WEEKDAY DISTRIBUTION OF HEAD TRAUMAS IN PATIENTS ADMITTED TO THE EMERGENCY DEPARTMENT OF A CITY HOSPITAL: EFFECTS OF AGE, GENDER AND DRINKING PATTERN

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1 Alcohol & Alcoholism Vol. 42, No. 5, pp , 2007 Advance Access publication 6 March 2007 doi: /alcalc/agm003 WEEKDAY DISTRIBUTION OF HEAD TRAUMAS IN PATIENTS ADMITTED TO THE EMERGENCY DEPARTMENT OF A CITY HOSPITAL: EFFECTS OF AGE, GENDER AND DRINKING PATTERN JUSSI PULJULA 1, OLLI SAVOLA 2, VELI TUOMIVAARA 1, JOSEPH PRIBULA 3 and MATTI HILLBOM 1 1 Department of Neurology, Oulu University Hospital, Finland 2 Department of Neurosurgery, Oulu University Hospital, Finland 3 Department of Neurology, District Central Hospital of Litomerice, Czech Republic (Received 6 June 2006; in revised form 21 December 2006; accepted 16 January 2007; advance access publication 6 March 2007) Abstract Aims: To define the alcohol-related risk for head traumas and to compare the weekly and monthly variations in alcohol consumption, and the occurrence of head traumas in a population with heavy episodic drinking as the prevailing drinking pattern. Methods: All consecutive admissions due to head trauma into a Finnish city hospital during 1 year (1999) were recorded. 832 consecutive patients with data on alcohol consumption were covered. We compared the number of final diagnoses of head traumas per day and month to the anticipated frequency in the absence of any weekly or monthly variation. Official statistics on alcohol consumption in Finland are presented as reference. Results: Alcohol-related head traumas were most common in young adults and people of working age. The occurrence of head traumas in sober subjects showed no temporal variations. By contrast, alcohol-related cases peaked on weekends and in the most popular vacation month (July). The alcohol-related risk from Friday to Sunday was 27.3% in women and 20.3% in men. The additional risk related to alcohol consumption in July was 16.1% in women and 5.3% in men. Conclusions: We found an excess of head traumas during weekends and the primary vacation month, and this excess was associated with heavy episodic drinking. Active measures are needed to prevent head traumas caused by this type of behaviour. INTRODUCTION Brain injury is the leading cause of death in trauma patients, and it is also the most common cause of permanent disability in young adults. Every year about subjects in Finland sustain traumatic brain injury, almost half of them are young adults (Alaranta et al., 2002). The prevalence of traumatic brain injury in the population amounts to 2%. Alcohol drinking is a significant modifiable risk factor for traumatic brain injury. Alcohol drinking has been found to be related to 40% of all deaths due to intentional (suicides and homicides) and unintentional (motor vehicle injuries, etc.) injuries in Finland (Mäkelä, 1998). In the United States, alcohol drinking may have caused 29% and 17% of all unintentional and intentional injuries leading to death, respectively (Brust, 2004). Many studies have shown a significant overrepresentation of subjects who have been drinking alcohol prior to their admission into an emergency room among trauma patients compared to non-trauma patients (Cherpitel, 1993; Cherpitel et al., 2003; Borges et al., 2006). We do not know the risk of acute alcohol drinking for head trauma. It was recently reported that the social, health and economic costs of acute alcohol-related problems may even exceed those due to chronic drinking (Chikritzhs et al., 2001). There are numerous reports indicating that chronic alcohol abuse is associated with different types of trauma, but the role of acute alcohol drinking has been poorly investigated. Accordingly, it is very important to know the exact role of acute alcohol drinking in relation to head injuries. More attention should be paid to *Author to whom correspondence should be addressed at: Department of Neurology, Oulu University Hospital, FIN OYS, Oulu, Finland; jpuljula@paju.oulu.fi heavy episodic drinking, in particular, because the risks of alcohol are not restricted to regular drinking (Savola et al., 2005). We collected data from all head trauma patients admitted into a city hospital during 1 