Author: Arwa Shaikh / Editor: Charlotte Davies / Questions: Chris Connolly / Codes: / Published: 21/07/2020
Working in the Emergency Department (ED), you are guaranteed to see and treat patients from all specialties of medicine and surgery. Most will prove to be interesting but also challenging at the same time.
Drug and alcohol related attendances, I think it’s safe to say, fall under the challenging category! Alcohol related attendances in the emergency department pose a significant burden on the National Health Service and other emergency services including the police. Despite the challenges we face with this particular group of patients we still have a duty of care and must provide safe effective treatment options and support in the department (and community) on discharge with the help of substance misuse teams and specialist nurses.
This blog includes a list of the most common presentations that you may encounter on your shift. But before we go ahead here are a few quick points to remember during your assessment;
In alcohol intoxication there is NO evidence that fluids speed up recovery.
In liver failure prescribe half the dose of chlordiazepoxide.
If severe liver failure use diazepam as it is not hepatically metabolised.
CIWA score is a helpful scoring system used to assess patients presenting with acute withdrawal.
Offer prophylactic thiamine (pabrinex) to patients who are malnourished or have a risk of decompensated liver disease.
Acute Intoxication
Patients often presents with agitation, reduced consciousness level, or “found outside”. They may be aggressive or lucid. They may smell of alcohol,
but there may be other substances involved, including deliberate overdose of medications. Check a blood sugar (mandatory), and other bloods (including venous blood gas) and imaging as clinical condition dictates. Perform a full clinical examination, and check carefully for any other injuries i.e. head injury. Refer to substance misuse team as outpatient or inpatient.
Withdrawal
These patients will present with the “CIWA Score” features shaky, agitated, anxious and sweaty. They should have a blood sugar and a CIWA score done at triage, with chlordiazepoxide as appropriate, according to your trust’s policy. IV fluids should be considered. The majority of these patients will need to be discharged with advice to keep drinking, and to seek help in the community.
New or existing alcohol related seizures (withdrawal)
Follow the seizure standard treatment algorithm. These patients must have regular CIWA scoring and chlordiazepoxide after their seizure, and be depending on your local guidelines, will either be referred to the medical team or discharged home.
Wernicke’s encephalopathy
Treat as per local trust protocol and refer to the medical team if any one sign present. A CT head may be indicated but should not delay medical referral:
Acute confusion
Memory disturbance
Ataxia/unsteadiness
Opthalmoplegia
Nystagmus
Unexplained hypotension with hypothermia
Decreased consciousness level
Presentation is usually after a long history of alcohol use. Consequent features may be alcoholic liver disease i.e. Liver cirrhosis, liver failure, jaundice, ascites and generalised lethargy. Patients may need admission for ascetic drains.
Look carefully for signs of hepatic encephalopathy confusion with raised ammonia and upper GI bleeds.
Admit patients on the basis of their clinical presentation, not on the degree of blood test abnormality.
So essentially most ED patients with alcohol related problems will fall under one of these five categories, each case will be unique and some may present with co-existing mental health conditions i.e. self-harm or drug overdoses. Ask for senior help if youre unsure of what to do and never assume a patient is “just drunk”.
