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A variety of factors increase the likelihood that a person will sustain a traumatic injury, and this chapter presents a model for conceptualizing these factors and their relation to injury. In this view, a traumatic injury is seen not as an "accident" but as a condition resulting from the interaction of many factors. An assumption of this view of injury as a public health problem is that, like heart disease, it can to a large extent be prevented when risk factors are reduced. This chapter does not attempt to provide a comprehensive description of traumatic injuries and their treatment. Only the major types of traumatic injury are described in detail, while others are highlighted. Particular points covered about each type of traumatic injury include its major causes, its incidence in the general population, and the proportion of patients for whom AOD use and dependence contribute to the injury. It is hoped that when reading this chapter, persons in the AOD treatment field begin to consider this diverse patient population in terms of identifying and treating the AOD-abusing and -dependent individual. This population is similar to other AOD treatment populations with comorbid conditions, such as persons with dual diagnoses (mental illness and AOD use disorders) or with serious, chronic medical conditions. Both conditions must be treated for the overall prognosis to improve. It is hoped that models or strategies for working with this patient group will suggest themselves to readers. Overview of the ProblemAs discussed in Chapter 1, about 2.5 million persons with traumatic injuries are admitted to U.S. hospitals each year (Rice et al., 1989). Annual direct costs for care, including personal medical and nonmedical costs of care, amount to nearly $45 billion; annual indirect or morbidity costs, which include the value of goods and services not produced by injured individuals, are estimated at nearly $65 billion (Rice et al., 1989). Comparable costs for cancer are approximately $35 billion in direct costs and $12 billion in indirect or morbidity costs (Rice et al., 1989). Thus, the measurable costs due to trauma injury amount to more than $100 billion each year, nearly twice the costs for cancer. Traumatic injury has been recognized as a leading public health problem, and policymakers at all levels have attempted to implement injury-prevention measures. As discussed in Chapter 1 and addressed in more detail later in this chapter, alcohol-and-other- drug use plays a major role in traumatic injury. Persons with untreated AOD problems who have sustained one traumatic injury are at increased risk of reinjury. Because of the growing emphasis on injury prevention, it is likely that hospitalized trauma patients will come increasingly to the attention of the AOD treatment field. However, many persons in the field -- treatment personnel, program administrators, and policymakers -- lack knowledge of or experience with this patient population. Such a lack may hamper present and future efforts to design and implement effective AOD interventions for this patient group.
Research FundingAlthough it has long been known that the costs of injury to society are higher than for any other disease, research on injury receives less than 2 cents of every Federal dollar spent for research on health problems (National Research Council, 1985). Annual spending on injury research amounts to approximately $160 million. The National Cancer Institute spends $1.4 billion annually on cancer research, and the annual budget for research on cardiovascular illness at the National Heart, Lung, and Blood Institute is $930 million. Injury research funds thus represent only 11 percent of funds spent on cancer research, and 17 percent of funds spent on heart disease research. Definition of Traumatic Injury and Views of the Trauma Patient DefinitionFor the purposes of this Treatment Improvement Protocol (TIP), traumatic injury is defined as tissue damage caused by external force or violence. Acute injury results from the rapid transfer (i.e., as little as a few seconds or less) of excessive amounts of one of the five forms of energy (kinetic, thermal, chemical, and electrical energy and radiation) or the excessive removal of one of these forms (for example, in asphyxiation or hypothermia). Acute injury can be intentional, such as injuries resulting from assaults or self-infliction. Unintentional injuries result, for example, from falls. Injuries may be fatal or nonfatal. Kinetic injuries are often classified as penetrating (passing into the body), such as a stab wound or gunshot wound, or blunt (striking the outside of the body), such as internal injuries resulting from a fall. This definition differentiates traumatic injury from overuse injuries such as carpal tunnel syndrome and from chronic disease, in which tissue damage occurs over a more extended time. In general, there is wide agreement on the types and severity of injuries that should be treated in the hospital. Although severity of injury is the main factor in determining whether a patient is hospitalized, some patients, such as those with mild head injuries or an altered mental status, who may not need hospitalization for their primary injury, are sometimes hospitalized for a short time for observation. Social factors, such as lacking caregiver supports and being homeless, sometimes play a role in the decision to hospitalize, although this decision is becoming increasingly difficult because of stringent admission criteria set by third-party payers. In general, hospitalized trauma patients are those with moderate to severe injuries requiring specialized evaluation and treatment.
