European Journal of Cardiovascular Medicine

Ethanol, commonly referred to as beverage alcohol, is a psychoactive substance that alters brain function and, in excessive doses, can be fatal (1). The consumption of alcoholic beverages has been an integral part of human civilization since recorded history. However, its detrimental effects on social and health outcomes have long been acknowledged (2). With increasing per capita consumption, alcohol has emerged as one of the most widely used addictive substances worldwide. The most rapid growth in alcohol consumption has been observed in developing nations, particularly in the Asian subcontinent, where the per capita pure alcohol consumption increased by over 50% between 1980 and 2000 (3).

Although recorded alcohol consumption per capita has declined in many developed nations since 1980, it has continued to rise in developing countries, particularly in India. Between 1970–72 and 1994–96, alcohol consumption among individuals aged over 15 years in India increased by 106.7% (3). This shift is attributed to a change in drinking patterns, from occasional and ritualistic use to widespread social consumption (4). The increasing burden of alcohol-related problems imposes significant personal, social, and economic consequences. While moderate drinking may not be harmful, excessive alcohol consumption has been associated with various social issues such as domestic violence, child abuse, and criminal activities, including assault and robbery. Additionally, it is a known risk factor for several medical conditions, including liver diseases, cardiovascular disorders, and certain cancers (5,6).

The relationship between alcohol and injuries has been widely documented. In many developing countries, where alcohol consumption is rising and injury rates remain alarmingly high, the lack of effective public health interventions exacerbates the problem (7). According to a study by Rehm et al. (8), alcohol was responsible for 32% of unintentional injury-related mortality and 28% of injury-related morbidity worldwide. Moreover, alcohol is implicated in up to 30% of adult hospital admissions, particularly in emergency departments (9).

Alcohol consumption has been definitively established as a contributing factor in injuries (10). Improvements in injury surveillance and documentation have led to the inclusion of alcohol intoxication codes (Y90 for BAC levels and Y91 for clinical assessment of intoxication) in the International Classification of Diseases (ICD-10), facilitating better monitoring and comparison of alcohol-related morbidity and mortality across populations (11). The burden of alcohol-related injuries varies across emergency departments and is influenced by individual drinking behaviors, as well as broader socio-cultural and environmental factors (12).

Given the increasing burden of alcohol-related injuries and the advantages of breath alcohol testing, this study aims to estimate alcohol levels using a breath alcohol analyzer in medico-legal cases and assess its association with the severity and nature of injuries in a tertiary care hospital setting.

Study Design and Setting

A cross-sectional analytical study was conducted in the Emergency Department of a tertiary care hospital over a period of two years (January 2016 – June 2017). The study involved medico-legal cases reporting to the casualty department, with data collection and analysis spanning the study period.

Study Population and Sample Size Calculation

The study population comprised individuals reporting to the casualty department with medico-legal cases. The sample size was determined using the following formula:

n=DEFF×N(1−p)(d2/Z1−α/22×(N−1)+p(1−p))n = \frac{{DEFF \times N(1-p)}}{{(d^2 / Z^2_{1-\alpha/2} \times (N-1) + p(1-p))}}n=(d2/Z1−α/22​×(N−1)+p(1−p))DEFF×N(1−p)​

Where:

• N = Population size (1,000,000)
• p = Hypothesized frequency of the outcome factor (20% ± 5)
• d = Confidence limits (5%)
• DEFF = Design effect for cluster surveys (1)

Using a 95% confidence level, the calculated sample size was 246 cases.

Selection Criteria

Inclusion Criteria

• All medico-legal cases reporting to the casualty department of the tertiary care hospital during the study period.
• Patients aged 12 years and above.

Exclusion Criteria

• Children below 12 years.
• Patients with a history of inhalational poisoning.
• Fatal cases where breath alcohol analysis could not be performed.

