentration exceeding 9 mg / l and GGT level exceeding 60 U / l were considered pathological. In the case of the MAST test the limit indicative of regular alcohol consumption was 5 points and for the CAGE or Ewing’s tests, 3 points. A persons whose markers exceeded the limit on at least two markers were considered regular drinkers.
3. Findings At the time of admission 30.3% of the injured were under the effect of alcohol. The proportion of males and females in the total group of patients is 1.41:1 and in the group of intoxicated patients, 5.48:1. The average age in the group is 46 whereas the average age in the intoxicated group is 38. Among patients injured in traffic accidents 37.9% were intoxicated at the time of hospitalisation, a rate only surpassed by crime victims (Table 1). The rate of intoxicated drivers was 46.8% followed by pedestrians (43.6%) and motorcyclists (38.7%) (Table 2). At the time of hospitalisation the average level of intoxication of the injured persons
T. Varga et al. / Forensic Science International 103 (1999) S25 –S29
S27
Table 1 Number and rate of hospitalised victims by type of accident (January 1.1996.– December 31. 1997.) (N619) Occurrence
Traffic accident Industrial accident Home accident Crime Others
Intoxication
(No.)
(%)
(No.)
(%)
237 41 208 42 91
38.3 6.6 33.6 6.8 14.7
90 13 37 24 24
37.9 31.7 17.8 57.1 26.4
Table 2 Traffic accident
Occurrence
Intoxication
(No.)
(%)
(No.)
(%)
Driver Passenger Motorcyclist Cyclist Single cyclist Pedestrian Single pedestrian
47 31 31 7 32 39 50
7.6 5 5 1.1 5.2 6.3 8.1
22 9 12 2 11 17 17
46.8 29.0 38.7 28.6 35.5 43.6 34.0
was medium. Intoxication of victims of single pedestrian accidents is particularly high (2.51 g / l, Table 3). Biochemical markers of chronic alcoholism were positive in 13.1 to 25.4% of the cases and psychological tests yielded similar results in 22.2 to 44.4% of the cases. Based on the result of two markers 22.9% of victims injured in traffic accidents are regular drinkers. Their occurrence is highest among drivers (Table 4).
4. Discussion The contribution of intoxication to traffic accidents was revealed a long time ago. More than 50 years have elapsed since the first sanctions were codified. Statistics show Table 3 Traffic accident
Mean blood alcohol conc. (g / l)
Driver Passenger Motorcyclist Cyclist Single cyclist Pedestrian Single pedestrian
1.94 2.00 1.81 2.02 1.79 2.15 2.51
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Table 4 Traffic accident
Drivers (car, motorcyclist) Other (passenger, cyclist, pedestrian) Single cyclist, pedestrian
Occurrence
Intoxication
Chronic
(No.)
(%)
(No.)
(%)
alcoholism (%)
78
12.6
34
43.6
27
77
12.4
28
36.4
21
82
13.2
28
34.1
20
an exponential increase in the frequency of accidents at 0.8 / l blood alcohol concentration. In recent years the former legal limit of 0.8 g / l has been lowered in several countries (to 0.2 g / l in Sweden, 0.5 g / l in Finland etc.) and similar measures are being considered in other countries (Germany). In all of the Central and Eastern European states including Hungary it is forbidden to drive after alcohol consumption. Comparison of statistics is very difficult as it is only occurrences in excess of the legal limit that are reported. Roadside surveys indicate a 0.2 to 19% frequency of drinking and driving [4] with regularly repeated surveys reporting a declining trend [3,9]. As differences among legal regulation systems somewhat distort the data. The blood alcohol concentrations of victims of traffic accidents who died on the spot is the best indicator as to the frequency of intoxication. Hungary’s data in this respect are not outstanding, though they exceed those of the Nordic countries and of most Western European states. On the other hand, Hungary scores extremely high on intoxication among pedestrians and cyclists (60–80%) [1]. Similarly high figures were only reported about the black population of the Republic of South Africa and the native population of the United States [10,11]. Intoxication of hospitalised victims seems to be more favourable compared to fatally injured victims. Frequency indexes of