Journal of Trauma-Injury Infection & Critical Care:
Alcohol and Trauma: The Perfect Storm
Moore, Ernest E. MD
From the Department of Surgery Denver Health Medical Center, Denver, Colorado.
Submitted for publication March 18, 2005.
Accepted for publication April 21, 2005.
This article was written for the proceedings from a conference entitled Alcohol Problems among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism in Arlington, Virginia, May 28-30, 2003. It does not reflect the official policy or opinions of the Centers for Disease Control and Prevention (CDC) or the U.S. Department of Health and Human Services (HHS) and does not constitute an endorsement of the individuals or their programs—by CDC, HHS, or the federal government—and none should be inferred.
Address for reprints: Ernest E. Moore, MD Chief, Department of Surgery Denver Health Medical Center 777 Bannock St., MC 0206 Denver, CO 80204; E-mail: email@example.com.
Alcohol misuse, when combined with the right circumstances, culminates in a “Perfect Storm” that has catastrophic results. Alcohol misuse impairs judgment and increases the likelihood of serious injury. Once injured, the intoxicated patient is more likely to be hypotensive and less likely to be able to protect his or her airway. Alcohol also impairs multiple compensatory responses to injury that are critical to survival, thereby increasing the likelihood of serious complications. When complications do occur, they may be more severe for intoxicated patients because both acute and chronic ethanol use adversely affect immunity. Thus, all phases of trauma care are potentially affected by excessive alcohol use. This paper presents facts about trauma care and the physiologic consequences and clinical implications of alcohol intoxication. Further, it shows how health-care costs increase when evaluating and managing an intoxicated trauma patient. This financial burden further escalates in the surgical ICU because the care of an intoxicated patient falls outside the realm of standard care. Trauma surgeons, perhaps more than other health-care providers, have a unique opportunity and a responsibility to address potential alcohol misuse with their patients. They witness the Perfect Storm almost daily and are fully aware of the short- and long-term consequences of alcohol misuse. A trauma center visit provides an opportune time and place to incorporate alcohol screening and brief interventions as a part of standard trauma care.
Trauma is the leading cause of death for Americans ages 1 to 44. Alcohol consumption contributes to these deaths, increasing the risk of trauma-related injuries.1 Moreover, acute alcohol intoxication and chronic alcohol abuse compromise the patient’s response to injury, affecting all phases of trauma care. This brief overview highlights basic facts about trauma care; the physiologic consequences and clinical implications of alcohol intoxication; the added costs of care for alcohol-related trauma; and the responsibilities of trauma surgeons in addressing alcohol problems with their patients.
BASIC FACTS ABOUT TRAUMA CARE
Trauma is defined fundamentally as tissue damage caused by a transfer of external energy. Kinetic energy-induced trauma is classified as either blunt (force to the external surface) or penetrating (foreign object penetrates the external surface). Trauma is also referred to as intentional (e.g. resulting from an assault), or unintentional (e.g. occurring in a motor vehicular crash). Trauma care represents a continuum from the scene of the injury (prehospital), to emergency department, operating room, interventional radiology, intensive care unit, or physical therapy (in hospital), through rehabilitation.
Trauma centers are hospitals that have specialized equipment and personnel specifically trained to treat trauma patients. These centers are categorized as Level I, II, III, IV, or V based on the center’s capability to provide a specific level of care. Level I trauma centers provide the most comprehensive patient care and serve as key resources for education and research. Typically, Level I trauma centers admit 3,500 to 5,000 injured patients per year, and should be able to manage more than 650 severely injured patients annually (Injury Severity Score greater than 15) to optimize quality of care and cost-effectiveness.2
Trauma surgeons are general surgeons who have experience in the treatment of trauma patients. Most trauma surgeons in Level I trauma centers have completed fellowships in surgical critical care and trauma research. They are qualified to provide the full range of in-hospital care for the injured patient—from emergency department resuscitation through rehabilitation.3
ALCOHOL AND TRAUMA
Why Should Trauma Surgeons Care about Alcohol Problems?
