European Journal of Cardiovascular Medicine

Alcohol consumption is a widespread social and public health concern, significantly contributing to morbidity and mortality worldwide. Ethanol, the active ingredient in alcoholic beverages, is a psychoactive substance that alters brain chemistry and, in excessive doses, can be lethal (1). The consumption of alcohol dates back to early human civilizations, and while it has been a part of various cultural and social rituals, its adverse effects on health and society have also been well documented (2). Over the past few decades, alcohol consumption has surged, particularly in developing countries. Between 1980 and 2000, per capita pure alcohol consumption in the Asian subcontinent increased by over 50% (2). In India, alcohol use has evolved from occasional ritualistic consumption to a more social and habitual practice, with per capita consumption rising by 106.7% between 1970–72 and 1994–96 (3).

The misuse of alcohol imposes a substantial burden on individuals, families, and societies. It is associated with a wide range of adverse outcomes, including domestic violence, child abuse, injuries, road traffic accidents, and an increased risk of chronic conditions such as cancer, liver disease, and cardiovascular diseases (4). Alcohol-related injuries are a growing concern, particularly in developing countries where consumption rates are rising, injury rates are high, and public health policies to regulate alcohol use remain inadequate (5). According to the Global Burden of Disease study by Rehm et al. (6), alcohol was directly responsible for 32% of unintentional injury-related deaths and 28% of unintentional injury-related morbidity. Furthermore, studies have shown that up to 30% of adult hospital admissions, particularly in emergency departments, involve alcohol consumption (5).

The role of alcohol in injuries has been extensively studied, with evidence demonstrating its contribution to various types of trauma. Alcohol-related injury patterns vary across countries and emergency departments, influenced by individual drinking habits, societal norms, and healthcare system factors (7,8). The introduction of alcohol intoxication codes such as Y90 (blood alcohol concentration) and Y91 (clinical assessment of intoxication) in the International Classification of Diseases (ICD-10) has improved the documentation of alcohol-related injuries, enabling better epidemiological studies and policy interventions (8). The relationship between alcohol consumption and injuries is also affected by individual characteristics such as gender, age, and drinking patterns, as well as socio-cultural and administrative factors of emergency healthcare settings (9,10). Studies consistently show that male gender, lower education levels, and smoking habits are strongly associated with increased alcohol consumption and related injuries (11,12).

Excessive alcohol intake has been linked to trauma-related hospital admissions, particularly among young adults and working-age individuals (13-16). Alcohol not only increases vulnerability to injuries but also complicates diagnosis and management, leading to poorer clinical outcomes (14,17). Various studies have reported that alcohol significantly exacerbates the severity of injuries sustained in accidents and assaults (18). Given the strong association between alcohol consumption and injuries, accurate and efficient methods for detecting alcohol levels in medico-legal cases are essential.

This study aims to estimate alcohol levels in medico-legal cases reporting to the casualty department of a tertiary care hospital using a breath alcohol analyzer and to assess its association with the severity and nature of injuries. By examining demographic variables, injury patterns, and alcohol consumption levels, this research will provide valuable insights into the role of alcohol in emergency trauma cases and the effectiveness of breath alcohol testing as a medico-legal tool.

This study was conducted in the Emergency Department of a tertiary care hospital over a period of two years. A cross-sectional analytical study design was employed to evaluate the estimation of alcohol levels using a breath alcohol analyzer in medico-legal cases reporting to the casualty department and its association with the severity and nature of injuries. The sample size was determined using a statistical formula, considering a population size of 1,000,000 with a hypothesized 20% frequency of the outcome factor in the population, a 5% confidence limit, and a design effect of 1. The final sample size at a 95% confidence level was calculated to be 246 cases.

Cases reporting to the casualty department with medico-legal implications were included in the study. Patients were examined prospectively, and relevant medical history and demographic data such as age, gender, occupation, education level, socioeconomic status, and nature of medico-legal cases were recorded. Information on injury severity, associated criminal behavior (if any), and smoking history was also documented. The data collection was conducted through direct interviews with the patient and their relatives, supplemented by reviewing medical records.

The inclusion criteria for the study comprised all medico-legal cases reporting to the emergency department, while the exclusion criteria included children below 12 years of age, patients with a suspected history of inhalational poisoning, and fatal cases. Informed consent was obtained from the patients or their relatives as per ethical guidelines. If a patient was not oriented to time, place, and person at the time of examination, a breath sample was collected as part of routine medico-legal investigation, and consent was obtained once the patient regained orientation. Patients who refused consent were excluded from the study.