year. We hypothesized that the number of head traumas would increase during weekends and during the most popular vacation month (July) because of the acutely increased alcohol consumption and other leisure time activities. We wanted to see whether drinking of alcohol or other leisure time activities during weekends increase the number of head traumas. We were also interested in the associations between age, gender and the severity and external causes of head trauma. We compared the temporal pattern of head trauma admissions to our hospital and the available surveys of alcohol consumption in Finland. METHODS The study includes all head trauma patients (N = 832) admitted into the Oulu University Hospital emergency department during 1 year (1999). We included all kinds of head trauma, ranging from small wounds to severe brain injuries. The study was approved by the ethical committee of the Faculty of Medicine of the University of Oulu. Oulu University Hospital serves the city of Oulu and a large rural area in northern Finland. The hospital admits patients from a defined region, and there is no selection of patients on racial or economic grounds. It is the only hospital with modern neuroimaging facilities and neurological/neurosurgical services in northern Ostrobothnia, an area with a population of Accordingly, all acute head trauma patients suspected to have brain injury should be admitted into this hospital. The Author Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved

2 DRINKING INCREASES THE OCCURRENCE OF HEAD TRAUMA 475 Information on age, sex, diagnoses, day of the week when the trauma occurred, month of the year when the trauma occurred, etc. were collected from the hospital records using a structured checklist developed for this purpose. All patients with alcohol in blood or breath as well as those who, according to the emergency department records, had been found by a nurse or a physician to be under the influence of alcohol were classified as having alcohol-related trauma. Breath or blood samples were obtained from 189/832 (22.7%) patients, and additional 113/832 (13.6%) patients were judged by professional emergency care providers to be intoxicated. The criteria were based on smell of alcohol in breath combined with signs suggesting alcoholic intoxication such as unsteady gait, slurred speech or aggressive behaviour. Informed consent to obtain breath or blood alcohol is not required in our hospital. Samples are usually taken at least from all head trauma subjects with impaired consciousness. If there was no precise determination of the patient being under the influence of alcohol by the care providers or measured alcohol concentration in the hospital data, the patient was classified as sober. The 113 non-tested alcohol-related cases were randomly distributed and showed the same distribution by weekday and month as the 189 tested cases. One hundred and forty-two (17.1%) patients were admitted >6 h after the trauma, and 39 of them were verified or judged to be intoxicated. Head traumas were classified according to the EFNS guidelines (Vos et al., 2002). Moderate-to-severe traumatic brain injury (TBI) included brain contusions and traumatic intracranial haematomas, while mild TBI included the categories 1 to 4 of mild TBI (Vos et al., 2002). The third group was wound/laceration in the head or facial bone/skull fracture without brain injury (category 0 according to the EFNS guideline). Of those having mild TBI as their final diagnosis, 12 also had a skull, facial bone or cervical vertebral fracture. Table 1. Characteristics of head injury patients by gender First, we compared the occurrence of head injuries by the day of the week between the alcohol-related cases and the others, also taking into account gender. Then, we compared the weekly variation of head injuries with the weekly rhythm of alcohol consumption in Finland. The distribution of drinking occasions during a typical autumn week and the amounts of alcohol consumed per day (= on one occasion) were elicited from a sample of Finnish people aged years randomly chosen from the population register (Metso et al., 2002). Finally, we looked at the seasonal distribution of head injuries in order to see whether there was a peak in July, which