Alcohol remains a pervasive public health problem in the United States.4 First, alcohol is a widely embraced agent used to facilitate social interaction, and there is convincing evidence that moderate alcohol consumption provides cardiovascular benefits. Consequently, unlike illicit drugs, there is societal acceptance—if not encouragement—of alcohol use. Second, excessive consumption of alcohol has been a traditional “right of passage” for college freshmen; this activity is now prevalent at the high school level. In fact, widespread marketing targets underage consumers, notably in beer advertising or commercials during sports events. Finally, many of the baby boomer generation, now in a position to influence policy, have experienced an extended period of society’s tolerance of alcohol indiscretion.
A recent analysis shows that from 1993 to 2001, binge drinking increased in the United States, and 69% of these episodes occurred in individuals 26 years of age and older.4 The annual economic cost of alcohol misuse is estimated to be $185 million.5 Alcohol intoxication is well documented as a major risk factor for injury. In more than 40% of patients admitted to trauma centers, alcohol is the precipitating factor leading to acute injury.6,7 It is widely acknowledged that alcohol impairs judgment and motor function in a dose-response fashion, but alcohol also provokes hazardous activity by unmasking aggression.8 Without intervention, injury associated with alcohol use tends to recur.1
How Does Alcohol Affect the Patient’s Response to Trauma?
Alcohol intoxication can adversely affect early physiologic responses to injury.
* Alcohol impairs cardiovascular response to acute blood loss.9–14
* Alcohol exaggerates post-shock myocardial contractility dysfunction.10–12
* Alcohol increases pulmonary vascular resistance.9
* Alcohol blunts catecholamine release. The net result is inadequate oxygen delivery to tissue and metabolic uncoupling.11,13,14
* Acute alcohol ingestion reduces the electrical threshold for ventricular arrhythmias and promotes electro-mechanical dissociation.15–17
Thus, intoxicated patients have a higher risk of dying at the scene following blunt thoracic trauma.
Alcohol consumption can also have profound adverse effects on the outcome of a traumatic brain injury (TBI). In clinical studies, alcohol intoxication is estimated to double the severity of TBI.18 Research has shown alcohol to blunt hypercarbic ventilatory drive and to reduce cerebral blood flow.19 Although alcohol does not have a direct influence on the coagulation cascade,20 it may indirectly promote bleeding by potentiating the inhibitory effects of aspirin on platelet function.21
Acute alcohol exposure is directly immunosuppressive, increasing the risk for post-injury infections, acute respiratory distress syndrome, and multiple organ failure.22 Specific defects in both innate and adaptive immunity are also results of acute alcohol intake.23,24 In vitro, clinically relevant levels of alcohol inhibit polymorphonuclear neutrophil (PMN) signaling pathways for phagocytosis, the respiratory burst, and degranulation that are critical for eradicating bacteria.25–27 Clinical studies have confirmed a dose-dependent relationship between alcohol consumption and these PMN functional deficiencies.28 Alcohol also inhibits monocyte and macrophage production of key cytokines, including tumor necrosis factor alpha (TNF [acute]α) and interleukin 8 (IL-8).29,30 Finally, experimental work demonstrates that alcohol impairs T helper lymphocyte (TH-1) regulated cellular responses, while it enhances the production of TH-2 humoral agents.31,32 Of note, in vivo studies suggest the immunomodulatory effects of acute alcohol intake persist for seven days. Part of the mechanism for these protracted changes may be the interaction of alcohol with the bone marrow.33 Alcohol may also be cytotoxic to functional cells, such as the gut epithelium34 and hepatocyte.35 Collectively, the direct effects of alcohol on the primary cells of the immune system and indirect cytotoxicity to other cells act synergistically to promote global immunosuppression.
How Do Alcohol Problems Magnify the Cost of Trauma Care?
Intoxication increases expenses associated with evaluating and managing a trauma patient. For example, consider a scenario in which there is a car accident. A motor vehicle crash (MVC) is the predominant injury mechanism requiring patient evaluation in a trauma center. The typical seat-belt restrained individual, involved in an MVC with significant vehicular damage, arrives in the emergency department (ED). The patient is frightened and has an elevated heart rate, but is otherwise alert and cooperative with a normal blood pressure. After a thorough physical examination, literally from head to toe, the routine supplementary evaluation of a nonintoxicated patient consists of a chest x-ray, abdominal ultrasound, a complete blood cell (CBC) count, and urinalysis. Unless there are abnormal findings on the physical examination or tests, the evaluation is complete and the vast majority of these patients are sent home following an eight-hour observation period in the ED.
