What is the initial workup for a patient with a history of ethanol (ETOH) abuse who was involved in a scooter accident and landed on their face?

Initial Workup for Trauma Patient with Scooter Accident and Alcohol Abuse History

A patient with a history of alcohol abuse who has landed on their face in a scooter accident requires immediate CT imaging of the head and face, regardless of their Glasgow Coma Scale (GCS) score, due to the high risk of intracranial injury and facial fractures. 1

Primary Assessment

• Assess airway, breathing, circulation, and disability (ABCD) as per standard trauma protocols 1
• Determine Glasgow Coma Scale (GCS) score - even patients with GCS 15 require neuroimaging if they have risk factors 1
• Check for signs of intoxication - alcohol intoxication is a significant risk factor for positive CT findings 1
• Evaluate for physical evidence of trauma above the clavicle - this is a strong predictor of intracranial injury 1

Neuroimaging Indications

Head CT is indicated in this patient due to multiple high-risk factors:

• History of alcohol abuse - chronic alcohol use affects metabolism and increases bleeding risk 2, 3
• Facial trauma - physical evidence of trauma above the clavicle is a predictor of intracranial injury 1
• Mechanism of injury (scooter accident) - e-scooter accidents frequently cause craniofacial injuries 4, 5

Risk Factors Requiring Head CT:

• Alcohol intoxication 1
• Physical evidence of trauma above the clavicle 1
• Headache or vomiting 1
• Age >60 years 1
• Deficits in short-term memory 1
• Seizure 1

Facial Trauma Assessment

• Maxillofacial CT is indicated due to the mechanism of injury (landing on face) 4
• E-scooter accidents commonly result in:
  • Craniofacial fractures (62.7-83% of cases) 4, 5, 6
  • Dental injuries 4
  • Soft tissue injuries 6

Laboratory Workup

• Complete blood count to assess for anemia or thrombocytopenia 1
• Basic metabolic panel to evaluate electrolyte abnormalities 1
• Coagulation studies (PT/INR, PTT) - alcohol abuse may affect coagulation 3
• Blood alcohol level - important for both medical and legal documentation 4, 5
• Liver function tests - chronic alcohol abuse may affect liver function 2, 3

Observation and Monitoring

• Even with a normal initial CT scan, patients with alcohol intoxication require extended observation 1
• Two studies noted that intoxicated patients with initially normal examinations later required craniotomy 1
• Serial neurological examinations are essential, as deterioration can occur within the first 24 hours 1

Special Considerations for Alcohol Abuse

• Patients with chronic alcohol abuse may have:
  • Coagulopathy due to liver dysfunction 3
  • Nutritional deficiencies affecting healing 3
  • Risk of alcohol withdrawal during hospitalization 2
  • Higher risk of complications from trauma 3

Common Pitfalls

• Relying solely on GCS score - patients with GCS 15 can still have significant intracranial injuries, especially when alcohol is involved 1
• Discharging intoxicated patients too early - alcohol can mask deterioration 1
• Failing to obtain facial CT - e-scooter accidents have high rates of facial fractures that may require surgical intervention 4, 6
• Overlooking the need for dental evaluation - dental injuries are common in facial trauma from e-scooter accidents 4

Follow-up Recommendations

• Neurosurgical consultation for any positive findings on head CT 1
• Maxillofacial surgery consultation for facial fractures 4
• Dental consultation for dental injuries 4
• Addiction medicine referral for alcohol abuse management 3