Assessing a patient with alcohol intoxication
How to examine, assess, clerk, and safely discharge patients presenting with alcohol intoxication
Box 1: Learning points
- At weekends, up to 70% of presentations to the emergency department may be alcohol related
- Acute alcohol intoxication presents a diagnostic challenge because it can mask and mimic a range of other physical and mental diagnoses. Keep an open mind about other causes of the patient’s symptoms
- Ask about the frequency and quantity of alcohol consumption, and use the AUDIT-C questionnaire to assess the risk of dependency and harmful drinking
- Ask about recent events and social circumstances to explore the causes of increased alcohol intake
- Use the Royal College of Emergency Medicine’s discharge checklist to work out whether it is safe for a patient to be discharged
How common is this presentation?
Intoxicated patients often present to the emergency department. About 83% of the UK population drink alcohol and 24% of adults in the UK exceed the government guidelines on maximum weekly alcohol consumption (14 units). At peak times (midnight to 5 am at the weekend), up to 70% of all attendances in the emergency department might be alcohol related. Acute alcohol intoxication can present a diagnostic challenge because it can be difficult to take a history and examine patients experiencing an altered mental state. Intoxication can also mask and mimic a range of other physical and mental diagnoses, such as intracranial bleeds, encephalitis, and hypoglycaemia, so you need to be wary of attributing all of the patient’s symptoms to alcohol intoxication and keep an open mind for other diagnoses.
A 45 year old man presents to the emergency department with a superficial laceration to his right arm. The staff nurse has cleaned and dressed the wound. His observations are all within normal range (heart rate 75 beats/min, blood pressure 126/74 mm Hg, respiratory rate 17 breaths/min, temperature 36.5 °C), and the triage sheet states: “Cut to arm. Very drunk.” Your consultant asks you to assess the patient’s intoxicated state and make a decision about whether you think it is safe for him to be discharged.
What to find out from the patient’s history
Approach the consultation in a non-judgmental manner. Speak clearly and avoid using medical jargon.
Find out what caused the patient to present to the emergency department
Piece together the sequence of events that led to the patient being admitted. Ask why he thinks he is in the emergency department and if there was a trigger that caused him to increase his alcohol consumption. Try to quantify the quantity and frequency of alcohol consumption before his arrival at the emergency department. Speak to friends or relatives and check handover sheets from paramedics and any hospital letters to build up a more complete picture.
Screen for high risk drinking
The Royal College of Emergency Medicine recommends that all patients attending the emergency department with an alcohol related presentation should be screened for high risk drinking. The National Institute for Health and Care Excellence (NICE) recommends using the three question screening tool AUDIT-C (fig 1 ). Ask about high alcohol consumption sensitively. Reassure the patient that although your questions might be personal, they are often asked in the emergency department.
If patients score 5 or more on the AUDIT-C tool, it indicates that their drinking is at the level of “increasing” or “higher” risk. You can carry out a more comprehensive assessment of their reliance on alcohol using the Alcohol Use Disorder Identification Test (AUDIT) and the Severity of Alcohol Dependence Questionnaire (SADQ) scoring tools, which can be found in the alcohol toolkit from the Royal College of Emergency Medicine. Figure 2 can help you to determine how many units are in each drink (fig 2).
Ask about any falls or head injuries
If patients have a history of falls or trauma, ask them whether they have sustained any other injuries, specifically head injuries. Alcohol intoxication makes assessment of head injuries more difficult, and substantial head injuries can present with similar signs to intoxication, such as drowsiness and confusion. The NICE guidelines on head injury say that in intoxicated patients with a decreased level of consciousness, serious brain injury must be excluded before attributing symptoms to intoxication alone.
Medical history and social history
Ask about the patient’s medical and psychiatric history, as well as previous hospital attendances. In patients who are depressed or seem low in mood, ask about suicidal ideation and self harm. If patients have a history of previous mental illness, ask how it is managed and whether they have input from a psychiatrist or community psychiatric nurse. Inquire about regular drug regimens and any recreational drugs.
The decision to discharge patients who are intoxicated is made on a case by case basis. Consider how they will travel onwards from the emergency department and their ability to manage themselves safely at home. Social factors such as employment, accommodation, and having other members of the family to assist are important for planning ongoing care.
Ask about any children or dependants the patient might be responsible for or live with. Find out where the children live and what level of supervision they have while patients are in the hospital. If you have any concerns about a child’s welfare, raise it with a senior doctor.
Box 2: How to clerk notes from the patient’s history
Presenting complaint—Laceration to arm. Probable alcohol intoxication
History of presenting complaint—Drinking in local pub. Argument when asked to leave. Pushed, cut arm on door. Drinking all day, unsure of exact quantities. Daily drinking since the loss of his job two years ago. Low mood but denies suicidal ideation. Denies any other drug use
Medical history—No other medical problems
Drug history—No known drug allergies
Social history—Unemployed and lives alone
What to look for in the patient examination
Observe how the patient is behaving in the emergency department. Patients in the early stages of intoxication will be disinhibited and might show signs of elation. As the level of intoxication increases, patients become increasingly ataxic and off balance, drowsy, and potentially comatose.