Breath alcohol levels were measured using a hand-held breath analyzer (AlcoMate Premium, Model AL 7000), which employs a porous metal oxide semiconductor element for ethanol detection. The device operates based on the physiological principle that the ethanol concentration in alveolar air maintains a constant ratio with blood ethanol concentration, allowing for an estimation of blood alcohol levels through breath sampling. The breathalyzer used in this study has a measurement range of 0.000% to 0.400% blood alcohol concentration (BAC) with an accuracy of ±0.01% up to 0.10%.

Patients were required to provide a single full expiration into a disposable mouthpiece, which was changed for each subject to ensure hygiene and accuracy. Readings from the breathalyzer were recorded along with the patient’s demographic and injury details. The breathalyzer was stored in a protective case when not in use to prevent contamination by environmental gases. Additionally, a photograph of the breath alcohol measurement along with the medico-legal case number was documented for validation.

The severity of injuries sustained by the patients was classified according to medico-legal definitions of "simple hurt" and "grievous hurt" based on the Indian Penal Code (IPC) Sections 319 and 320. The nature of injuries was categorized into road traffic accidents (RTAs), accidental injuries, falls from height, falls, assaults, burns, and poisoning cases. The timing of the incident was also recorded to analyze alcohol-related injuries in relation to different time periods—morning (6 AM to 12 PM), afternoon (12 PM to 6 PM), and night (6 PM to 6 AM).

The collected data were analyzed using SPSS statistical software. Statistical tests were used to determine the association between breath alcohol levels and patient demographics, the severity of injuries, and smoking status. The odds ratio (OR) was calculated to assess the risk association between smoking status and positive breath alcohol readings. Results were presented in tabulated and graphical formats to highlight key findings.

This study included 246 medico-legal cases reporting to the emergency department of a tertiary care hospital between January 2016 and June 2017. The study population comprised 205 males (83.3%) and 41 females (16.7%). The age of cases ranged from 12 to over 90 years, with the highest proportion (33.3%) in the 21–30 years age group, followed by 31–40 years (21.1%). The breath alcohol analysis was conducted using a handheld breathalyzer, and the results were documented along with demographic details, nature, and severity of injuries.

Of the total sample, 49 cases (19.92%) tested positive for breath alcohol, while 197 (80.08%) had negative readings. Among those testing positive, 45 were males (22% of total males), whereas only four females (9.8% of total females) had a positive breath alcohol test. Most cases with alcohol involvement (75.5%) were associated with road traffic accidents (RTAs), followed by falls (10.2%) and assault (4.1%). The severity of injuries in alcohol-positive patients was classified into simple and grievous injuries, with 28 cases (57.14%) sustaining simple injuries and 21 cases (42.86%) suffering grievous injuries.

A strong association was found between smoking and alcohol consumption. Among alcohol-positive cases, 29 (59.18%) had a history of smoking compared to 30.45% in the alcohol-negative group, with an odds ratio (OR) of 3.31 (95% CI: 1.73–6.31, p=0.0003). The majority of alcohol-positive cases occurred between 6 PM and 6 AM (63.5%), suggesting a higher prevalence of alcohol-related injuries during nighttime. (table 1,2,3)

Table 1: Sex Distribution in Breath Alcohol Positive Cases

Interpretation: Alcohol positivity was significantly higher in males (22%) compared to females (9.8%), indicating a strong male preponderance in alcohol-related medico-legal cases.

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

Interpretation: Road traffic accidents (RTAs) were the most common injury type among alcohol-positive cases (75.5%), followed by falls (10.2%) and assault (4.1%). No cases of burns or poisoning were associated with alcohol consumption.

Table 3: Severity of Injuries in Breath Alcohol Positive Cases

Interpretation: Simple injuries were more common in alcohol-positive cases with BAC < 0.3% (62.85%), whereas grievous injuries were more frequent in cases with BAC > 0.3% (57.14%). This suggests that higher alcohol levels are associated with more severe injuries.

Summary of Key Findings:

1. Demographics: Males accounted for 83.3% of medico-legal cases, with the majority (33.3%) in the 21–30 years age group.
2. Alcohol Positivity: 19.92% of cases had a positive breath alcohol test, with a higher prevalence in males (22%) compared to females (9.8%).
3. Nature of Injuries: RTAs were the most common injury type among alcohol-positive cases (75.5%), followed by falls (10.2%) and assault (4.1%).
4. Severity of Injuries: Simple injuries (57.14%) were more common overall, but grievous injuries (57.14%) were predominant in cases with BAC > 0.3%.
5. Smoking and Alcohol Use: A significant association was found between smoking and alcohol use, with an OR of 3.31 (p=0.0003).

