REBEL Cast Episode 50 – Intoxicated Patients can Equal Badness

07 May
May 7, 2018

Background: Visits to the ED for alcohol intoxication can create quite the clinical conundrum both for acute medical and traumatic reasons.  Acutely intoxicated patients, just like young kids, don’t always have the ability to communicate due to sedation, agitation, or some other critical medical/traumatic process that is ongoing.  This makes getting a complete history or depending on the physical exam unreliable at best.

REBEL Cast Episode 50 – Intoxicated Patients can Equal Badness

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Predicting Critical Illness in Acute Alcohol Intoxication [1]

What They Did:

  • Single center, retrospective observational study
  • ED patients with acute alcohol intoxication without other acute medical or traumatic complaints

Outcomes:

  • Primary: Unanticipated subsequent use of critical care resources during the encounter or admission to an ICU
  • Secondary: Potential predictors associated with critical care resource use 

Inclusion:

  • ED patients ≥18 years of age
  • Chief complaint of altered mental status or alcohol intoxication
  • Breath alcohol level >0 mg/dL

 Exclusion:

  • Patients started in the ED or relocated to another room outside the alcohol detox unit

Results:

  • 31,364 eligible patient encounters
    • Median age = 38 years
    • 71% men
    • Median breath alcohol = 234 mg/dL
    • 325 (1%) of encounters used critical care resources
  • Most common diagnoses per 1,000 ED Encounters:
    • Acute hypoxic respiratory failure = 3.1
    • Alcohol withdrawal = 1.7
    • Sepsis or infection = 1.1
    • Intracranial hemorrhage = 1.0
  • Predictors of Developing Critical Illness
    • Hypoglycemia = aOR 9.2
    • Fever = aOR 7.6
    • Hypothermia = aOR 4.2
    • Hypoxia = aOR 3.8
    • Hypotension = aOR 3.8
    • Parenteral Sedation = aOR 2.4
    • Tachycardia = aOR 1.8

Strengths:

  • Data acquired from the electronic medical record were by a blinded data analyst
  • Despite this being an electronic medical record study the variable evaluated had a very low rate of missing data ≈0.3% in most instances
  • Data quality was ensured by two assessments of agreement to confirm agreement between data extractors

Limitations:

  • Study UNDERESTIMATES the true incidence of critical illness:
    • Patients with alcohol intoxication and concomitant medical/traumatic issues not included in this study
    • Many frequent user visits (≈11,000 patients for ≈33,000 visits), that did not use critical care resources
  • Study variables were obtained from an electronic medical record. Some variables may not be accurate due to recall bias
  • No sample size calculations, but there has been no previous work to guide expected incidence rates for these outcomes
  • Laboratory and imaging results were not used as predictor variables in this study
  • The appropriateness of critical care resources used was not completely assessed

Discussion:

  • At this single institution the use of antipsychotics is a more common practice pattern rather than the use of benzodiazepines due to higher risk of respiratory depression. The most common antipsychotics used:
    • Olanzapine = 26%
    • Haloperidol = 9%
    • Droperidol = 9%
    • ZERO cases of torsades de pointes, but 3 cardiac arrests…suspected to be due to critical illness rather than medication side effect

Author Conclusion: “Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk.  Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.”

Clinical Take Home Point: Due to the methodology of this study, the true incidence of critical illness is underestimated.  However, in acutely intoxicated patients, abnormal vital signs, hypoglycemia, and/or need for chemical sedation are the factors most associated with increased critical illness.