hospitalised victims are significantly lower. In Australia 27.1% of male and 8.7% of female drivers injured in accidents had blood alcohol level exceeding the legal limit [12]. In a London hospital 26.2% of male and 18.4% of female accident victims had alcohol in their blood [13]. The findings of our survey underpin reports whereby the frequency of intoxication is lower among survivors than among fatally injured victims. However, 37.9% frequency is very high in international comparison. Higher frequency was found only among victims of crime (57.1%). It is hard to explain why almost half of the car drivers injured in accidents are intoxicated – a finding somewhat contradictory to the previous statement. Similarly, in their case the level of intoxication is essentially identical with that of the fatally injured victims [1]. At the same time there is a notable decline in the frequency and level of intoxication among passengers and other victims suffering less severe injuries. Specificity of biochemical and psychological markers of chronic alcoholism is 85–91%. This means that based on at least two positive markers, chronic alcoholism is a probable diagnosis. Per capita alcohol consumption in Hungary is around 1 l pure alcohol per year and despite the decreasing trend in recent years, it is still one of the
T. Varga et al. / Forensic Science International 103 (1999) S25 –S29
S29
highest in Europe. The increase in the frequency of alcohol related hepatic cirrhosis as cause of death is another indicator of high alcohol consumption. According to estimates, ´ 5 to 8% of the adult population are chronic alcoholics but in a survey, Jozan indicated that a quarter of the adult male population can be considered as regular drinkers [14]. The 22.0% frequency of intoxication the authors found, and specifically the 27% frequency of intoxication among drivers, are certainly above the average and point at the hazards alcoholism imposes on traffic.
References ´ [1] T. Varga (Ed.), Traffic Accidents and Their Main Risk Factors in Hungary, Pediatria, Szeged, 1997. ´ ´ The occurrence frequency of alcohol, medicine and drug and its [2] J. Szendrenyi, E. Jerszenszky, I. Kovacs, role in the traffic (in Hungarian). Dissertation Hungarian Academy of Sciences, 1996. [3] R. Voas, J. Wells, D. Lestina, A. Williams, M. Greene (Eds.), Drinking and Driving in the US: The 1996 National Roadside Survey. Alcohol, Drugs and Traffic Safety-T97, Ed. C. Mercier-Guyon, CERMT, Annecy, 1997, 1159–1166 [4] A.F. Williams, The 1996 U.S. Roadside Survey and its Implication. Alcohol, Drugs and Traffic Safety T-97, Ed. C. Mercier-Guyon, CERMT, Annecy, 1997, pp. 37–40. [5] R. Iffland, Evolution of an increased blood level of GGT, CDT, methanol, acetone and isoropanol in alcohol intoxicated automobile drivers. Alcoholism indicators instead of medical-psychological examination., Blutalkohol 31 (1994) 273–314. [6] R. Iffland, M. Staak, Methanol and isopropanol as markers of alcoholism, Beitr. Gerichl. Med. 48 (1990) 173–177. [7] M. SeIzer L, The Michigan alcoholism screening test: the quest for a new diagnostic instrument, Am. J. Psychiatry 127 (1971) 1653–1658. [8] F.J. Alvarez, Screening for problem drinkers in a general population survey in spain by use of the CAGE scale, J. Stud. Alcohol 55 (1994) 471–474. [9] J. Pikkarainen, A. Penttila, Drinking, Driving, and Road Side Studies – The Finnish Experience. Alcohol, Drugs, and Traffic Safety-T92, Cologne, Verlag TUV Rheinland, 1993, pp. 1582–1602. [10] L. Lerer, The social epidemology of transport injury in South Africa – some brief comments, in: T. Varga ´ (Ed.), Traffic Accidents, Perdiatria, Szeged, 1996, pp. 115–122. [11] M. Levy, Identification of the Alcohol-Pedestrian Crash Problem Among Culturally Diverse Groups. Office of Research and Traffic Records, NHTSA, NTS-31, 1998. [12] S. McDermott, Compulsory blood alcohol testing of road crash casualties in Victoria: the first three years, Med. J. Aust. 2 (1978) 612–615. [13] I. Ghodse, Treatment of drug and addiction in London. Lancet i (1997) 636–639. ´ [14] P. Jozan, Health Behaviour Survey, 1994, CSO, Budapest, 1996.