At the scene of injury: Recognizing brain injury in intoxicated patients (Research Summary)

What do we already know?

Alcohol intoxication is present in 10-18% of trauma patients

• Intoxication can affect verbal & motor responses and mimic other signs of a traumatic brain injury (TBI)
• Recognizing more severe TBIs in intoxicated individuals can be challenging

Emergency Medical Service (EMS) professionals are the first professionals at the scene of a trauma (e.g., car accident)

If signs of a TBI are mistaken for or overshadowed by signs of intoxication, individuals may be undertriaged (i.e., not sent to higher-level trauma centers) and therefore undertreated (i.e., delay in receiving specialized care)

What did they want to know?

How does alcohol intoxication influence EMS professionals’ pre-hospital assessment of people with severe TBI?

• E.g., Both Person A and Person B have sustained a severe head injury. Person A is sober. Person B shows visible signs of intoxication. How likely are EMS professionals to suspect a head injury in Person A? What about Person B?

What is the relationship between suspicion of alcohol intoxication and severe head injury?

What did they do?

Collected records from 19,206 patients aged 16+ transported by ambulance to 5 emergency departments in the Netherlands from 2015-2017

Analyzed pre-hospital records written by EMS professionals

• Suspected head injury: Suspicion by EMS professional of injury with score >= 3 in the head region of the Abbreviated Injury Scale (AID)
• Suspicion of alcohol intoxication: Intoxicated behaviour, smell of alcohol, or patient-reported alcohol use as described by EMS professionals

Analyzed data from registry of all trauma patients admitted to hospital

• Glasgow Coma Scale (GCS) score: Measure of impaired consciousness; GCS 13-15 = mild TBI, GCS <13 = moderate/severe TBI
• Recognized injury: Diagnosed moderate-severe TBI in hospital AND suspected at scene
• Unrecognized injury: Diagnosed moderate-severe TBI in hospital AND not suspected at scene

What did they find?

10.1% patients suspected to be intoxicated

• More likely to be younger (median age 47.1 years) & male (71.3%)
• Cause of injury did not affect the findings (findings the same for both injuries from motor vehicle collisions and from falls)

Recognition of head injury in the field is difficult in both intoxicated and non-intoxicated patients

In intoxicated patients:

• Sensitivity: 45.3%
• Specificity: 92.5%

This means that 45.3% of the time, severe head injury is correctly recognized but 54.7% of the time the head injury is missed (i.e., later diagnosed in the hospital).

Similar findings in non-intoxicated patients:

• Sensitivity: 40.2%
• Specificity: 95.3%

37.2% patients with an unrecognized severe head injury were transported to a higher-level trauma center

• Versus 85.9% patients in which a severe head injury was recognized

Intoxicated patients were more likely to be:

• Diagnosed with a severe head injury in the hospital & have GCS score <13 (mild-moderate TBI)
• Suspected of having a severe head injury in the field by EMS professionals

Intoxicated patients with a severe head injury were more often transported to a higher-level trauma center than non-intoxicated

What does this mean?

Severe head injuries are frequently not recognized at the scene of injury in both intoxicated and non-intoxicated patients

EMS professionals should be aware of the signs of brain injury and remember that intoxicated patients are at higher risk for having a moderate-severe head injury

In this study, patients suspected to be intoxicated were slightly more often recognized to have a severe head injury & more often transported to a higher-level trauma center

• EMS professionals were likely more cautious for severe injuries in intoxicated patients – this may help avoid delays in specialized care for those with head injuries

Source:

Lokerman, R. D., Gulickx, M., Waalwijk, J. F., van Es, M. A., Tuinema, R. M., Leenen, L. P., … & Triage Research Collaborative (Pttrc). (2022). Evaluating the influence of alcohol intoxication on the pre-hospital identification of severe head injury: a multi-center, cohort study. Brain Injury, 1-9.

doi: 10.1080/02699052.2022.2158228

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