Cervical Spine Clearance in Intoxicated Patients [2]

What They Did:

  • Single center, prospective observational study
  • Intoxicated patients with blunt trauma
  • Evaluated for cervical spine injuries (CSI) & missed injuries

Outcomes:

  • Primary: Clinically relevant CSIs requiring cervical stabilization (MRI findings, operative findings, and/or clinical status at discharge)
  • Secondary: Missed injuries (Bony, ligamentous, or spial cord injury identified by any means during index hospitalization that was not identified on initial radiology interpretation of the cervical spine CT scan)

Inclusion:

  • ≥18years of age
  • Blunt trauma
  • Underwent evaluation of cervical spine with cervical CT scan

Exclusion:

  • Delayed presentation after index trauma
  • Transfer patients without available CT scans
  • Known recent cervical spine fractures or surgery

Results:

  • 1668 patients with blunt trauma
    • MVC (44.0%) and ground level falls (34.7%) were the most common mechanisms of injury
    • 2% of patients were positive for drugs and/or alcohol
  • CSI Identified in 157 pts (9.4%) of intoxicated patients
  • 567 Normal CT scans
    • 4 (0.7%) had central cord syndrome
    • 1 (0.2%) had unstable ligamentous injury
    • All 5 injuries had neurologic deficits on physical exam
    • 316 patients (50.0%) kept in cervical collar for intoxication
      • 0 missed CSIs
      • Immobilized for a mean of 15.1 hours
    • NPV of CT Scans for CSIs = 99.2%
    • NPV of CT Scans for CSIs Requiring Immobilization or Stabilization = 99.8%

Strengths:

  • Prospective evaluation in a homogenous group of obtunded patients

Limitations:

  • Decisions made by trauma surgeons was at the surgeons discretion and not protocolized
  • Morbidity and complications associated with prolonged immobilization were not evaluated
  • A composite endpoint for identifying all CSIs and clinically significant injuries was used
  • Significant heterogeneity both in the source of intoxication and degree of intoxication
  • This study used a 128-slice modern CT scanner at a level I trauma center with highly experienced trauma radiologists and the results of this study may not be applicable in less advanced CT scanners or with less experienced radiologic interpretation

Discussion:

  • In 2015, the Eastern Association for Surgery of Trauma published their practice management guideline. They reviewed 11 trials with ≈1700 patients with an overall incidence of missed injury with CT of 9%, but the majority of missed patients were clinically insignificant
  • It is important to recognize that spinal precautions are not meant to immobilize all patients but protect patients with unstable injuries from worsening a spinal cord injuries. Sometimes this means removing cervical immobilization
  • Prolonged spinal immobilization can lead to increased intracranial pressure, pressure sores, etc…we have covered this on REBEL EM before
  • In a meta-analysis published in 2017 [3], 23 studies with 5,286 patients were evaluated with CT followed by MRI of cervical spine. CT scanners used were mostly 16 – 64 slice scanners. A negative CT missed:
    • 16 out of 5,286 (0.30%) unstable injuries overall
    • 4 out of 3,370 (0.12%) unstable injuries who were obtunded
    • 10 out of 1,387 (0.72%) unstable injuries who were awake, and not intoxicated
    • Unfortunately the definition of unstable injuries is not clearly stated in all these studies

Author Conclusion: “In this study, alcohol or drug intoxication was common and resulted in significant delays to cervical spine clearance.  Computed tomographic scans were highly reliable for identifying all clinically significant CSIs. Spine clearance based on a normal CT scan among intoxicated patients with no gross motor deficits appears to be safe and avoids prolonged and unnecessary immobilization.”

Clinical Take Home Point: In intoxicated patients, with blunt trauma, and no focal neurologic deficits on physical exam, a negative 128 slice CT scan of the cervical spine, read by an experienced radiologist, appears to be enough to clear cervical hard collars without prolonging cervical immobilization for clinical sobriety or MRI results.  These patients should be re-examined when clinically “sober” or able to cooperate with the physical examine before disposition.

References:

  1. Klein LR et al. Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Ann Emerg Med 2018. PMID: 28844504
  2. Bush L et al. Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients with Blunt Trauma. JAMA Surg 2016. PMID: 27305663
  3. Malhotra A et al. Utility of MRI for Cervical Spine Clearance After Blunt Traumatic Injury: A Meta-Analysis. Eur Radiol 2017. PMID: 27334017 

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
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  1. […] to potential badness in our ER patients. Having served as an expert witness I have seen how costly a missed critical diagnosis in the intoxicated patient can be costly to our patient…and to us […]

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