METHODOLOGY

Breath Alcohol Analysis

Alcohol estimation was performed using a hand-held breath alcohol analyzer (AlcoMate Premium, Model AL 7000). The device employs electrochemical sensor technology and measures Breath Alcohol Concentration (BrAC), which is converted to Blood Alcohol Concentration (BAC) using a standardized blood:breath ratio (BBR).

Procedure for Breath Alcohol Testing

1. Informed consent was obtained from the patient (Appendix ‘B’ & ‘C’):
• If the patient was oriented to time, place, and person, their direct consent was obtained.
• If the patient was disoriented, the breath sample was taken as part of routine medico-legal investigation, and consent was obtained once they regained orientation.
• If the patient refused, they were excluded from the study.
2. Breath Alcohol Testing Protocol:
• The patient was instructed to blow fully into a disposable mouthpiece attached to the breath analyzer.
• A new mouthpiece was used for each subject to ensure accuracy and hygiene.
• The device measured a single exhalation of breath from the patient.
• The BrAC values were recorded along with:
• Patient demographics (name, age, gender, occupation, education level, socioeconomic status)
• Time of the incident
• Nature and severity of injuries
• History of criminal behavior (if applicable)
• A photograph of the breath alcohol reading was taken alongside the Medico-Legal Case (MLC) number for documentation.
3. Storage and Maintenance of the Breath Analyzer:
• The breathalyzer was kept in a protective case when not in use to prevent sensor contamination from environmental gases.
• Regular calibration and sensor module replacement were done as per manufacturer guidelines (every 200 tests or annually).

Classification of Injuries

The injuries were categorized based on the Indian Penal Code (IPC):

• Simple injuries – Minor injuries not affecting major bodily functions.
• Grievous injuries – Severe injuries with long-term impairment or fatal risk.

The severity of injuries was recorded for each breath alcohol-positive case and correlated with BAC levels.

Data Collection and Variables

Data were collected from:

1. Patient history
2. Medico-legal reports
3. Hospital records
4. Breathalyzer readings

The following variables were recorded:

• Demographics: Age, gender, occupation, education level, socioeconomic status.
• Alcohol status: Breath alcohol positivity or negativity.
• BAC levels: Categorized as:
• <0.3% (within legal limits)
• >0.3% (above legal limits)
• Nature of medico-legal case: Road traffic accident (RTA), assault, fall, burns, poisoning, etc.
• Time of reporting: Morning (6 AM – 12 PM), Afternoon (12 PM – 6 PM), Night (6 PM – 6 AM).
• Smoking history: Smoker/non-smoker.
• Criminal behavior: If applicable.

Statistical Analysis

The data were analyzed using SPSS software (version 25.0, IBM Corp, USA). The statistical methods included:

• Descriptive statistics: Frequencies, means, and percentages.
• Chi-square test: To analyze the association between alcohol use and injury severity.
• Odds Ratio (OR): To determine the risk association of alcohol use with smoking.
• Multivariate logistic regression: To assess the independent predictors of alcohol-related injuries.

Significance level: p < 0.05 was considered statistically significant.

Demographic and Clinical Characteristics of Medico-Legal Cases

The study included 246 medico-legal cases reporting to the casualty of a tertiary care hospital between January 2016 and June 2017. Among them, 205 (83.3%) were male and 41 (16.7%) were female (Table 1). The majority of the cases were from the age group of 21–30 years (33.3%), followed by 31–40 years (21.1%).

Among the cases studied, 95.5% (235) belonged to Hinduism, while 3.7% (9) followed Islam. The largest occupational group was service-class individuals (45.9%), followed by students (23.6%) (Table 1). A significant proportion of cases (36.2%) had a history of smoking, which was found to have a strong association with alcohol use (OR = 3.31, 95% CI 1.73–6.31, p = 0.0003).

Association of Breath Alcohol Concentration with Nature and Severity of Injuries

Out of 246 medico-legal cases, 49 (19.92%) tested positive for breath alcohol using the breathalyzer, whereas 197 (80.08%) tested negative (Table 2). The highest proportion of breath alcohol-positive cases was observed among road traffic accidents (75.5%), followed by falls (6.1%) and assaults (4.1%) (Table 2).