Different Views of the Trauma PatientClinically, trauma patients can be viewed in several ways. Physicians focus on the patients' immediate needs, according to the physicians' specialties. Because these patients are often near death or in danger of sustaining permanent disability from conditions needing immediate treatment, views of them are often narrow and necessarily focused on the injury. The emergency department physician and staff, as well as the trauma physician, generally see the patient from the perspective of the mechanism of injury, which alerts them to look for particular types of injuries. Neurosurgeons or orthopedic surgeons mainly view the patient from the perspective of the organ or organ system injured. For example, to a specialist called in to deal with the patient's brain injury or shattered hip bone, the mechanism of injury is not as important as the site of the injury and the type of injury. Similarly, physical rehabilitation specialists may focus on restoring the patient's muscle strength or range of limb movement or independent functioning. As can be seen, these views of the trauma patient begin with the point of injury and focus on the outcomes of the traumatic event. This approach can be fragmented and does not result in a holistic picture of trauma patients. In terms of injury prevention, these views of trauma patients have served them poorly. Injury as a DiseaseA different approach to this patient group is to view traumatic injuries as a disease, like heart disease, with many potential risk factors (Waller, 1987). For example, the initial medical workup of a patient who has had a heart attack generally includes several questions related to family history of heart disease, nicotine use, diet, and level of activity. These questions are asked to clarify the clinical picture and to help the patient understand the underlying cause of his or her condition and the required treatments -- and to prevent further illness.
Such educational and preventive efforts rarely take place with hospitalized trauma patients whose injuries are related to alcohol and other drug use. However, when injury is viewed as a disease, clinicians are more likely to address underlying risk factors, such as a family history of AOD use, episodes of heavy drinking, and other areas of unsafe behavior such as the failure to use seatbelts. From the disease perspective, many interacting risk factors contribute to the occurrence of a traumatic event such as a motor vehicle crash. A poorly lit road with dangerous curves increases the risk of a vehicle crash. Add to that icy conditions and an adolescent short on driving experience, attention, and concentration but long on risk-taking behavior, and the risk of a crash increases greatly. Add alcohol consumption to this mix, and from this perspective, the situation appears to be one that almost certainly will end in a crash.
Predisposing Factors in Traumatic InjuryEpidemiologists and other researchers have made enormous strides in their understanding of factors leading to injury. Beginning in the 1940s with the work of Hugh De Haven, M.D., at Cornell University and continuing through the 1960s and 1970s with the work of William Haddon, Jr., M.D., researchers have attempted to model risk factors for injury in order to develop more effective prevention strategies. Several sophisticated models of risk factors and matrices for prevention strategies have been used (Haddon, 1980). However, for the purposes of this TIP, a simpler conceptual model is described. Risk Factors Other Than AOD UseAs shown in Exhibit 2-1, factors other than AOD use that increase the risk of traumatic injury can be classified into four areas: physical, environmental, socioeconomic, and personality/psychological factors. As described above, several factors often interact to contribute to a traumatic injury. Reducing the level of any single factor, such as improving the lighting and paving of roads, can greatly reduce resulting injuries. Physical factors. Physical factors are those related to the individual person, such as age, gender, and physical health. Younger persons, especially males, are at increased risk of injury because they are generally more active than older persons. Elderly people with poor vision, weak lower extremities, and impaired or decreased balance are at greater risk of falling; because of progressive bone loss they may also sustain severe injuries as the result of relatively low-impact forces. Environmental factors. Environmental factors increase the risk of traumatic injury. Certain States have passed legislation to reduce speed limits, increase the legal drinking age, and make helmets mandatory for motorcyclists and bicyclists, thereby greatly reducing people's risk of injury. Environmental factors can also relate to an individual's access to guns and use of cars or alcohol and other drugs, as well as to the safety of the person's location, such as his or her living near a body of water or in a high-rise building. Socioeconomic factors. Socioeconomic factors such as being employed in a high-risk job or living in a high-crime neighborhood or in a poorly maintained building with few safety features also contribute to the risk of traumatic injury. Driving old or poorly maintained cars also increases