More than one-third (37 percent) of the injured patients in the National Trauma Data Bank® (NTDB®) 2013 Annual Report tested positive for alcohol. Some of these intoxicated patients may have chronic drinking problems and alcohol dependence. As the length of the hospital stay to treat their injuries increases, the time of abstinence from alcohol also rises, which may pose its own set of problems.
Dealing with DTs
In alcohol-dependent individuals, signs and symptoms of alcohol withdrawal syndrome (AWS) may develop within 24 to 48 hours after their last drink. AWS is common and most often is mild; however, the abrupt cessation in a patient who is alcohol-dependent may lead to delirium tremens (DTs)—a state of severe dysautonomia and encephalopathy—as well as withdrawal-related seizures, either of which may be fatal.*
The severity of baseline symptoms of AWS can be measured using the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). This scale includes 10 items that score the severity of symptoms, including nausea, sweating, agitation, headache, anxiety, tremor, clouded orientation, and tactile, auditory, and visual disturbances. Algorithms are available to determine the administration of medications based upon the patient’s score.*
Untreated or undertreated AWS in an alcohol-dependent patient may lead to DTs. This condition is characterized by fluctuating disturbances in consciousness and change in cognition, accompanied by exacerbation of autonomic symptoms (nausea, sweating, tremor, palpitations) along with exacerbations in psychological symptoms, such as anxiety. This constellation of symptoms may progress and result in complications that include injury to the patient or staff, aspiration pneumonia, arrhythmia, or myocardial infarction. In contrast to older studies that cited mortality of up to 20 percent with adequate recognition and management, mortality from DTs should approach just 1 percent.*
Withdrawal and injury
To examine the occurrence of injuries in which alcohol withdrawal was involved, the author searched the admissions records in the NTDB dataset for 2013 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses codes. Specifically searched were records containing diagnosis code 291.81, Alcohol withdrawal (processes and symptomatic effects resulting from abstinence from alcohol). A total of 550 records containing a diagnosis of alcohol withdrawal were found; 529 of these records contained a discharge status, of which 349 patients were discharged to home, 92 to acute care/rehab, and 83 to skilled nursing facilities; five died. These patients were 81 percent male, on average 51.9 years of age, had an average hospital length of stay of 12.4 days, an intensive care unit length of stay of 7.3 days, an average injury severity score of 11.3, and were on the ventilator for an average of 7.3 days (see Figure 1). The top three incident locations of initial injury were home (45 percent), street (40 percent), and public building (10 percent). (See Figure 2)
Figure 1. Hospital discharge status
Figure 2. Incident location
In this group of AWS patients, injury occurred more often at home than in the street where one would typically find the homeless population. Although the mortality was low for AWS patients, these patients had a longer average hospital length of stay in comparison with other groups of injured patients as reported in previous issues of the Bulletin, and one-third had discharge dispositions that included further hospitalization or long-term care.
AWS does not discriminate
Alcohol dependence shows no distinction between race, age group, ethnicity, or social class. One needs to be mindful and identify injured patients who may have alcohol dependence issues and adequately treat AWS to mitigate the potential complications, including unanticipated withdrawal.
Throughout the year, we will be highlighting these data through brief reports in the Bulletin. The National Trauma Data Bank 2013 Annual Report is available on the ACS website as a PDF file at www.ntdb.org. In addition, information about how to obtain NTDB data for more detailed study is available on the website. To learn more about submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at firstname.lastname@example.org.
Statistical support for this article has been provided by Chrystal Caden-Price, Data Analyst, and Alice Rollins, NTDB Coordinator.
*McKeon A, Frye MA, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry. 2008;79(8):854-862.