Among the breath alcohol-positive cases, 57.14% sustained simple injuries, while 42.8% sustained grievous injuries. A higher blood alcohol concentration (BAC >0.3%) was significantly associated with grievous injuries (57.14%), whereas BAC <0.3% was more common in cases with simple injuries (62.85%) (Table 3).

Time Distribution of Alcohol-Related Injuries

The highest number of breath alcohol-positive cases (63.5%) was reported during the night hours (6 PM to 6 AM), followed by 22.4% in the afternoon (12 PM to 6 PM). The least number of cases were recorded during the morning hours (6 AM to 12 PM, 14.3%) (Table 3).

Table 1: Demographic and Clinical Characteristics of Medico-Legal Cases

(In-text citation: Table 1 presents the demographic distribution of medico-legal cases, highlighting a higher proportion of males and young adults in the sample.)

Table 2: Association of Breath Alcohol Positivity with Nature and Severity of Injuries

(In-text citation: As shown in Table 2, road traffic accidents constituted the highest proportion of alcohol-positive cases, with a significant correlation between high BAC levels and grievous injuries.)

Table 3: Time Distribution of Alcohol-Related Injuries

(In-text citation: Table 3 indicates that the highest number of alcohol-related injuries occurred during nighttime hours, reinforcing existing literature on alcohol consumption patterns and injury risks.)

Key Findings Summary

1. Male dominance in alcohol-related medico-legal cases (83.3%), with the highest prevalence in young adults aged 21–30 years (33.3%) (Table 1).
2. Road traffic accidents (75.5%) were the most common injury among alcohol-positive cases, followed by falls (6.1%) and assault (4.1%) (Table 2).
3. BAC levels above 0.3% were strongly associated with grievous injuries (57.14%), whereas BAC levels below 0.3% were more frequently associated with simple injuries (62.85%) (Table 2).

Alcohol-related injuries peaked during nighttime hours (6 PM – 6 AM, 63.5%), consistent with patterns of alcohol consumption and risk behavior (Table 3).

The relationship between blood alcohol concentration (BAC) and clinical outcomes in trauma patients has been extensively studied, revealing significant associations with hospital and intensive care unit (ICU) admissions. A retrospective analysis of 4,699 adult trauma patients demonstrated that a positive BAC correlates with increased odds of hospital admission (odds ratio [OR] 1.5) and ICU admission (OR 1.3), even after adjusting for injury severity score (ISS) (1).

Self-reported alcohol use disorders (AUDs), assessed via the Alcohol Use Disorders Identification Test (AUDIT), further influence patient disposition. In cases with minor to moderate injuries (ISS 1–15), higher AUDIT scores were linked to elevated rates of hospital and ICU admissions. Specifically, ICU admission rates increased progressively with AUDIT scores, from 29.3% in low-risk individuals to 42.0% in those likely alcohol-dependent (P < 0.01) (2).

The presence of alcohol at the time of injury may complicate clinical assessments, as intoxication can mask or mimic symptoms of severe conditions, prompting more cautious management and a higher likelihood of admission for observation (3). Additionally, chronic alcohol use is associated with comorbidities such as liver disease and coagulopathies, which can exacerbate injury outcomes and necessitate intensive monitoring (4).

Contrastingly, some studies suggest that higher BAC levels might be associated with less severe injuries. For instance, research indicates that elevated BAC may correlate with reduced injury severity without significantly impacting mortality or length of hospital stay (5). However, these findings are not universally observed, and the protective effect of alcohol remains controversial (6).

In summary, both acute intoxication and chronic alcohol use are significant factors influencing the clinical management and outcomes of trauma patients. The evidence underscores the importance of routine alcohol screening in trauma settings to inform treatment strategies and improve patient care (7).

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