In contrast, the inebriated patient in the same scenario arrives in the ED belligerent, and often noncompliant. Alcohol intoxication can obscure initial test results and signs of injury during the physical examination. This prompts additional tests. To rule out fractures, spine and pelvic x-rays are required. Similarly, any aberration in mental status mandates a CT scan of the head to exclude TBI, and most trauma surgeons would add chest and abdominal CT scans if there was significant damage to the car. At this point, the extra hospital cost alone readily exceeds $4,000, and virtually all these patients are admitted to the hospital for at least 23 hours of observation.
Another example of the economic burden of alcohol abuse is, regrettably, a common occurrence in urban trauma centers: a witnessed fall from a six-foot wall associated with a five-minute loss of consciousness would prompt a 911 call and subsequent ambulance transport of the victim to a trauma center. The nonintoxicated patient, despite a normal examination and mental status, is evaluated with a precautionary CT scan of the head. If the scan is normal, the patient is sent home. On the other hand, the severely inebriated patient is presumptively intubated to prevent hypoxic secondary brain injury and undergoes both head and abdominal CT scans, because the physical examination is notoriously insensitive. Despite normal scans, the patient is admitted to the surgical intensive care unit (SICU) for frequent neurologic assessments and airway extubation. Recognizing the exorbitant cost from this course of action, rather than admit the patient, occasionally a “frequent flyer” (recurrent inebriated trauma patient) is delivered to the ED and a well-intentioned physician allows the patient to sober-up in the observation unit. However, this time, the patient fails to improve and a delayed CT scan of the head demonstrates an acute subdural hematoma requiring urgent operative decompression. Unfortunately, the window of opportunity has passed and the patient sustains permanent brain damage.
The financial penalties of alcohol abuse go beyond initial management costs and can be enormous in the SICU. The standard care for patients with significant head injury, identified by CT scanning, is frequent clinical neurologic assessment in the SICU. This mode of care is not feasible for the intoxicated patient and, therefore, invasive monitoring of brain physiology is required (e.g. intracranial pressure monitors). Similarly, the confounding effects of alcohol on the cardiovascular response to blood loss frequently lead to more invasive monitoring (e.g. pulmonary artery catheter). The well-known immunosuppressive consequences of alcohol ingestion result in presumptive antibiotic therapy to combat the body’s normal response to injury or early invasive infection. Finally, evidence of acute intoxication appropriately raises concern for withdrawal from chronic alcohol abuse and often prompts the excessive use of sedatives. This frequently prolongs mechanical ventilation of the patient, which further augments the risk for pneumonia in the SICU.
What are the Responsibilities of the Trauma Surgeon?
Trauma surgeons, perhaps more than any other health-care provider, have tremendous opportunities to address potential alcohol misuse with their patients. On a daily basis, it is the trauma surgeon who sees the elements of “The Perfect Storm” come together—the young man who thought he could drive home after the graduation party; a family on their way home from vacation who just happened to be in the wrong place, at the wrong time; or perhaps it’s the pedestrian who has had one too many drinks and decides to walk home. The list of scenarios is long and varied, and the trauma associated with alcohol abuse becomes painfully familiar. The trauma surgeon sees first-hand the short- and long-term consequences of alcohol-related injury—the devastating realities of massive head injuries and spinal cord injuries compounded by the overwhelming grief of the patient’s family and friends—a constant reminder that, in a fraction of a second, misjudgment can change many lives forever.
Recently, we sent our youngest son off to college. I sadly reflect on tragedies involving our son’s friends who were killed or permanently disabled near the end of their high school years—a time when infinite opportunities were on the horizon. Trauma surgeons can have a definite impact on reducing and preventing these terrible tragedies. As leaders of trauma teams, we must ensure that alcohol screening, brief intervention, and motivational behavioral modification are an integral part of overall trauma care.36,37
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Alcohol; Trauma; Injury; Intervention; Trauma center; Trauma systems; Injury prevention
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