is the month when most Finns take their annual leave. Categorical variables were compared by means of Fisher s exact 2-tailed test or Pearson s χ 2 test. Continuous variables between the groups were compared using Student s t-test. Confidence intervals (CIs) for percentages and relative risk ratios were also calculated. Analyses were performed using the SPSS (version 10.0 to 13.0) for Windows and Medstat software, version 2.2. We hypothesized that, if the occurrence of head trauma is unrelated to the day of the week, head traumas would be evenly distributed throughout the week. The observed frequencies of head traumas in alcohol-related and sober subjects according to the day of the week were compared. The risk related to alcohol was obtained by calculating the difference in risk between the alcohol-related and sober subjects: ARR (alcohol related risk) = Risk use of alcohol Risk sober. RESULTS Table 1 shows the characteristics of the patients by gender. Head traumas were most common in young adults and working-age people. Women had more often a diagnosis of mild TBI than men, showing a relative risk ratio (RR) of Characteristic Men (N = 567) Women (N = 265) Total (N = 832) P value Mean age, y (SD) 37(20) 42(27) 39(23) a Age groups, N (%) 14 years 68 (12) 54 (21) 122 (15) b years 202 (36) 64 (24) 266 (32) b years 186 (33) 59 (22) 245 (29) b years 83 (14) 42 (16) 125 (15) NS 75 years 28 (5) 46 (17) 74 (9) <0.001 b Severity of head trauma No brain injury 318 (56) 106 (40) 424 (51) <0.001 b Mild TBI 172 (30) 125 (47) 297 (36) <0.001 b Moderate-to-severe TBI 77 (14) 34 (13) 111 (13) NS External cause of injury Fall 177 (31) 123 (46) 300 (36) <0.001 b Traffic 122 (21) 57 (22) 179 (22) NS Intentional 111 (20) 32 (12) 143 (17) b Sport 39 (7) 711 (4) 50 (6) NS Other 118 (21) 42 (16) 160 (19) NS P -values are shown for differences between men and women. NS, not significant. a Student s t test. b χ 2 test.

3 476 J. PULJULA et al (95% CI 1.30 to 1.86), whereas men had more often a diagnosis of wound/laceration of the head than women (RR 1.40, 95% CI 1.19 to 1.65). Moderate-to-severe TBIs were equally frequent in men and women. The severity of head trauma did not significantly correlate with the measured alcohol concentration. However, subjects who were under the influence of alcohol had less frequently, moderate-to-severe TBI than sober subjects (7.3% vs 16.8%, P<0.001). Patients who appeared to be clearly drunk were probably more likely to have been tested for blood or breath alcohol because rather high blood and breath alcohol levels (mean 2.23, SD 0.83 per mille) were recorded. Only 5.3% of those tested had less alcohol than 1.00 per mille. The external causes of trauma also showed some heterogeneity (Table 1). Falls were more frequent in women (RR 1.49, 95% CI 1.24 to 1.78), whereas men had more often sport-related and intentional traumas (RR 1.62, 95% CI 1.13 to 2.34 for intentional traumas). Traffic and other causes of trauma did not show gender differences. Table 2 shows the characteristics of alcohol-related head traumas by gender. Alcohol-related intentional traumas in those aged from 15 to 74 years accounted for 74.1% of all intentional traumas (106/143). Correspondingly, 43.6% of all fall traumas (131/300) and 22.3% (40/179) of traffic traumas were alcohol-related in this age group. No significant gender difference was observed. The number of sober head trauma patients remained rather constant throughout the week. The occurrence of head traumas according to the weekday (Fig. 1) was evenly distributed among the patients who were sober on admission. By contrast, alcohol-related traumas peaked on Saturdays and Sundays, and alcohol drinking seemed to increase the overall incidence of head traumas during weekends. Assuming that the traumas from Friday through Sunday should have accounted for only 3/7 of the total, we found an 11.5% (95% CI 6.77 to 16.31) increase of head traumas during weekends. The figures for alcohol-related and nonrelated cases were 25.2% (95% CI 17.5 to 32.8) and 4.0% (95% CI 2.03 to 9.96), respectively. This yields an alcoholrelated excess risk of 21.1% (95% CI 14.4 to 27.9). The Women Sun Sat Fri Thurs Wed Tues Table 2. Proportion of alcohol-related cases by age, gender, and