Evaluation and Management of Drug and Alcohol Problems in the Emergency Department

EVALUATION OF THE PATIENT WITH DRUG OR ALCOHOL ABUSE

Introduction

Evaluating patients with drug or alcohol abuse poses significant challenges in the emergency department. Belligerence and disinhibition may make patients demanding, difficult, and dangerous. Obnoxious behavior may alienate medical personnel and interfere with appropriate and methodical evaluation and treatment. The symptoms of intoxication and withdrawal may mask or mimic other potentially life-threatening conditions.

Evaluating Intoxicated Patients

Paramount concerns in the evaluation of intoxicated patients are:
- to guarantee the safety of the patient and the medical staff
- to conduct a sufficiently exhaustive examination to rule out potentially life-threatening entities in the differential diagnosis
- to identify the substance abuse problem accurately
- to lay the foundation for effective management and referral.
The signs and symptoms of intoxication vary with the intoxicating substance, of course, but they often share the common characteristics of disinhibition, such as impaired judgment and emotional lability, any varying degrees of slurred speech, confusion regarding time, place, and/or situation, and ataxia
The differential diagnosis of such a presentation includes the following:
- Alcohol intoxication
- Sedative-hypnotic intoxication
- Anticholinergic poisoning from medication toxicity or overdose
- Hypoglycemia/hyperglycemia/ketoacidosis/hyperosmolar states
- Hepatic encephalopathy
- Postictal confusion
- Acute cerebrovascular events, including subdural hematoma, subarachnoid bleeds, transient ischemic attacks, etc.
- Encephalitis/meningitis
- Alcohol or sedative-hypnotic withdrawal, which may occur in a setting suggestive of ongoing intoxication, for example, alcohol on the breath, elevated blood alcohol levels
- Other causes of delirium (hypertensive encephalopathy, hypoxia, sepsis, etc.).
Evaluation of the intoxicated individual should include:
- An adequate history, including:
  - substance abuse and psychiatric history
  - last substance ingested, including amount and time since ingestion
  - previous history of withdrawal complications, especially seizures
  - medical history, including currently active medical problems and symptoms
  - current medications that the patient is taking or to which the patient has access
  - collateral information from family, friends and other observers
- Physical examination, which is admittedly difficult in some belligerent individuals, should include at a minimum:
  - Careful observation of the patient, to determine spontaneous and symmetric movement of all extremities, and for signs of ataxia, orientation in space, and any indication that the person is responding to visual, auditory, or tactile hallucinations, as well as for any signs of head injury and any ictal phenomena.
  - Vital signs
  - Evaluation of skin color, moisture, and temperature
  - Pupillary size and presence of nystagmus and ophthalmoplegia
  - Abnormalities in any of these may necessitate a more thorough examination, even if restraint or sedation is necessary. In the absence of elevated pulse or fever and in the absence of any obvious neurologic impairment in an individual who is oriented to place and situation, further intrusive or invasive examination is probably not necessary, at least initially.
- Mental status examination. The mental status examination of intoxicated individuals focuses on:
  - Cognitive functions, including orientation to space, time, person, and situation; attention; concentration; and memory
  - Fluctuations in the level of consciousness
  - The presence or absence of hallucinations, especially visual, tactile, olfactory, or auditory; other disorders of thought content or form
  - Flow, rate, prosody, and content of speech
  - Suicidal or homicidal ideation and impulses
  - Other psychiatric signs and symptoms
- Laboratory evaluation. Laboratory evaluation should be directed by clinical suspicion for specific organic disease processes, and may include: a urine toxic screen to identify any intoxicant or concomitant intoxicants in addition to an obvious one (e.g., undeclared drug use in an individual obviously intoxicated with alcohol); a complete blood count (CBC), blood urea nitrogen (BUN), serum glucose, electrolytes, liver function tests, calcium, and magnesium. Blood alcohol levels are of little clinical usefulness, other than to identify alcohol as an intoxicating agent.
The evaluation of intoxicated individuals should permit the physician to determine:
- Whether there is a significant collateral medical or surgical condition requiring immediate management, for example, acute poisoning, stroke, sepsis
- Whether there are acute complications of the intoxication requiring immediate management, for example, respiratory depression, cardiac arrhythmias, hepatic toxicity, etc
- Whether there is evidence of current or imminent withdrawal that requires management
- Whether there is concomitant psychiatric illness that requires acute management, for example, suicidal ideation