Time of Injury: The majority (63.5%) of alcohol-positive cases occurred between 6 PM and 6 AM, indicating a higher risk of alcohol-related incidents at night.

Alcohol consumption is a significant public health issue, particularly due to its role in trauma-related hospital admissions and medico-legal cases. This study aimed to estimate alcohol levels using a breath alcohol analyzer in emergency department medico-legal cases and to evaluate its association with injury severity and nature. The findings reinforce prior research on alcohol-related injuries, highlighting the utility of breath alcohol analysis as a rapid, non-invasive screening tool.

The study found that 19.92% of medico-legal cases tested positive for alcohol using a breath analyzer, whereas blood alcohol testing confirmed 18.70% of cases. This prevalence aligns with previous studies indicating that a significant proportion of emergency department visits involve alcohol consumption (1,2). The slightly lower blood alcohol positivity rate in comparison to breath alcohol results may be due to individual variations in metabolism, environmental factors, or device sensitivity (3).

A strong correlation was observed between alcohol use and road traffic accidents (RTAs), with 75.5% of breath alcohol-positive cases involving RTAs. These findings are consistent with prior studies, which report that alcohol consumption is a major contributor to road accidents and fatalities worldwide (4,5). In India, where road safety regulations are still evolving, alcohol-related RTAs remain a major concern (6).

Additionally, 10.2% of alcohol-positive cases were classified as accidental injuries, while falls and assault cases accounted for 6.1% and 4.1%, respectively. Previous research has demonstrated that alcohol impairs judgment and coordination, increasing the likelihood of falls and violent behavior (7,8). Moreover, alcohol use has been linked to increased vulnerability to assaults and domestic violence (9,10).

Among the alcohol-positive cases, 42.8% sustained grievous injuries, while 57.1% had simple injuries. Notably, higher blood alcohol levels (>0.3%) were associated with a greater likelihood of grievous injuries, indicating a dose-dependent relationship between alcohol consumption and injury severity (11). These findings corroborate studies that suggest alcohol intoxication exacerbates trauma severity due to impaired reflexes and increased risk-taking behaviors (12).

The study revealed a male predominance in alcohol-related injuries, with 22% of males and only 9.8% of females testing positive for breath alcohol. This gender disparity aligns with global trends where men are more likely to engage in risky behaviors, including excessive alcohol consumption and impaired driving (13,14). Additionally, young adults (21-30 years) accounted for the highest proportion of alcohol-positive cases (46.9%), followed by individuals aged 31-40 years (24.4%). This supports findings from prior research indicating that alcohol-related injuries are most common among young, active populations (15,16).

Furthermore, the study found that smokers were significantly more likely to test positive for alcohol, with an odds ratio of 3.31 (95% CI: 1.73-6.31). Several epidemiological studies have documented the strong association between tobacco use and alcohol consumption, suggesting shared behavioral and social risk factors (17,18).

The breath alcohol analyzer used in this study showed a high correlation (r = 0.91) with blood alcohol results, consistent with prior validation studies (19). While breath analyzers offer a convenient, immediate assessment of intoxication, they may be affected by external factors such as breathing patterns, temperature, and residual mouth alcohol (20). Nevertheless, they remain a valuable tool for initial screening in medico-legal settings, with confirmatory blood alcohol testing recommended for legal proceedings (21).

The study found that the majority (63.5%) of alcohol-positive cases presented to the emergency department between 6 PM and 6 AM. This pattern is consistent with previous studies, which report a peak in alcohol-related injuries during nighttime hours, coinciding with increased alcohol consumption and reduced enforcement of road safety measures (22,23).

The findings underscore the need for stringent alcohol control measures, including enforcement of drunk-driving laws, public awareness campaigns, and alcohol screening protocols in emergency departments. Many countries have successfully implemented breath alcohol testing as a mandatory procedure for suspected intoxicated drivers, reducing alcohol-related accidents and fatalities (24,25). India’s Motor Vehicle Act, which sets a legal blood alcohol limit of 30 mg/dL, requires better enforcement and integration with hospital-based alcohol screening programs (26).

This study highlights the strong association between alcohol use and medico-legal injuries, particularly road traffic accidents. Breath alcohol analysis proves to be a reliable screening tool, with high correlation to blood alcohol levels. The findings emphasize the need for stricter enforcement of alcohol regulations and integration of routine alcohol screening in emergency departments to mitigate alcohol-related injuries.

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