the risk. Other socioeconomic factors are related to the breakdown of families that is often associated with poverty. Young people may join gangs to replace the family bonds, and enter a culture where violence is promoted and accepted as a routine of daily life. Personality/psychological factors. Risk taking, antisocial behaviors, and mental illness contribute to risk. Persons who have depression are at increased risk of suicide, and those with schizophrenia or other psychotic disorders may lack the judgment to remove themselves from dangerous situations. AOD Use as a Risk Factor in Injury And ReinjuryUse of alcohol and other drugs has long been recognized as a major, independent risk factor in unintentional fatal and nonfatal injuries and in intentional injuries such as assaults, homicides, and suicides. Indeed, some clinicians believe that traumatic injury is a marker of alcohol abuse (Clark et al., 1985; Maull, 1982). In 40 to 50 percent of fatal motor vehicle crashes and 25 to 35 percent of nonfatal crashes, at least one participant is legally intoxicated. Alcohol has been found to play a role in more than 50 percent of homicides and more than 50 percent of burns as well as 48 percent of hypothermia and frostbite cases and 40 percent of falls (National Institute on Alcohol Abuse and Alcoholism, 1989). It has been conservatively estimated that 20 to 25 percent of all persons hospitalized for injury are alcoholics or have a drinking problem (Waller, 1988). Evidence of chronic alcoholism has been found in up to three-fourths of some samples of trauma patients (Rivara et al., 1993a). A substantial proportion of injured pedestrians have blood alcohol concentrations above 100 mg/dl (National Research Council, 1985), which is the legal definition of intoxication in most States. Although the role of drugs other than alcohol in traumatic injuries has not been as thoroughly investigated, studies have shown that cocaine, amphetamines, and marijuana, especially in combination with alcohol, play a significant role in traumatic injuries of all kinds, especially motor vehicle crashes (Bailey, 1993, 1990; Brookoff et al., 1993; Clark and Harchelroad, 1991; Marzuk et al., 1990; Rivara et al., 1989; Sloan et al., 1989; Soderstrom et al., 1988). In a recent study in Memphis, drivers who had been arrested for reckless driving and who had received negative results on Breathalyzer tests for alcohol use were given rapid urine tests in a van set up at the scene of the arrest (Brookoff et al., 1994). Of 150 drivers who submitted urine samples at the scene, 59 percent tested positive for either cocaine (13 percent) or marijuana (33 percent) or for both drugs (12 percent). How AODs Increase RiskThe risk of injury is increased both by immediate use of alcohol and other drugs (impairment and intoxication) and by chronic AOD use. Many aspects of AODs and their effects play a role, including the following:
ReinjuryPersons who experience one traumatic injury have been found to be at greatly increased risk for reinjury. For example, after one head injury, a person is three times more likely than someone in the general population to sustain a second head injury. After a second injury, the relative risk for a third injury increases to eight times the normal risk (Annegers et al., 1980).
Untreated AOD use disorders play a significant role in reinjury. In one study, the readmission rate for more than 2,500 adult patients treated at a Level 1 trauma center was determined over a 28-month period. Patients who were intoxicated on the initial admission were 2.5 times more likely than other patients in this group to be readmitted for new injuries. Chronic alcohol use among this group was determined by using the Short Michigan Alcohol Screening Test (SMAST) and by measuring gamma-glutamyltransferase (GGT) values. The relative risks for patients with positive SMAST scores and abnormal GGT values were 2.2 and 3.5, respectively (Rivara et al., 1993b). Neglect of AOD Use as a Risk FactorAlthough use of alcohol and other drugs is a major predisposing factor in traumatic injury, and the role of AODs is well known and has been heavily documented, medical management of trauma patients seldom addresses their AOD use and dependence. Indeed, one recent study at a Level 1 trauma center found that intoxicated patients with traumatic injuries were significantly less likely than uninjured intoxicated patients to receive onsite psychiatric evaluation or referral to AOD use treatment (Lowenstein et al., 1990). Another study reviewed the care provided to 84 injured drivers (average blood alcohol concentrations more than twice the legal limit) admitted to a hospital over a 6-year period; only two patients, both of whom had been previously given a diagnosis of alcoholism, were referred for AOD counseling (Colquitt et al., 1987). One of the goals of this TIP is to focus the attention of agency and program administrators, policymakers, and treatment providers from many disciplines on this glaring omission in the treatment of trauma patients. It is the hope of the consensus panel that addressing the AOD risk factor in the treatment of trauma patients will become as much a part of overall, holistic medical treatment as addressing diet and exercise in the treatment of heart patients.
