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Strayer RJ, Friedman BW, Haroz R, Ketcham E, Klein L, LaPietra AM, Motov S, Repanshek Z, Taylor S, Weiner SG, Nelson LS. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023; 64:517-540. [PMID: 36997435 DOI: 10.1016/j.jemermed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey
| | - Eric Ketcham
- Department of Emergency Medicine, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Española, New Mexico
| | - Lauren Klein
- Department of Emergency Medicine, Good Samaritan Hospital, West Islip, New York
| | - Alexis M LaPietra
- Department of Emergency Medicine, Saint Joseph's Regional Medical Center, Paterson, New Jersey
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Zachary Repanshek
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Taylor
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Terayama T, Sasa R, Nakatani Y, Tanaka F, Terashige S, Higashiyama D, Sugiura T, Hatanaka K, Nishiyama T, Takeshima S. Effect of intravenous fluid therapy for acute alcohol intoxication on length of time from arrival at the emergency department until awakening: A prospective observational cohort study. Acute Med Surg 2023; 10:e841. [PMID: 37153868 PMCID: PMC10156605 DOI: 10.1002/ams2.841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/02/2023] [Indexed: 05/10/2023] Open
Abstract
Aim To evaluate the association of intravenous fluid (IVF) therapy on the length of time from arrival at the emergency department (ED) until awakening in cases of acute alcohol intoxication. Methods This single-center, prospective, observational study was conducted in the ED of the Self-Defense Forces Central Hospital during October 1, 2018 to July 31, 2019. Patients with 1,000 mL bolus of lactated Ringer's solution and those without bolus were compared. The primary outcome was the length of time until awakening. Secondary outcomes were the length of stay in the ED and occurrence of conditions requiring extra care. Predictors of the occurrence of any event requiring extra care were identified. Results We included 201 patients, of whom 109 received IVF and 92 did not. No significant difference existed in the baseline characteristics between the groups. The median length of time until awakening did not significantly differ between the groups (P = 0.77). Multivariable regression analysis adjusted by age, sex, hemoglobin, blood alcohol concentration, and initial Glasgow Coma Scale (GCS) score demonstrated that the regression coefficient of IVF for length of time until awakening was -9.55 (95% confidence interval [CI], -36.2 to 17.2). Hemoglobin (regression coefficient, 10.1; 95% CI, 0.38-19.9) and initial GCS score (regression coefficient, -7.51; 95% CI, -10.8 to -4.21) were significantly associated with length of time. Conclusion IVF therapy was not associated with the length of time until awakening in patients with acute alcohol intoxication in the ED. Routine IVF administration was unnecessary.
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Affiliation(s)
- Takero Terayama
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
- Department of Psychiatry, School of MedicineNational Defense Medical CollegeSaitamaJapan
| | - Ruka Sasa
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
| | - Yuka Nakatani
- Department of Health InformaticsKyoto University School of Public HealthKyotoJapan
| | - Fumika Tanaka
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
| | - Sho Terashige
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
| | | | - Takao Sugiura
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
| | - Kosuke Hatanaka
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
| | - Takashi Nishiyama
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
| | - Shigeto Takeshima
- Department of EmergencySelf‐Defense Forces Central HospitalTokyoJapan
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IV crystalloid fluid for acute alcoholic intoxication prolongs ED length of stay. Am J Emerg Med 2017; 36:673-676. [PMID: 29289398 DOI: 10.1016/j.ajem.2017.12.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/24/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Acute alcohol intoxication is often treated in emergency departments by intravenous crystalloid fluid (IVF), but it is not clear that this shortens the time to achieving sobriety. The study aim was to investigate the association of IVF infusion and length of stay in the ED. METHODS This single-center retrospective cohort study was conducted in Japan and included patients aged ≥20years of age and treated for acute alcohol intoxication without or with IVF. The primary outcome was the length of the ED stay and the treatments were compared by time-to-event analysis. RESULTS A total of 106 patients, 42 treated without IVF and 64 with IVF. The baseline characteristics of the two groups were similar. Kaplan-Meier analysis and the generalized Wilcoxon test found no significant difference between the two treatments in the time to ED discharge. The median time was 189 (IQR 160-230) minutes without IVF and 254.5 (203-267 minutes with IVF; p=0.052). A Cox proportional hazards regression model adjusted for potential confounding variables found that patients treated with IVF were less likely to be discharged earlier than those treated without IVF (HR 0.54, 95% CI: 0.35-0.84, p=0.006). CONCLUSIONS IVF for treatment of acute alcoholic intoxication prolonged ED length of stay even after adjustment for potential confounders. Patients given IVF for acute alcohol intoxication should be selected with care.
