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Editor,—Carrigan et al through the use of toxicological screening suggests a significant prevalence of drug and alcohol use in the British accident and emergency (A&E) trauma population.1 Our own audit of 351 patients attending St Thomas's Hospital A&E in London, examined the part alcohol plays in the use of radiological investigation for traumatic injuries, found a similar prevalence. However, a simple questionnaire type assessment carried out by the A&E doctor seems to be as effective at indicating alcohol intoxication as blood alcohol concentrations, thus avoiding any ethical and financial issues in obtaining blood specimens. Validation for such screening assessments already exists2, 3 and as such we advocate the routine use of such questionnaires in the accident department. Screening for blood alcohol concentrations in A&E as a means of identifying at risk drinkers has no role.
The author's reply
In the discussion of our paper, we highlighted the limitations of toxicological screening in trauma, and acknowledged the role of questionnaires in confirming alcohol (and other drug) misuse or dependence, or both.
Hunt and Rust suggest that questionnaires are as effective as blood alcohol estimation in detecting alcohol intoxication, and blood alcohol estimation has no role in an “accident” department. Questionnaires, in fact, have been shown to be more sensitive and some more specific than blood alcohol estimations for diagnosing alcohol dependence and harmful drinking as compared with the gold standard DSM III-R criteria.1, 2
Their referenced paper by Soderstrom indeed predicted certain attributes of presenting patients that could be used to identify alcohol excess and play a part in selective screening in trauma patients, but questionnaires were not validated as such here.3 Soderstrom actually recommends in a subsequent journal edition that blood alcohol estimation, in combination with the CAGE questionnaire, should be used when screening trauma patients.2
Also, a recent article demonstrates the efficacy of brief interventions in decreasing alcohol misuse and most importantly injury recurrence in trauma patients, using blood alcohol estimation and a short questionnaire to identify as many patients as possible for their randomised controlled trial of an applicable treatment to the emergency department.4
The opportunity for questioning may be limited by early discharge, by trauma severity, by cognitive impairment, or by non-compliance. The reliability of questionnaires while the patient is intoxicated or fearful of prosecution is also debatable.
Their other referenced paper, the Paddington Alcohol Test study,5 has been shown to be efficacious in a self selecting general emergency population with respect to decreasing alcohol misuse. I thank Hunt and Rust for referencing this paper, as it highlights the major deficiencies of questionnaires in the emergency department, that of poor utilisation by busy staff and variable acceptance by the patient. This must be tackled.
Financially, the marginal cost of a plasma ethanol screen is approximately 50 pence, and ethically, it is a standard test used to identify a cofactor in the altered mental status of a patient in many emergency departments.
In summary, neither brief questionnaires nor blood alcohol estimation are the gold standard in the detection of alcohol misuse or dependence in trauma patients in the emergency department. Rational discussion of such priorities, be it selective screening or the use of toxicological and/or questionnaire screening, needs to take place.
In an ideal department, this should detect as many trauma patients as possible, but should be implemented only if the appropriate referral and brief intervention programmes are concurrent, and these processes evaluated in a cost and outcome effective manner.
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