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Just Drunk or Critically Ill?

April 11, 2018

Written by Clay Smith

Spoon Feed
One percent of patients presenting with acute alcohol intoxication eventually needed critical care admission.  Be wary of abnormal vital signs, hypoglycemia, or the need for additional chemical sedation, as these were associated with an increased odds of needing the ICU in such people.

Why does this matter?
It’s so easy to chalk altered mental status up to simple intoxication, given the right patient scenario – college freshman, dressed in green on St. Patrick’s Day, covered in vomit.  There’s only one thing that can be, right?  It’s easy to have premature closure of our differential diagnosis and not consider other causes.  How often does a patient who is “just drunk” come in with something far more serious?

Just drunk or something worse?
This was a retrospective look at over 31,000 drunk Minnesotans over 5 years. After paramedic, nursing, and initial physician evaluation, these patients were initially considered low risk and placed in an alcohol intoxication unit within the ED.  They found that most of the patients were screened appropriately and were just drunk.  But 325 (1%) needed critical care.  The most common causes of critical illness were respiratory failure, withdrawal, sepsis, or intracranial bleed.  What were the clinical clues associated with these patients who went on to need critical care?  Hypoxia, hypotension, tachycardia, hypothermia, fever, hypoglycemia, or need for IV sedation were all associated with an increased odds of needing critical care.  Though it seems like an obvious reminder to pay attention to vital signs, it’s easy to explain away abnormal values in a homeless, drunk patient in the middle of winter in Minnesota. Be careful.

Another Spoonful
There was another article this month that appears to have come from the same authors that details the cause of altered mental status in about 29,000 patients with a prehospital report of ethanol intoxication.  Five percent had no alcohol detectable, and 10% of them needed hospital admission.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.  Ann Emerg Med. 2018 Mar;71(3):279-288. doi: 10.1016/j.annemergmed.2017.07.021. Epub 2017 Aug 24.

Peer reviewed by Thomas Davis.

What are your thoughts?