Treatment of Trauma PatientsDecisions About Trauma Care SettingsTrauma patients receive initial treatment in one of several different settings, depending on the community where they are injured, their State's emergency transport and medical system, and the initial assessment of their injuries. In many communities, transport systems are designed to circumvent hospital emergency departments for seriously injured patients, often carrying them (many by helicopter) directly to a regional Level 1 trauma center (see below). Although Level 1 trauma centers play a crucial role in treating very seriously injured persons, it is important to note that most trauma patients are treated in community hospitals. Levels of Trauma CenterTrauma centers are specialized inpatient units that care for injured patients only. They are usually part of full-service hospitals, and a few are freestanding. Trauma centers are set up to treat serious, life-threatening injuries and have resources that go far beyond what is found in a community hospital emergency department. They follow strict diagnostic and resuscitation protocols utilizing a highly organized, highly trained team of trauma professionals. Blood and urine samples are routinely drawn from patients, and it is relatively simple to fit blood alcohol concentration (BAC) determinations and toxicologic screens into the existing structure. Trauma centers are categorized as Levels 1 through 4 in the Resources for Optimal Care of the Injured Patient, developed by the American College of Surgeons (ACS) committee on trauma (ACS, 1993). This document sets standards for access to care, prehospital care, hospital care, and rehabilitation. There are ACS-verified Level 1 trauma centers in many urban areas and many university medical centers nationwide. Level 2 facilities meet the same standards of care without research or teaching components. Level 3 facilities have the primary purpose of treating less serious injuries and transporting more seriously injured patients to the next higher level of trauma care. Many community hospitals are categorized as Level 2 or 3. Level 4 facilities are generally in rural areas. According to the ACS document on optimal care, all Level 1 and 2 trauma centers should have the laboratory capability of performing blood alcohol testing and routine toxicology. Although the American College of Surgeons has a voluntary, formal certification procedure for trauma centers, the majority of trauma centers are self-designated and do not undergo the verification process. However, many States are beginning to regulate trauma care legislatively, establishing standards that are very close to those in the Resources for Optimal Care of the Injured Patient.
Trauma Patient FlowPatient flow in community hospitals differs from that in Level 1 trauma centers, even though community hospitals may be categorized as Level 2 or 3 trauma centers. One important difference is that the most seriously injured patients at the community hospital emergency department will be transported to higher levels of care (i.e., trauma centers). In community hospitals, care is less protocol driven, especially when it comes to drawing blood and urine for alcohol and other drug screening. In community hospitals, the emergency department staff decides who is screened, and many do not order screening tests. Studies have shown that many emergency department physicians believe they can recognize an intoxicated patient without screens and that they consistently overestimate their ability to do so. Standard trauma protocols, defined by the Advanced Trauma Life Support Manual, issued by the American College of Surgeons committee on trauma, are followed at most trauma centers. The manual defines the standard of care in all hospitals treating trauma victims, from rural Level 4 facilities to Level 1 urban trauma centers. Trauma is a distinct specialty with practitioners trained to perform specific tasks. The emergency department is the entry point into the hospital system for trauma patients, and the emphasis is on immediate life-threatening issues that include management of the airway, breathing, and circulation. Once these vital functions are stabilized, the patient is rapidly moved to the next stage of treatment. Emergency department personnel perform initial assessment of the patient's immediate needs and status to decide whether the patient will be admitted to the hospital.
The total amount of time spent in the emergency department by a trauma patient can be as short as several minutes. These are critically injured patients and any treatment delay could mean permanent disability or death; therefore, trauma treatment procedures in the emergency department must be as brief as possible. From the emergency department, patients may be transported to the operating room, to the intensive care unit, to the hospital ward, or to other areas of the hospital for further diagnostic tests. In trauma centers, trauma surgeons remain the principal healthcare providers throughout the patient's hospital stay. Most community hospitals do not employ a full-time trauma surgeon, and patient care is directed by the attending physician. The organ system most injured tends to determine who the attending physician will be. For example, patients with fractures are assigned to orthopedic surgeons, and those with closed-head injuries go to either neurologists or neurosurgeons. Patients with nonsurgical traumatic injuries, such as those who have attempted suicide with pills and/or alcohol or who are suffering from hypothermia or smoke inhalation, may go to intensive care units of hospitals, where they receive care from physicians, usually internal medicine physicians, with specialized training in intensive treatment. The treatment of trauma patients is a team effort involving a wide range of professionals with specialized knowledge from several disciplines. The trauma team can include a wide range of personnel. The following personnel are involved in early care of the trauma patient and contribute specialized knowledge to clinical decisions during the patient's hospitalization:
After the acute phase of treatment, other personnel may become involved in the patient's care. These include
The Addictionist and Other AOD CliniciansUnfortunately, the addictionist or other AOD clinician is rarely included in this wide array of specialized personnel, and treatment of these patients often proceeds with little attention to the acute management problems related to AODs and to the underlying cause of the injury. Because use of AODs is the underlying cause of approximately 50 percent of traumatic injuries, AOD treatment personnel should play a prominent role on the trauma team. As is discussed in Chapter 3, use of AODs complicates the assessment and treatment of these patients and sometimes presents a significant obstacle to their medical recovery and overall prognosis.
