Intoxication! Talk about a red flag! Let’s consider two “flavors,” if you will. First, the patient with an actual chief complaint AND who happens to be intoxicated. Next, the patient who presents with apparent intoxication and no other immediately obvious issues. And for those of you who have not had a busy shift in an urban emergency department, the number of patients with altered mentation secondary to alcohol can be remarkable. Unfortunately, many of these patients get to be regular visitors; they are well known by the emergency providers and are often on a first-name basis.
When you work in a “take-all-comers” type of environment, practicing high-quality medicine can be quite a challenge. In the ED or urgent care center, if you see 25 patients in a shift, you might see 25 different chief complaints. Navigating through patients with acute onset chest pain, abdominal pain, headaches, head injury and children with fever requires a broad knowledge base and the accurate application of clinical judgement. No small feat!
Now throw intoxication into the mix, and all bets are off. There may be a great evidence-based rule to rule out the need for a neck X-ray in a neck pain patient, but not if they’re intoxicated. There is a good head injury rule to indicate the need for or to be able to avoid a CT scan, but not if the patient is intoxicated. There is simply no way to apply high-quality evidence-based medicine to the intoxicated patient. Intoxication takes the baseline from a very elevated risk of emergency medicine and ratchets it up several notches. In a world where medical evidence now more carefully drives clinical behavior and patient evaluation, the intoxicated patient throws it all to the wind!
In general, you cannot depend upon either the history or the physical exam in an intoxicated patient. “Do you have pain here?” Ask this question of a patient with an alcohol level of 250mg/dl, and the answer is almost certainly NO, not even if they have a fractured cervical vertebra, a bowel perforation or an intracranial bleed. Therefore, once intoxication is factored into the equation, the prudent practitioner takes the very conservative approach to evaluation and management. If there is evidence of a head injury, no rule can eliminate the need for a CT scan; likewise, if the patient has an abdominal issue, there is typically no way to eliminate the need for sophisticated imaging.
Intoxication is one of the biggest red flags in the specialty of emergency medicine. Every veteran emergency practitioner will tell their story about getting burned, or close to it, by the clinical impact of ethyl alcohol!
Now consider the flip side. Old Ben comes in every Friday night, sleeps it off, and everyone says goodbye in the morning. Well, intoxication is the great fooler! Old Ben’s presentation becomes white noise. After being seen several times, the tendency is to write off Old Ben as simply intoxicated, and the history and physical exams get more and more abbreviated. There are times when regulars like Old Ben just get pushed into a corner with minimal to no examination.
Patients like this tend to get a bit loud and demanding; they are often placed in restraints, and all too often are pushed into a quiet room. However, a restrained and secluded patient should set off alarms for every practitioner; without a direct visual, that patient is at incredibly high risk.
Once again, the prudent emergency or urgent care practitioner as well as other members of the team must step back, take a deep breath, and recall that Old Ben and other regulars are dramatically compromised physiologically. These patients MUST receive a careful evaluation to be certain that it is the usual presentation, that there is nothing more than intoxication, and that this is not Old Ben presenting with sepsis, a disguised head injury, or some other dramatic clinical event. Once again, every veteran emergency practitioner has a story about a “regular” that turned out to be a clinical nightmare. The white noise often results in a delay in evaluation and management that can lead to serious patient injury, adverse outcomes, and unfortunately, related litigation.
Case Report
Sam presented to the ED on a Friday night, intoxicated as usual. Sam was put on a stretcher in the hallway while the physician continued seeing the “actual sick people.” Sam did his usual — he got loud and kept trying to get off the cart — so the nurses ordered his routine management and put him in restraints. There was still no physician evaluation.
Then Sam got louder. So one of the staff members passing by pushed Sam into the cast room and closed the door. The emergency practitioner had been busy intubating a patient in status epilepticus and was not aware of the patient in the hallway, and now had no way of knowing there was a patient in restraints and in seclusion in the cast room!
Well, Sam hated being restrained; he managed to get his hand into his pocket, pulled out his lighter, and tried to burn off his wrist restraint. By the time anyone became aware there was a problem, the restraints, bed sheets and Sam himself were on fire. The staff ran in and had to put Sam out with a fire extinguisher. Unfortunately, this is an actual case from a hospital just down the street from mine. It resulted in years of litigation and a community that was up in arms. Sam lived, but with horrible burn injuries.
There is a tendency to become cavalier with this patient population, and the adverse outcomes can be dramatic. It is always prudent to let your “sixth sense” guide you to take a step back, drown out that white noise, and apply a careful clinical evaluation and your reasoned judgment in this incredibly high-risk patient population.
Learn more in this course for CME - Alcohol Intoxication.
