Advertisement

Medical needs of emergency department patients presenting with acute alcohol and drug intoxication

Published:January 01, 2021DOI:https://doi.org/10.1016/j.ajem.2020.12.079

      Abstract

      Study objective

      Some contend that patients with acute alcohol or illicit substance intoxication should be treated in outpatient detoxification centers rather than in the ED. However, these patients often have underlying acute medical needs. We sought to determine the frequency of medical interventions required by ED patients with alcohol or illicit substance intoxication.

      Methods

      This was a prospective observational study of consecutive ED patients presenting to an urban tertiary care ED with altered mental status due to alcohol or illicit substance use. We performed data collection for patients deemed to be low-risk for complications, as defined by receiving care in an intoxication observation unit. Trained staff observed and recorded all medical interventions, including medications administered, diagnostic testing, procedures performed, and airway interventions. The incidence of agitation was recorded using the Altered Mental Status Scale (AMSS, ordinal scale from −4 to +4, where +4 is most agitated). The data analysis is descriptive.

      Results

      This analysis included 2685 encounters (1645 unique patients; median age 39; 73% male) from January to May 2019. Average breath alcohol concentration was 0.20 g/dL (range 0.00–0.47). There were 89% encounters with alcohol intoxication, and in 17% encounters the patient was suspected or known to have drug intoxication (either alone or in conjunction with alcohol use). On arrival to the ED, 372 (14%) had agitation (AMSS +1 or higher) and 32 (1%) were profoundly agitated (AMSS +4). In total, 1526 (56%) received at least one intervention that could not be provided by a local detoxification or sobering facility. Of the study population, 955 (36%) received a sedating medication, 903 (34%) required physical restraints for patients or staff safety, 575 (21%) underwent imaging studies, 318 (12%) underwent laboratory testing, 367 (13%) received another intervention (IV access, EKG, splinting, wound care, etc). Additionally, 111 (4%) patients received an airway intervention (19 intubation, 23 nasal airway, 85 supplemental oxygen) and 275 (10%) required repositioning to protect the airway. There were 168 (6%) patients admitted to the hospital.

      Conclusion

      In this population of relatively low-risk ED patients with drug and alcohol intoxication, a substantial proportion of patients received medical interventions.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mokhlesi B.
        • Garimella P.S.
        • Joffe A.
        • Velho V.
        Street drug abuse leading to critical illness.
        Intensive Care Med. 2004; 30: 1526-1536
        • Klein L.R.
        • Cole J.B.
        • Driver B.E.
        • Battista C.
        • Jelinek R.
        • Martel M.L.
        Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.
        Ann Emerg Med. 2018; 71: 279-288
        • Verelst S.
        • Moonen P.-J.
        • Desruelles D.
        • Gillet J.-B.
        Emergency department visits due to alcohol intoxication: characteristics of patients and impact on the emergency room.
        Alcohol Alcohol. 2012; 47: 433-438
        • Vonghia L.
        • Leggio L.
        • Ferrulli A.
        • et al.
        Acute alcohol intoxication.
        Eur J Intern Med. 2008; 19: 561-567
        • Dischinger P.C.
        • Mitchell K.A.
        • Kufera J.A.
        • Soderstrom C.A.
        • Lowenfels A.B.
        A longitudinal study of former trauma center patients: the association between toxicology status and subsequent injury mortality.
        J Trauma. 2001; 51 ([discussion 884-886]): 877-884
        • Smith-Bernardin S.M.
        • Kennel M.
        • Yeh C.
        EMS can safely transport intoxicated patients to a sobering center as an alternate destination.
        Ann Emerg Med. 2019; https://doi.org/10.1016/j.annemergmed.2019.02.004
        • Pletcher M.J.
        • Maselli J.
        • Gonzales R.
        Uncomplicated alcohol intoxication in the emergency department: an analysis of the National Hospital Ambulatory Medical Care Survey.
        Am J Med. 2004; 117: 863-867
        • Smith-Bernardin S.
        • Carrico A.
        • Max W.
        • Chapman S.
        Utilization of a sobering Center for Acute Alcohol Intoxication.
        Acad Emerg Med. 2017; 24: 1060-1071
        • Miner J.R.
        • Gaetz A.
        • Biros M.H.
        The association of a decreased level of awareness and blood alcohol concentration with both agitation and sedation in intoxicated patients in the ED.
        Am J Emerg Med. 2007; 25: 743-748
        • Klein L.R.
        • Driver B.E.
        • Miner J.R.
        • et al.
        Intramuscular midazolam, olanzapine, ziprasidone, or haloperidol for treating acute agitation in the emergency department.
        Ann Emerg Med. 2018; 72: 374-385
        • Martel M.
        • Sterzinger A.
        • Miner J.
        • Clinton J.
        • Biros M.
        Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam.
        Acad Emerg Med. 2005; 12: 1167-1172
        • Miner J.R.
        • Klein L.R.
        • Cole J.B.
        • Driver B.E.
        • Moore J.C.
        • Ho J.D.
        The characteristics and prevalence of agitation in an Urban County emergency department.
        Ann Emerg Med. 2018; 72: 361-370
        • Heydari F.
        • Gholamian A.
        • Zamani M.
        • Majidinejad S.
        Effect of intramuscular ketamine versus haloperidol on short-term control of severe agitated patients in emergency department; a randomized clinical trial.
        Bull Emerg Trauma. 2018; 6: 292-299
        • Isbister G.K.
        • Calver L.A.
        • Page C.B.
        • Stokes B.
        • Bryant J.L.
        • Downes M.A.
        Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study.
        Ann Emerg Med. 2010; 56: 392-401.e1
        • Martel M.L.
        • Driver B.E.
        • Miner J.R.
        • Biros M.H.
        • Cole J.B.
        Randomized double-blind trial of intramuscular Droperidol, ziprasidone, and lorazepam for acute undifferentiated agitation in the emergency department.
        Acad Emerg Med. 2020; ([accepted article in press])https://doi.org/10.1111/acem.14124
        • Cole J.B.
        • Klein L.R.
        • Martel M.L.
        Parenteral antipsychotic choice and its association with emergency department length of stay for acute agitation secondary to alcohol intoxication.
        Acad Emerg Med. 2019; 26: 79-84
        • Mullins P.M.
        • Mazer-Amirshahi M.
        • Pines J.M.
        Alcohol-related visits to US emergency departments, 2001-2011.
        Alcohol Alcohol. 2017; 52: 119-125
        • Klein L.R.
        • Driver B.E.
        • Horton G.
        • Scharber S.
        • Martel M.L.
        • Cole J.B.
        Rescue sedation when treating acute agitation in the emergency department with intramuscular antipsychotics.
        J Emerg Med. 2019; 56: 484-490
        • Biros M.
        The frequency of unsuspected minor illness or injury in intoxicated patients.
        Acad Emerg Med. 1996; 3: 853-858
        • Ngo D.A.
        • Ait-Daoud N.
        • Rege S.V.
        • et al.
        Differentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university.
        Drug Alcohol Depend. 2018; 183: 89-95
        • Marshall B.
        • McGlynn E.
        • King A.
        Sobering centers, emergency medical services, and emergency departments: a review of the literature.
        Am J Emerg Med. 2020; https://doi.org/10.1016/j.ajem.2020.11.031