Patients who drink every day are at risk of developing alcohol withdrawal if they stop drinking or suddenly reduce the amount of alcohol they drink. Patients withdrawing from alcohol can seem flushed and anxious and, at the severe end of the spectrum, develop hallucinations and seizures. See box 3 for signs of alcohol intoxication and alcohol withdrawal.
Box 3: Signs of alcohol intoxication and alcohol withdrawal
Alcohol intoxication—Slurred speech, disinhibition, elation, confusion, labile mood, nausea and vomiting, ataxia, nystagmus, sedation, decreased respiratory effort, coma
Alcohol withdrawal—Flushing, tremor, sweating, anxiety, confusion, tachycardia, nausea and vomiting, hypertension, pyrexia, hallucinations, seizures
Use the Clinical Institute Withdrawal Assessment (CIWA-Ar) to quantify the severity of patients’ withdrawal symptoms. Scores of 8 and below indicate minimal symptoms; higher scores—of more than 19—are associated with severe withdrawal. In some hospitals, the CIWA-Ar score might be used as part of a protocol to guide treatment of acute alcohol withdrawal with benzodiazepines.
Examine the patient for signs of withdrawal, such as tremor, flushing, sweating, anxiety, agitation, and tachycardia. Acute alcohol withdrawal can cause visual and auditory hallucinations, delusions, confusion and, in some cases, seizures. Cognitive impairment secondary to alcohol withdrawal is sometimes referred to as delirium tremens.
Assess the effects of alcohol misuse
Assess the patient’s conscious state by using the Glasgow Coma Score (GCS) and level of cognition using an Abbreviated Mental Test Score (AMTS). Cognitive and cerebellar dysfunction can be caused by acute alcohol intoxication and Wernicke Korsakoff Syndrome, a consequence of chronic alcohol misuse. Examine patients for cerebellar signs, such as dysdiadochokinesis and ataxia, and assess coordination with functional tasks, such as doing up a shirt button.
In patients with a history of alcohol misuse, examine for signs of liver disease. Palpate the abdomen, remembering that abdominal tenderness may indicate alcohol related illness such as pancreatitis. If there is any history of falls or trauma, conduct a brief survey looking for signs of any injury. The Royal College of Emergency Medicine recommends that all patients presenting with signs of intoxication or alcohol misuse should have their blood glucose level checked at the bedside to exclude hypoglycaemia.
Safe to discharge?
The Royal College of Emergency Medicine’s alcohol toolkit provides a discharge checklist. All the questions must be answered “no” for patients with an alcohol related presentation to be discharged (fig 3 ). Patients who lack capacity because of intoxication cannot discharge themselves from the emergency department. Assessing capacity in these patients can be challenging, and a senior doctor should review intoxicated patients who want to leave the emergency department against medical advice. Encourage patients with impaired cognition and balance, and with ataxia due to intoxication, to remain in hospital for further assessment, as they are at higher risk of falls and further injury.
Case scenario—what happens next?
The patient has a Glasgow Coma Score of 15 and scores 6 out of 10 on the Abbreviated Mental Test Score, which indicates he has impaired cognition. His speech is slurred and he is unsteady on his feet, nearly falling when trying to get up and walk. He is ataxic and has signs of lateral nystagmus and past pointing. He is unable to heel-toe walk because of poor balance and coordination.
On examination, the patient does not have any visible signs of liver disease. His abdomen is soft and not tender, and he does not have any organomegaly. He shows no evidence of a head injury or any trauma other than the wound to his arm.
What to say to your consultant
The patient tests positive on AUDIT-C and is unable to complete an AUDIT or SADQ assessment because of his level of intoxication. He lives alone and you recommend that it is not safe for him to be discharged.
Your consultant reviews the patient and agrees that it is not safe for him to be discharged alone. After a period of observation in the emergency department, the patient remains confused and is unable to walk without falling. The consultant decides that the risk of further injury to the patient is too high for him to go home without supervision, and he should be admitted to hospital.
You explain to the patient that he will be admitted to hospital and that he will be cannulated. He will be given an intravenous infusion of vitamins (thiamine) and if he starts to withdraw from alcohol then he will be given medicine to manage these symptoms. You make a referral to the hospital alcohol liaison nurse, who will visit him on the ward to coordinate ongoing management of his alcohol intake.Andrew Charlton, registrar in emergency medicine1, Richard Keeble, consultant in emergency medicine2
1Leeds Teaching Hospitals NHS Trust, UK, 2Airedale NHS Foundation Trust, UK
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
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