Treatment PhasesAcute PhaseThe acute phase of treatment comprises the patient's time in the emergency department/resuscitation area and operating room. This period usually lasts several hours and may extend to 12 hours or more. Subacute PhaseAfter the patient leaves the emergency department, he or she is admitted to the hospital under the care of the trauma team. The severely injured patient may spend days or months in the acute or intensive care unit. The goal of the subacute phase of treatment is to enhance recovery from the injury so that the patient can be discharged from the intensive care unit to a step-down unit within the hospital (a nonintensive care setting) and eventually to an inpatient physical rehabilitation unit or facility. Less severely injured patients are discharged to their homes with needed support services. RehabilitationInpatient physical rehabilitation usually begins in the acute care setting and is emphasized in the subacute and step-down areas of care. Some patients require only a few days of inpatient physical therapy before discharge. For others, rehabilitation stays may last 6 to 12 weeks (third-party payers often limit stays to 90 days). Sometimes the patient is transferred to a freestanding rehabilitation facility. Rehabilitation staff may include occupational and physical therapists, physiatrists, specialized nurses, a speech therapist, a psychiatrist, a neurologist, a prosthetics designer, and a social worker. The goal of rehabilitation is to restore as much of the patient's functioning and independence as possible and to educate the patient, the family, and other caregivers about the ongoing effects of the injury. For example, decubitus ulcers (i.e., bedsores or pressure sores) can be a serious problem in paraplegic and quadriplegic patients who have lost sensation in their hips and legs, and they must learn to adhere to a schedule of shifting their position to avoid these problems. Ongoing outpatient management of some patients may include continuing physical and cognitive rehabilitation and periodic medical examinations to ensure that they are complying with treatment regimens and schedules. Many trauma patients, especially those with severe head and spinal cord injuries, require periodic lifetime medical followup and ongoing assistance with personal care and activities of daily living when they return to the community. Their families may require training to learn to assist them. Family counseling may be necessary to help all family members adjust to the changes and challenges. Lifetime goals are the achievement and maintenance of maximum health, functioning, and independence.
Types of InjuryIn this section, two types of central nervous system injury are highlighted -- traumatic brain injury and spinal cord injury. These are perhaps the most devastating types of injury because they often result in permanent loss of function and because many of these patients are very young. However, fractures are the most common types of injury seen in hospitals. Fractures may occur as part of multiple injuries sustained in motor vehicle crashes or may be isolated injuries resulting from falls. Falls are the leading cause of nonfatal injury. Elderly persons are especially at risk for fractures resulting from falls (see discussion of the elderly later in this chapter). Traumatic Brain InjuryDefinition and DescriptionTrauma to the head may involve the skull (cranium) or the brain, or both (craniocerebral trauma). The latter form of injury is divided into three categories: closed head injury, depressed fracture of the skull, and compound fracture of the skull. Traumatic brain injury (TBI) may produce a diminished or altered state of consciousness, ranging from slight dizziness to coma. TBI results in impairment of cognitive abilities and/or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and may cause partial or total functional disability or psychosocial maladjustment. Even patients with mild head injuries can experience devastating effects in their long-term recovery from injury. Subtle but profound effects, especially in relation to executive function (problem solving, abstraction, impulse control, and judgment), can produce in these patients a shaken sense of self. Other effects can include insomnia and vertigo. Many patients who experience significant improvement in cognitive skills during inpatient rehabilitation discover that when they return to their jobs or to other life tasks, they cannot read at the same level, cannot think abstractly or solve problems as they used to, and have poor impulse control. Some undergo personality changes. Many patients experience notable mood disturbance (anger, depression, agitation) within 6 to 12 months after their injury.