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Abstract
ED observation units (EDOUs) are designed for patients who require diagnostics or therapeutics beyond the initial ED visit to determine the need for hospital admission. Best evidence is that this care be delivered via ordersets or protocols. Occasionally, patients present with conditions that are amenable to EDOU care but fall outside the commonly used protocols. This article details a few of these conditions: abnormal uterine bleeding, allergic reaction, alcohol intoxication, acetaminophen overdose and sickle cell vaso-occlusive crisis. It is not meant to be exhaustive as patient care needs can vary hospital to hospital.
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Affiliation(s)
- Matthew A Wheatley
- Department of Emergency Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive Southeast, Atlanta, GA 30303, USA.
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Abstract
Ethanol intoxication and ethanol use are associated with a variety of metabolic derangements encountered in the Emergency Department. In this article, the authors discuss alcohol intoxication and its treatment, dispel the myth that alcohol intoxication is associated with hypoglycemia, comment on electrolyte derangements and their management, review alcoholic ketoacidosis, and end with a section on alcoholic encephalopathy.
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Affiliation(s)
- Michael G Allison
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD, USA; Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Baltimore, MD 21201, USA
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD, USA; Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Baltimore, MD 21201, USA.
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Perez SRS, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol‐intoxicated patients in the emergency department: A randomised controlled trial. Emerg Med Australas 2013; 25:527-34. [DOI: 10.1111/1742-6723.12151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Siegfried RS Perez
- Department of Emergency Medicine Gold Coast Hospital Southport Queensland Australia
- Faculty of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
| | - Gerben Keijzers
- Department of Emergency Medicine Gold Coast Hospital Southport Queensland Australia
- Faculty of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
- Griffith Health Institute Griffith University Gold Coast Queensland Australia
| | - Michael Steele
- Griffith Graduate Research School Griffith University Gold Coast Queensland Australia
| | - Joshua Byrnes
- Griffith Health Institute Griffith University Gold Coast Queensland Australia
- Centre for Applied Health Economics, School of Medicine Griffith University Gold Coast Queensland Australia
| | - Paul A Scuffham
- Griffith Health Institute Griffith University Gold Coast Queensland Australia
- Centre for Applied Health Economics, School of Medicine Griffith University Gold Coast Queensland Australia
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Influence of antemortem perfusion on autopsy blood ethanol concentration. Forensic Toxicol 2011. [DOI: 10.1007/s11419-011-0127-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
This article discusses the physiology and clinical syndromes involved in ethanol absorption, intoxication, and withdrawal, with special emphasis on the evidentiary backing for common treatments, as well as some discussion of the medicolegal sequelae of treatment of ethanol abusers in the emergency department.
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Tosun Z, Aksu R, Guler G, Esmaoglu A, Akin A, Aslan D, Boyaci A. Propofol-ketamine vs propofol-fentanyl for sedation during pediatric upper gastrointestinal endoscopy. Paediatr Anaesth 2007; 17:983-8. [PMID: 17767636 DOI: 10.1111/j.1460-9592.2007.02206.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of this study was to compare the clinical efficacy and safety of propofol-ketamine with propofol-fentanyl in pediatric patients undergoing diagnostic upper gastrointestinal endoscopy (UGIE). METHODS This was a prospective, randomized, double blinded comparison of propofol-ketamine with propofol-fentanyl for sedation in patients undergoing elective UGIE. Ninety ASA I-II, aged 1 to 16-year-old patients were included in the study. Heart rate (HR), systolic arterial pressure, peripheral oxygen saturation, respiratory rate (RR) and Ramsey sedation scores of all patients were recorded perioperatively. Patients were randomly assigned to receive either propofol-ketamine (PK; n = 46) or propofol-fentanyl (PF; n = 44). PK group received 1 mg x kg(-1) ketamine + 1.2 mg x kg(-1) propofol, and PF group received 1 microg x kg(-1) fentanyl + 1.2 mg x kg(-1) propofol for sedation induction. Additional propofol (0.5-1 mg x kg(-1)) was administered when a patient showed discomfort in either group. RESULTS The number of patients who needed additional propofol in the first minute after sedation induction was eight in Group PK (17%), and 22 in Group PF (50%) (P < 0.01) and those who did not need additional propofol throughout the endoscopy were 14 in Group PK (30%) and three in Group PF (7%) (P < 0.01). HR and RR values after induction in Group PF were significantly lower than Group PK (P < 0.01). CONCLUSIONS Both PK and PF combinations provided effective sedation in pediatric patients undergoing UGIE, but the PK combination resulted in stable hemodynamics and deeper sedation though more side effects.
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Affiliation(s)
- Zeynep Tosun
- Department of Anesthesiology, Erciyes University School of Medicine, Kayseri, Turkey.
