Very High Blood Alcohol Concentration and Fatal Hemorrhage in Acute Subdural Hematoma

Alcohol intoxication is often present concurrently with traumatic brain injury (TBI). Recent studies have looked at the effect alcohol has on TBI and on coagulopathy. Typically, cases reviewed in the current literature report only on the effects of modest alcohol intoxication.

A 43-year-old male presented to the trauma center after a fall, with rapidly deteriorating mental status. Computed tomography of the head demonstrated a 1.9-cm acute subdural hematoma. Of note, classical coagulation studies were normal, but blood ethanol level was high, 436 mg/dL. Postoperatively, the patient suffered an intracerebral hemorrhage requiring emergent return to the operating room, where a large volume of unclotted blood and clinical coagulopathy was encountered.

We review the literature pertaining to coagulopathy in the context of TBI and ethanol intoxication. This case is a cautionary tale of a phenomenon of unmeasured coagulopathy in the face of severe alcohol intoxication manifested by intraoperative coagulopathy with new postoperative hemorrhage. Although routine preoperative testing indicated normal clotting function, a thromboelastogram demonstrated delayed clot formation. The protective effects of alcohol are well described; however, we believe that there is a population of patients with severe acute intoxication who have coagulopathy that may go undetected by routine preoperative screening.

Caution should be exercised when taking care of patients with very high levels of alcohol because physiologic derangements may be unpredictable. Additional research is needed for patients with very high levels of alcohol intoxication and the effect it may have on coagulation.