Prevalence and IncidenceThe National Head Injury Foundation reports that a traumatic brain injury occurs about every 15 seconds. From 75,000 to 100,000 persons die annually from these injuries. It is conservatively estimated that 500,000 new cases of hospitalizable TBI occur every year. About one of every three survivors of TBI has some degree of permanent disability (National Head Injury Foundation, 1994). Brain injuries can occur at any age but peak incidence is in young adults between the ages of 15 and 24; nearly 70 percent of head injuries occur in persons under 30 (National Head Injury Foundation, 1994). Men are three to four times more likely to incur such injuries. The annual incidence of TBI for the general population is about 1.8 to 2.4 per 1,000, based on epidemiological studies of patients admitted to a hospital for head trauma. Those who have had one head injury are at increased risk for a reinjury, especially if AODs are involved in the first injury. It has been commonly observed that those who sustain a second injury have increased likelihood of being intoxicated at the time. The effects of multiple head injuries are not well understood. Most clinicians believe that the effects are cumulative. These effects and those of AODs are likely to be synergistic. The total direct and indirect costs of medical treatment and rehabilitative and support services for brain-injured patients are about $25 billion per year. Because this is mostly a group of young patients, costs for lifetime care are high, as is the loss to society of potentially productive individuals. The National Head Injury Foundation has estimated that the total lifetime cost for an individual with severe head injury is about $4,600,000. This is about twice the lifetime cost of care for an individual with cancer or heart disease. CausesAccording to the National Head Injury Foundation, motor vehicle and motorcycle crashes cause about one-half of all traumatic brain injuries. Falls account for 21 percent, assaults and violence for 12 percent, and sports and recreation incidents for about 10 percent. Low socioeconomic status is a significant risk factor for traumatic brain injury. In a large prospective study, Parkinson and colleagues (1985) found that chronically unemployed persons and welfare recipients accounted for 11 percent of the population but 47.5 percent of the cases of head injury. Rimel and associates (1982) found that 42 percent of head-injured persons were chronically unemployed or unskilled laborers. AOD use -- especially use of alcohol -- and head trauma are very closely related. Findings vary from study to study, but they generally indicate that more than 50 percent of all those who sustain head injuries have been drinking alcohol. Other estimates of alcohol use in head-injured patients have ranged as high as 72 percent (Rimel and Jane, 1983).
In addition, the physiological effects of alcohol and many drugs have the potential for causing brain damage and for increasing the susceptibility of brain tissue to injury. Alcoholics may be more vulnerable to brain injury because of bone loss in the skull. The mean density of bone in alcoholics with good nutrition is diminished to as much as 58 percent of that of nonalcoholics with good nutrition (Bikle et al., 1985). Patient Management ProblemsPhysical disabilities resulting from head injury range from minimal motor deficits to complete paralysis. The spectrum of cognitive disabilities resulting from head injury includes impairments in
Many head-injured patients need extensive rehabilitation for serious cognitive deficits caused by the injury. AOD counselors who encounter these patients may be baffled by their impulsivity and impaired memory and may become frustrated about the compliance problems these patients have with any type of treatment, including AOD abuse treatment. Spinal Cord InjuriesDefinition and DescriptionSpinal cord injuries involve complete or incomplete disruption of the spinal cord. Such injuries can result in permanent motor disability, usually paralysis of the arms or legs (paraplegia) or both (quadriplegia) and in varying degrees of motor and sensory deficits. Spinal cord injuries can also result in loss of bowel and bladder control and sexual function. Frequently, spinal-cord-injured patients also have traumatic brain injury. Patients who sustain injuries to the spinal cord only do not have the cognitive deficits that result from traumatic brain injury. However, many have cognitive problems related to AOD use, which for many patients precedes their injury. CausesThe causes of spinal cord injuries are similar to those of TBI, and the two injuries can occur as a result of the same event. About 50 percent of spinal cord injuries are due to motor vehicle and motorcycle crashes; falls account for about 20 percent of these injuries, and acts of violence for about 15 percent (Stover and Fine, 1986). All of these causes are significantly associated with alcohol use, and research suggests that between 39 and 50 percent of spinal cord injuries are attributable to intoxication at the time of injury (Fullerton et al., 1981; Heinemann et al., 1988).
