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PED-EM-L  February 2012

PED-EM-L February 2012

Subject:

Re: ETOH intoxication

From:

Doc Holiday <[log in to unmask]>

Reply-To:

Doc Holiday <[log in to unmask]>

Date:

Tue, 21 Feb 2012 00:40:52 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (74 lines)

From: [log in to unmask]
> Sir Holiday,
 
--> "Sir"?
 
No need for that... A curtsy would be sufficient...;-)
 
> When you say that you'll treat what needs treating, could you give examples of such treatments?
 
--> Sure. But I must point out that I have not yet received anything from anyone to let me know what drugs people would be looking for in a urine tox - as I mentioned, we don't do them, so I am curious to know what drugs one looks for and what one does about those numbers to modify what one would do in terms of treatment if one did not have the numbers.
 
Also I still have no idea what a "banana bag" is...
 
But as for examples of what we treat... What I had said in my e-mail was "while intoxicated or otherwise symptomatic, we'll treat what we see that needs treating (e.g. vomit, airway, seizure); not certain this will be helped by knowing the chemical causing it - do please tell"
 
I'll make up a case to demonstrate, say a patient - 15 YO male - who comes in APPEARING to be intoxicated. Let's say smells of beer on his clothes, his friends say he had "a couple of pints". It's what they always say here - "a couple" means anywhere between a sip of it and a bath in it... He has also had a minor fall, hit his head a bit. Friends deny any other substances. His GCS makes him unreliable at giving a history.
 
Now, say he's vomiting. We'll suction & posture for drainage, but if airway is at risk of not being protected and or looks like might aspirate, we'll manage the airway with a tube. We would make that decision without knowing what drugs might be in the urine. If we discover, as we prepare to intubate, that he actually never took a sip of anything, but spilled the whole drink on his clothing, we still do the same.
 
We would probably give an anti-emetic, e.g. ondansetron.
 
He then gets a CT, as he is GCS<15 and head injury (or otherwise no known cause for low GCS).
 
If he needs airway protection for other reasons, it gets done (e.g. if we need to sedate for CT).
 
If he has seizures - benzo's. If I knew he had some benzo's in his urine, it would still be the 1st line. Again, I am just imagining here, as I have no idea even what units this will be reported as, but if he has benzo's in his urine it does not mean to me that it's not the drug to try, as it is not in our guideline for seizure management to avoid benzo's in people who have some in their urine.
 
If he has low GCS and MIGHT have ingested opiates (maybe small sluggish pupils) and no respiratory depression, then he gets his CT. If he has respiratory depression and nothing on CT to suggest we should be sedating, then we'd try naloxone to see if it helps. We would not try flumazenil, regardless of whether we know he did or did not ingest benzo's. Rather ventilate if, say, respiratory depression or airway issue. Would not want to risk causing seizure if he happens to be a user.
 
etc...
 
> The follow-up question would be: are there any notable risks associated with them?
 
--> Of course!
 
> Might it beneficial to prevent the need for such treatment in the first place.
 
--> Would love to! This is why I asked!
 
So I need to know, in the case above, how would a urine tox help me?

- If GCS is low in an "intoxicated" head injury and I THINK it's only alcohol. I REALLY think so. But I still have to do a CT to make sure there's no intracranial bleed from the trauma. Which urine tox level will affect this? At what alcohol/drug level (in blood/urine/sweat/snot) would I NOT do this CT with its radiation risk?

- If patient needs airway protection from vomit with low GCS, despite naloxone and anti-emetic, what drug at what level in which body fluid will tell me to wait and NOT risk intubation?

- If same patient has seizure activity, what drug at what level in which body fluid will tell me not to treat the seizure with benzos (risk of respiratory depression), then the rest...
 
> If someone is altered from alcohol and other depressants...and the patient seems to be on their way down rather than their way up (sobering up), it might make sense to counteract the other toxins rather than respond to them after they become a problem. While a tox screen might not be required
 
--> I think this is where we are. If we see SIGNIFICANT CLINICAL FEATURES of potential opiate toxicity, we would try naloxone. I don't need a tox for that. If we see signs of "hyper" which needs sedating then we sedate. EVIDENT cholinergic syndrome - we treat. Etc. Is there a drug we might find in the urine which will indicate we shouldn't?
 
Actually, I think I will learn better here if YOU give me an example of a case like this or similar and then show me how YOU would change management using the tox screen.
 
The bottom line is that I can sit here and tell you we never do it and claim that it's therefore not necessary, or we would have found out by now that we're not getting results. But it would not make sense for me to do that and then rudely ignore the fact that you generally DO get these tests and you also think you're doing OK! We also live in different societies with different drug habits...
 
And when you do give me an example, I will try to tell you how we'd deal with that case.
 
Maybe you could also give me an idea of how often you change your management of a case because of a urine tox finding, i.e. you do something different after the tox result that you would not have done if the lab called and said "oops - our machine's broken and we can't do tox until it's fixed". Do you have an estimate (or better - some stats) on how many out of 100 urine tox samples actually CHANGED management.
 
I would also appreciate if you could give me a case example where the clinical management changes by the level of alcohol in the blood...
 
That would be good.
 
> it could be useful....both for physical treatment, as well as psychiatric/social worker referral.
 
--> OK. You'll be giving me an example of how it might affect physical treatment. But as for psych referal, this is even more in need of an explanation, please. Unless I misunderstand you... In a patient who has symptoms/signs which make me want to have psych come and do an assessment (let's assume the patient has regained a sufficient level of alertness and conversation), then I would call psych to come and do this assessment and they would come. Obviously, I would not call them to come when the patient is not at a state that he could speak to them. But once he is, which tox level would cause me not to call them?
 
Please bear in ming that here we do our best not to let our psych colleagues fall into the trap of expecting EM to "medically clear" (I learned this term from another EM list I am on, with Americans on it) before they come and do what we want. I would be concerned that they would start expecting us to NOT call them if drug X is in the urine, but rather wait for it to get out of the system and see whether psych is still required. They might demand a tox screen on every patient before referal, just in case the result may be used to justify them NOT coming!! We prefer them to come when we call and assess when we want them to. IF there was a drug AND it then disappears AND the psych syndrome also goes away, then so be it. I guess that would mean, in retrospect, that the psych review was not required. But then the psych review was harmless and the alternative would risk falling into a system in which so many other patients end up being delayed under EM to wait until they are "healthy enough" to be seen by psych. This will cause a massive burden on ED space and nursing and we have enough burdens as things are now!
 
Your turn... 		 	   		  
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