external cause a Characteristic Men Women Total Alcohol-related cases by age, N (%) years Fall 29 (12) 10 (17) 39 (14) Traffic 14 (6) 3 (5) 17 (6) Intentional 53 (22) 9 (16) 62 (21) Other 4 (2) 0 4 (1) years Fall 50 (21) 13 (24) 63 (21) Traffic 13 (5) 6 (11) 19 (6) Intentional 32 (13) 8 (15) 40 (14) Other 7 (3) 2 (4) 9 (3) years Fall 27 (11) 2 (4) 29 (10) Traffic 4 (2) 0 4 (1) Intentional 3 (1) 1 (2) 4 (1) Other 6 (2) 1 (2) 7 (2) a Patients 14 years (1 alcohol-related case) and 75 years (4 alcoholrelated cases) were excluded. excess risk related to alcohol was 10.3% (95% CI 1.4 to 19.2) on Fridays, 23.9% (95% CI 15.4 to 32.4) on Saturdays, and 21.9% (95% CI 13.2 to 30.5) on Sundays. The excess risk related to alcohol from Friday through Sunday was 27.3% (95% CI 14.2 to 40.4) in women and 20.3% (95% CI 12.3 to 28.3) in men. Figure 2 shows the percentage of patients with alcoholrelated head traumas admitted into our hospital in relation to the drinking pattern of the Finnish general population by weekday. The curves indicate a close relationship between head traumas and alcohol consumption. Finally, the occurrence of head traumas per month of the year revealed an even distribution for sober subjects, whereas we observed more (P <0.05) alcohol-relatedcasesinjulyandfewer (P < 0.05) in February compared to the other months (Fig. 3). In Finland, most people have their annual leave in July, and they spend it mainly in leisure time activities, including sports, Men Mon % % Fig. 1. Percentage distribution of patients by gender and weekday. Stippled area = alcohol-related cases.

4 DRINKING INCREASES THE OCCURRENCE OF HEAD TRAUMA 477 percent, % drinking occasions alcohol-related cases 0 Tues Wed Thurs Fri Sat Sun Mon Fig. 2. Percentage distribution of alcohol-related head trauma cases and drinking occasions (general population) in Finland by weekday. percent, % Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Fig. 3. Percentage distribution of occurrence of head traumas in different months. Stippled area = alcohol-related cases. travelling and also alcohol drinking. The excess risk caused by alcohol was 7.9% (95% CI 3.3 to 12.5) in July for both genders, 16.1% (95% CI 4.8 to 27.5) for women and 5.3% (95% CI 0.1 to 10.6) for men. DISCUSSION We observed a marked increase in the admission of head trauma patients during weekends. This seemed to suggest that alcohol consumption increased the incidence of head traumas. The overall increase in head traumas related to alcohol drinking was 21.1%. The weekday distribution of sober head trauma patients was fairly even. A very modest 4.0% increase was observed from Friday to Sunday, whereas the corresponding increase among head trauma patients under the influence of alcohol was 25.2%. Our study is the first to show how much alcohol drinking really contributes to the occurrence of head traumas during weekends. Many previous studies have already shown a weekend accumulation of alcohol-related traumas (Peppiatt et al., 1978; Klauber et al., 1981; Moller-Madsen et al., 1986; Smith et al., 1989; Oikarinen et al., 1992; Schepens et al., 1998; Luke et al., 2002; O Sullivan and O Conor, 2003), but none have reported numerically the alcohol-related risk of head traumas during weekends. Our findings reflect the situation in Finland, where heavy episodic drinking is the prevailing drinking pattern (Simpura, 1985a; Simpura and Karlsson, 2001; Metso et al., 2002), and should perhaps not be generalized to other countries. However, heavy episodic drinking is also the prevailing drinking pattern in the other Nordic countries and in the USA and UK (Bråthen et al., 2000; Forsberg et al., 2002; Naimi et al., 2003; Jefferis et al., 2005), and alcohol consumption during weekends has recently been observed to increase in several other European countries (Sieri et al., 2002). The weekly variation of head traumas seemed to follow the weekly pattern of alcohol consumption, except on Sundays. Alcohol-related traumas, but not drinking occasions, were frequent on Sundays. This discrepancy is explained by the heavy drinking on Saturdays and particularly on Saturday evenings (Simpura, 1985a). As a result, intoxication continues until the next day, which is reflected as a higher number of