IncidenceThe incidence of spinal cord injuries is lower than that of TBI, with about 10,000 to 20,000 Americans sustaining such injuries each year (Rice et al., 1989). Although these injuries account for a small percentage of hospitalized trauma patients, the injuries result in significant physical and psychological changes, and patients require extensive long-term medical treatment, rehabilitation, and lifetime followup care. Course of TreatmentAs with all injured patients, the goal of treatment is to maximize functioning to attain or approximate premorbid levels. Spine-injured patients often receive intensive acute inpatient treatment and several weeks of inpatient rehabilitation. During rehabilitation, these patients need to acquire many new self-care skills. They may need help with personal care after discharge. Other Types of InjuryInternal InjuriesInternal injuries include blunt and penetrating injuries to internal organs. Abdominal injuries include those to the liver, spleen, bowel, bladder, kidney, and blood vessels. Injuries to the chest include those to the heart, lungs, and large vessels such as the aorta and pulmonary artery. Often these injuries are multiple. Causes of internal injuries include motor vehicle and bicycle crashes, falls, sports, and violence. Those resulting from motor vehicle crashes and violence, especially stabbings, have a well-documented relationship with use of AODs. BurnsBurns are caused by flames, hot liquids, steam, chemicals, electricity, and contact with hot surfaces. Specialized burn units or facilities exist for the care of burn patients. About 54,000 persons are hospitalized each year for burns, with the very young and the elderly at highest risk (Rice et al., 1989). Two of the major risk factors for this type of injury are alcohol and smoking. Typically, an intoxicated person falls asleep with a lit cigarette. Others lose consciousness with a part of the body resting on a hot surface. Because of diminished pain sensation resulting from intoxication, they awaken with irreversible skin and soft-tissue damage. It has been estimated that alcohol plays a role in more than 50 percent of burn injuries (National Institute on Alcohol Abuse and Alcoholism, 1989). Obtaining data on the percentage of burns that can be attributed to alcohol use is more problematic than for other types of traumatic injury because, in many of these patients, blood is not drawn in the emergency room, and therefore BACs are often not determined. In one study, 64 percent of persons who died as a result of burns had BACs greater than 100 mg/dl (Waller, 1972).
Care and rehabilitation of burn patients is extensive; when burn scars cross joints involving the neck, arms, and legs, they can greatly restrict the range of limb motion as they heal. Patients must adhere to a careful and rigorous daily regimen of limb movement as well as many months of followup to control scar formation. To do so, they must be especially cooperative with the treatment team, and those experiencing withdrawal syndromes or AOD-related behavior problems can present significant problems. Near-DrowningMore than 5,000 persons drowned in 1985, and another 5,500 were hospitalized because of near-drowning incidents (Rice et al., 1989). Alcohol has been detected in the majority of adults who drown while swimming or boating (Dietz and Baker, 1974). Many patients in this group are adolescents or young adults. Disabilities in this group are related to brain and lung injury.
Special Populations of Trauma PatientsAs discussed in the early part of this chapter, a number of factors are associated with an increased risk of traumatic injury in addition to the primary risk factor of AOD use. Among these are individual physical factors such as age, gender, and preexisting illness; socioeconomic factors such as poverty and unemployment; environmental factors such as living in a high-crime area; and personality factors such as risk-taking behavior. As with any disease or public health problem, the loading of these factors in a particular subgroup of the population increases the prevalence of the phenomenon under study in that group. In this section, special populations of trauma patients and the risk factors that increase the prevalence of these injuries among them are described. AdolescentsInjury is the leading cause of morbidity and mortality in the adolescent age group, resulting in many years of potential life lost and untold loss to society. Adolescents are physically very active, and risk-taking behavior is prevalent in this group. The association between AODs and traumatic injuries among adolescents has not been as well studied as that among adults. In 1991, 1.4 million youths ages 12 to 17 reported use of alcohol and other drugs (Johnson et al., 1994). In one study of 202 adolescents in AOD abuse treatment, 25 percent reported prior emergency medical treatment resulting from an incident that occurred while they were under the influence of drugs or alcohol (Schwartz, 1986). Another study found that 34 percent of adolescents who were admitted to an urban pediatric emergency department had a toxicology screen positive for AODs. The mean age of those with a positive screen was under 15.5 years (Loiselle et al., 1993). Adolescence is the time when people are initially exposed to alcohol and other drugs, and many adolescents have little knowledge of the potential AOD effects. An AOD intervention at this time, especially among hospitalized adolescents, may have significant preventive effects on the development of chronic use and on injury and reinjury. Two other TIPs in this series, Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents and Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents, describe the special issues and concerns associated with treatment of adolescents.