Management of the Intoxicated Patient

Management of intoxicated behavior depends on maintaining control of the situation, avoiding needless struggles with the patient, vigorous and appropriate treatment of withdrawal, and recognizing and treating concomitant conditions.
Maintaining control of the situation
- It is important to have a proactive policy, developed with the various disciplines involved, as to how intoxicated patients will be managed. This involves decisions about:
  - Where in the emergency department such patients should be seen; how and by whom they should be triaged
  - What the initial workup will consist of
  - When, why, and how to treat signs of withdrawal
  - When and whom to consult and for what
  - The role of security officers, including specific guidelines for initiating and continuously reviewing the necessity for restraint
  - The expectations and requirements of the facilities to which intoxicated individuals are to be referred
- The more these issues can be resolved in advance, by a multidisciplinary team, the less likely it will be that intoxicated individuals will unduly disrupt their own and others’ care.
- Intoxicated people are often offensive, and they therefore can elicit defensive, sarcastic, or abrupt behavior from their caregivers. These responses often inflame the situation. It is imperative to have a welcoming, calm, and nonjudgmental attitude toward intoxicated patients. Offering water, coffee, a blanket, or other concrete comforts can reassure intoxicated people that they are welcome and do not need to be aggressive to get their needs met. Letting the person know what to expect and how long waits are likely to be as well as keeping the person informed as the process unfolds can avoid some difficulties.
- However, it is pointless and counterproductive to argue with an intoxicated person. Friendly, nondefensive firmness is best.
- It is imperative to know in advance, as described above, the parameters for detaining and even restraining individuals who are intoxicated. In general, patients who are suspected of posing a significant risk to themselves or others, by virtue of a mental illness, or whose judgment is so impaired by intoxication that they may pose an immediate risk to themselves or to the public if they were to leave the emergency department, should be detained and restrained if necessary. The legal issues involved in such decisions vary from state to state; consult legal counsel in your jurisdiction to be clear about these issues.
- Having made the decision to detain, and if necessary restrain, such an individual, it is imperative to have adequate, overwhelming force available to the emergency department staff to achieve this end.
Pharmacologic approach to management of belligerent intoxicated individuals.
- In the event that the nonpharmacologic approaches outlined fail to help the patient calm down and cooperate with care, or if the person’s behavior is significantly compromising his or her evaluation and treatment, or that of other patients in the emergency department, it may be necessary to provide sedation, even to intoxicated patients. In such instances, haloperidol (2.0-5.0 mg) with benztropine (1.0 mg) and lorazepam (1.0 mg) administered orally or intramuscularly, will usually result in sedation without placing the patient at undue risk. Alternatives are available as discussed in Chapter 67.

ALCOHOL-RELATED EMERGENCIES

Overview

Dimensions of the Problem

Alcohol is by far the most common drug of abuse encountered in most emergency departments. It is estimated that 13.6% of the general population suffers from alcohol abuse or dependence, and 100,000 deaths per year are attributable to alcohol. Of special importance in the emergency department, it is estimated that 25% of all suicides involve alcohol.

Diagnostic Issues

Alcohol-Related Diagnoses

Acute alcohol intoxication is not subtle. At low blood levels, patients generally experience euphoria, disinhibition, and impulsiveness; at increasingly higher blood levels one sees irritability, hostility, belligerence, slurred speech, incoordination, unsteady gait, nystagmus, impaired attention and concentration, and eventually sedation, respiratory depression, and coma.
Alcohol abuse is defined as at least 1 month of impaired social and occupational functioning associated with alcohol use. The person may use alcohol in dangerous circumstances and despite negative consequences. When tolerance to alcohol develops and increasing amounts are consumed, the appropriate diagnosis is alcohol dependence.
Alcohol withdrawal is characterized by autonomic hyperactivity in the setting of alcohol cessation; this often produces tremor, insomnia, nausea/vomiting, anxiety, agitation, and sometimes transient visual, tactile, or auditory hallucinations, and seizures.
When the hallucinations are not transient and are accompanied by disturbances of consciousness (with reduced ability to focus or attend), or in the face of other cognitive impairments such as decreased awareness of the environment, the diagnosis of alcohol-induced delirium should be considered. In a setting of alcohol cessation and falling (even if absolutely elevated) alcohol levels, this clinical picture suggests alcohol withdrawal delirium. In less than 5% of cases, such alcohol withdrawal delirium may proceed to delirium tremens, a potentially lethal syndrome of alcohol withdrawal requiring vigorous treatment.
Hallucinations or delusions in the presence of ongoing alcohol use, but without any impairment of consciousness (i.e., the person is oriented to person, place, and time, without impairments of memory, attention, or concentration) characterize the syndrome of alcohol-induced psychotic disorder (formerly called alcoholic hallucinosis).
Impairments in memory without impairments in concentration suggest the possibility of Wernicke-Korsakoff syndrome.

Differential Diagnosis

Except at toxic levels (blood levels generally above 400 mg/dL), alcohol intoxication in itself does not pose serious medical problems. It is important to remember, however, that serious medical conditions frequently accompany prolonged or “binge” alcohol abuse and these may easily be mistaken for, or attributed to, alcohol intoxication and therefore overlooked.
The differential diagnosis of alcohol intoxication includes the following:
- Alcohol intoxication and poisoning
- Sedative-hypnotic intoxication
- Anticholinergic poisoning from medication toxicity or overdose
- Hypoglycemia/hyperglycemia/ketoacidosis/hyperosmolar states
- Hepatic encephalopathy
- Postictal confusion
- Acute cerebrovascular events, including subdural hematoma, subarachnoid bleeds, transient ischemic attacks, and other acute strokes.
- Encephalitis/meningitis
- Alcohol or sedative-hypnotic withdrawal, which may occur in a setting suggestive of ongoing intoxication, for example, alcohol on the breath, elevated blood alcohol levels
- Other causes of delirium (hypertensive encephalopathy, hypoxia, sepsis, etc.)