alcohol-related traumas, although drinking occasions are not so frequent on Sundays. We did not observe any significant increase of head traumas during the weekends in sober subjects. This was somewhat surprising, since people move and engage in sports much more during weekends compared to weekdays. Traffic is also heavier, particularly on Fridays and Sundays, when people travel from cities to the countryside and back, and both amateur and professional sporting activities mostly take place on weekends. However, these activities did not seem to increase the number of head traumas in sober subjects. An early survey made in Finland showed alcohol to be a powerful contributor to leisure time injuries. The alcohol involvement rate was 38% in traffic and 45% in other free time injuries (Honkanen and Visuri, 1976). Seasonal fluctuation was also evident in the head traumas of intoxicated patients but not in those of sober subjects. Alcohol-related head traumas were more frequent than expected in July, which is the most popular vacation month in Finland. Also, the total amount of alcohol sold in Finland is high in July. Accordingly, both weekly and seasonal variations in head trauma occurrence seem to follow the pattern of alcohol consumption. The additional risk caused by alcohol was higher in women than in men both during weekends and in July. The reason is unclear. Drinking patterns may be different between women and men. Women could drink less frequently than men and therefore be more sensitive to the effects of alcohol (McLeod et al., 1999). The study included all trauma patients admitted into a city hospital during 1 year. Because the hospital is the only trauma centre in the whole region, our observations probably reflect reliably the temporal associations of alcohol consumption and head traumas. The district hospital serves a rural area where alcohol consumption is below the mean for the whole country (Hein et al., 2000). Blood or breath alcohol was measured from only two thirds of the patients judged to be intoxicated by the hospital staff. This, as well as the lack of data on drug use are limitations of the study. However, because the nontested alcohol-related patients were similarly distributed by season and the day of the week and showed similar results as those who were tested, bias is unlikely.

5 478 J. PULJULA et al. We may not have identified all subjects who were under the influence of alcohol. Alcohol-related cases may have been missed, particularly, among those who were admitted later than 6 hours after the index injury. However, we believe that not many cases were missed. A systematic search with blood or breath alcohol measurements was performed at our hospital at a later time (Savola et al., 2004). Of all emergency room trauma patients aged years, including all types of trauma, 43% were alcohol-positive. We found 51% of our head trauma patients aged years to be alcohol-positive. The main message of our paper is the huge risk of head traumas caused by drinking alcohol as a leisure time activity. The role of heavy episodic drinking as a cause of head traumas has been poorly investigated. Alcohol is a powerful risk factor for head traumas, but it is also the most important preventable risk factor. Head traumas are most numerous on weekends (Carmody et al., 2002), andasshownbyourstudy, this seems to be due to alcohol drinking. In this study, many traumas occurring during weekends and holidays were alcohol-related. Drinking for intoxication is a dangerous drinking pattern: the higher the blood alcohol concentration, the greater is the risk for head injuries (Savola et al., 2005). Particularly, adolescents and young adults are at risk (Elder et al., 2004; Turner and Shu, 2004). Our observations as well as those of others indicate that alcohol drinking as a leisure time activity at socially appropriate times causes a large number of different traumatic injuries. Other leisure time activities, which were not associated with alcohol drinking, did not seem to increase the incidence of head traumas during weekends. Drinking that is separate from work and associated with leisure time (Simpura, 1985b) carries a significantly increased risk. 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