Socioeconomic and Cultural GroupsNegative socioeconomic factors are associated with higher rates of injury. These factors include unemployment and poverty; poor education, housing, and healthcare; and a breakdown in the family support system as a result of multigenerational poverty. Many affected persons are members of cultural or ethnic minority groups. Several risk factors for traumatic injury affect these groups in addition to AOD use and its associated violence, increasing the risk of traumatic injury. Environmental factors include residence in high-density, high-crime areas. In addition, Native Americans live largely in isolated areas where access to educational, vocational, and social opportunities is reduced. Elderly PersonsAlthough most traumatic injuries occur in persons under age 44, physical factors such as decreasing motor and cognitive abilities increase the risk of injury among the elderly. Elderly persons are generally more unstable physically than younger persons; they exhibit lower extremity weakness and decreased balance and vision. Because of their relative physical fragility, they sustain more serious traumatic injuries relative to the forces or mechanisms. The elderly thus constitute a significant proportion of hospitalized trauma patients. Falls are the leading cause of nonfatal injury, accounting for nearly 800,000 hospitalizations annually; the death rate resulting from falls among people aged 75 and older (elderly) is nearly 12 times as great as the rate for all ages combined, and the risk of hospitalization is nearly seven times as great (Rice et al., 1989). The incidence of alcoholism is lower among elderly persons than in the general public, a reduced incidence that is related to the facts that chronic AOD users have lower life expectancies and that addiction seems to diminish with advancing years. However, even small amounts of alcohol can cause significant motor and cognitive impairments in this group. Many clinicians see relatively large numbers of elderly persons who continue to use alcohol. In addition, because of the stigma associated with alcoholism, especially in older generations, alcohol disorders frequently go undiagnosed as a result of lack of self-reporting by elderly patients and their families. Physicians frequently "enable" drinking in elderly persons by not confronting the issue. The use of multiple prescription medications may cause similar impairments in the elderly. Sedative-hypnotics, such as benzodiazepines, are frequently prescribed to the elderly. Even low doses of these medications can cause impairment. In particular, the long-acting benzodiazepines such as diazepam (Valium) have been associated with falls (Ray et al., 1989). Some elderly persons who have taken a particular psychoactive medication for years -- for example, pain medication -- may develop an addiction and may experience withdrawal symptoms when they stop, either on their own or in the hospital. Hip and femur fractures are a type of traumatic injury with a higher incidence rate among the elderly. In younger people, bones such as the hip and femur (thighbone) are more dense and protected by greater muscle mass, and thus are relatively more difficult to break than those of elderly persons. However, as a result of bone loss associated with osteoporosis in postmenopausal women and with aging in general, elderly persons frequently fracture these bones after simple falls. As mentioned above, alcoholic patients may also experience extensive bone loss, which multiplies the risk in this group.
Approximately 300,000 Americans sustained hip fractures in 1993. Nearly 90 percent of these injuries were sustained by persons over age 65. The American Academy of Orthopedic Surgeons has estimated that medical costs and lost income from hip fractures add up to more than $9.8 billion per year, or $35,000 per fracture (Rovner, 1994). Persons With Serious Mental IllnessSeveral risk factors for traumatic injury affect persons with serious mental illness, a group that has high rates of AOD use disorders. Studies have indicated that 40 percent of seriously mentally ill patients in the community abuse a psychoactive substance (Schuckit, 1989). In addition, many persons with serious mental illness have low socioeconomic status, and many are homeless, increasing their risk of assaults and other injuries.
Three groups of mentally ill persons are of note in discussions of traumatic injury. Severely depressed persons' suicide attempts can result in acute injuries; in a large proportion of such cases, alcohol is involved. Up to 70 percent of patients who attempt suicide use mind-altering drugs, especially alcohol, prior to the attempt. Attempted suicide may represent part of a chronic use problem. Depressed persons may be less attentive and less cautious. Hypomanic patients often place themselves in dangerous situations, taking risks or provoking others. Schizophrenic patients may become involved in risky situations because of poor judgment and misinterpretations of reality. Victims of AOD AbuseSome subgroups of trauma patients are of special note because they are in most cases the "innocent victims" of trauma events -- often the victims (and sometimes the repeated victims) of those whose AOD use has resulted in violent or irresponsible behavior. Up to 50 percent of those who are injured in motor vehicle crashes have no evidence of alcohol use at the time of injury even though alcohol or other drugs may have caused the injury (that is, for example, when the injury results from another person's drunk driving). Many children and elderly persons, as well as spouses and significant others, sustain extensive injuries as the result of abuse in which AOD use frequently plays a role. Crime and random violence continue to claim many victims. The medical and criminal justice costs to society are great. Any successful attempts to reduce AOD use and abuse among hospitalized trauma patients will also decrease the size of these special subgroups of trauma patients. |
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