Injured Ethanolintoxicated Patients

Alcohol is an important predisposing factor for trauma of all types, but most important as far as morbidity and mortality rates are concerned is its association with motor-vehicle collisions. The proportion of fatal collisions involving a driver with a blood alcohol level greater than 10 mg/dL dropped from 51 to 41 percent between 1987 and 1996, when alcohol-related fatalities totaled 17,126 ( Fig.299-1). Nevertheless, alcohol-related motor-vehicle accidents continue to represent a significant public health problem with a large impact on emergency medicine practice.

FIG. 299-1. Traffic fatalities 1977 to 1993: all versus those associated with use of alcohol. (From Campbell KE, Zobeck TS, Bertolucci D: Trends in Alcohol-Related Fatal Traffic Crashes, United States 1977-1993. Rockville, MD, National Institute on Alcohol Abuse and Alcoholism, 1995.)

Injured intoxicated patients present particular challenges for the clinician. In particular, the effect of ethanol on the sensorium complicates efforts at cost-effective diagnosis and treatment, since physical examination findings may be unreliable. Also, obtaining studies that require the patient's cooperation can be problematic, with the physician compelled to administer a second central nervous system depressant in order to satisfactorily evaluate injuries.

Evaluation of intoxicated head-injured patients is particularly difficult. Serious head injuries are easily overlooked in intoxicated patients, some of whom, especially in inner-city locales, may arrive at the emergency department with no definite history and no external signs of head trauma. In fact, the most common serious error made in management of intoxicated patients may be to assume for too long that a depressed or abnormal mental status is secondary to intoxication. Intoxicated patients should undergo computed tomography (CT) evaluation if there is a history of head injury and the rating on the Glasgow coma scale is less than 15; for any worsening of mental status while under observation; or if there is no improvement in mental status by 3 h after admission. Once the decision to perform CT has been made, no delay should be allowed due to lack of cooperation by the patient, which may be the result of ethanol, concomitant drug use, or head injury. Sedation may be required, with careful attention to airway protection and paralysis and intubation if necessary.

The general recognition that ethanol intoxication may also delay diagnosis of operatively remediable abdominal injuries makes it more likely that intoxicated injured patients will undergo such procedures and studies as intubation, diagnostic peritoneal lavage, and abdominal CT. 6 Such procedures and studies may not be necessary in all intoxicated patients. The results of one small study suggested that intoxicated trauma victims with a Glasgow coma scale rating of 15 and no abdominal complaints or physical findings suggestive of abdominal injury are candidates for careful observation. 7

It is uncertain whether ethanol intoxication itself worsens the prognosis of injured patients. A study of over a million motor-vehicle accidents that attempted to control for safety-belt use, vehicle deformation, vehicle speed, and other factors found that drivers who drank were more likely to suffer a serious injury or death, 8 but other studies have found no difference in outcome for intoxicated injured patients.9 Recent observations suggest that chronic alcoholism—but not acute alcohol intoxication—adversely affects the prognosis of injured patients.10 These findings most likely reflect the comorbidity of underlying organ system dysfunction.

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