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Karapinar B, Yilmaz D, Demirağ K, Kantar M. Sedation with intravenous ketamine and midazolam for painful procedures in children. Pediatr Int 2006; 48:146-51. [PMID: 16635173 DOI: 10.1111/j.1442-200x.2006.02186.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Children often require relief of pain and anxiety when undergoing painful procedures. The purpose of this study is to evaluate the effectiveness and safety of painful pediatric procedures performed by pediatric intensivist, using the combination of intravenous ketamine and midazolam for sedation and analgesia. METHODS The records of the patients who received intravenous ketamine-midazolam combination for painful procedures in the pediatric sedation unit of a university hospital over a 3 year period were retrospectively reviewed to determine indications, dosing, assessment of the level of sedation, adverse events, and recovery time for each procedural sedation and analgesia. RESULTS A total of 227 children aged 4 months to 18 years were admitted to the pediatric sedation unit for a total of 356 procedures. The indications for procedural sedation and analgesia included bone marrow aspiration or biopsy (50.8%), central venous catheter insertion (27%), and others (22%). A total of 46 adverse events (12.9%) were observed. These adverse events included SpO2 below 85% without apnea (n = 14), apnea (n = 3), transient stridor (n = 2), hypertension and tachycardia (n = 8), hypersalivation (n = 6), vomiting (n = 5), hallucinatory emergence reaction (n = 4), and rash (n = 4). There were no adverse outcomes attributable to ketamine and midazolam combination. CONCLUSION Skilled pediatric intensivists can safely and effectively administer ketamine and midazolam to facilitate painful procedures outside the operating room setting.
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Affiliation(s)
- Bülent Karapinar
- Pediatric Intensive Care Unit, Faculty of Medicine, Ege University, Izmir, Turkey.
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Lisander B, Lundvall O, Tomner J, Jones AW. Enhanced rate of ethanol elimination from blood after intravenous administration of amino acids compared with equicaloric glucose. Alcohol Alcohol 2005; 41:39-43. [PMID: 16087660 DOI: 10.1093/alcalc/agh188] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS To investigate the effect of an amino acid mixture given intravenously (i.v.) on the rate of ethanol elimination from blood compared with equicaloric glucose and Ringer's acetate as control treatments. METHODS In a randomized cross-over study, six healthy men (mean age 23 years) fasted overnight before receiving either Ringer's acetate, glucose or the amino acid mixture (Vamin 18 g N/l) by constant rate i.v. infusion over 4.5 h. Ethanol (0.4 g/kg) was given by an i.v. infusion lasting 60 min during the time each of the treatments was administered. At various times post-infusion, blood samples were taken for determination of ethanol by headspace gas chromatography. Blood glucose and heart rate were monitored at regular intervals. Concentration-time profiles of ethanol were plotted for each subject and the rate of ethanol disappearance from blood as well as other pharmacokinetic parameters were compared by repeated measures analysis of variance. RESULTS The rate of ethanol elimination from blood was increased significantly (P < 0.001) after treatment with amino acids (mean +/- SD, 0.174 +/- 0.011 g/l/h) compared with equicaloric glucose (0.121 +/- 0.016 g/l/h) or Ringer's acetate (0.110 +/- 0.013 g/l/h). Heart rate was also slightly higher during infusion of the amino acid mixture (P < 0.05). CONCLUSIONS When the rate of ethanol elimination from blood is relatively slow, such as after an overnight fast, it can be increased by approximately 60% after treatment with i.v. amino acids. The efficacy of amino acid treatment was not related to the supply of calories because glucose was no more effective than Ringer's acetate. We suggest that amino acids might increase hepatic oxygen consumption, resulting in a more effective conversion of NADH to NAD+ in mitochondria. An important feature of the experimental design was ensuring hepatic availability of amino acids during much of the time that ethanol was being metabolized.
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Affiliation(s)
- Björn Lisander
- Department of Anaesthesiology, University Hospital, 581 85 Linköping, Sweden
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Bauman LA, Cannon ML, McCloskey J, Allen S, James RL, Tobin JR, Politis GD. Unconscious sedation in children: a prospective multi-arm clinical trial. Paediatr Anaesth 2002; 12:674-9. [PMID: 12472702 DOI: 10.1046/j.1460-9592.2002.00947.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND We report the evaluation of six sedative-hypnotic and analgesic combinations administered to children undergoing brief periods of unconscious (or deep) sedation for painful procedures. METHODS In a prospective, open-label, randomized, controlled study of six groups of 27-30 children each, patients were randomly assigned to receive propofol or methohexital for sedation-hypnosis, and one of three incremental doses of fentanyl or remifentanil, respectively. RESULTS An infusion of methohexital (10 mg.ml-1) combined with remifentanil (6.67 micro g.ml-1) provided significantly shorter geometric mean times to initial emergence, to eye-opening and to discharge, and required airway interventions that were not significantly more frequent than all groups sedated with propofol and fentanyl. CONCLUSIONS The combination of methohexital and remifentanil appears to be a satisfactory method for unconcious sedation for short painful procedures in children.
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Affiliation(s)
- Loren A Bauman
- Department of Anesthesiology, Section of Pediatric Anesthesiology and Critical Care Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA.
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