Intubation in acute alcohol intoxications at the emergency department

Gender-specific differences in comorbidities, in-hospital complications and outcomes in emergency patients with ethanol intoxication with and without multisubstance use

AIMS OF THE STUDY

To analyse gender-specific differences in comorbidities, multisubstance abuse, in-hospital complications, intensive care unit transfers and referrals to psychiatric wards of emergency department patients with ethanol intoxication. Several lines of evidence suggest an influence of gender differences on diagnostic and therapeutic approaches to various diseases.

METHODS

Over a period of 7 years, all patients with signs or symptoms of ethanol intoxication and a positive blood ethanol test admitted for the first time to the emergency department of a Swiss regional tertiary referral hospital were prospectively enrolled. Patients were categorised into two subgroups: patients without additional drug use were considered ethanol-only cases, whereas patients who had also ingested other substances (as determined from bystanders, physicians and urine drug screening) were considered multisubstance cases. A retrospective analysis of this database evaluated gender-specific differences in comorbidities, multisubstance abuse, in-hospital complications, intensive care unit transfers and referrals to psychiatric wards within these two subgroups. Statistical analysis included Fisher's exact test for categorical data and Wilcoxon rank sum test for continuous data.

RESULTS

Of 409 enrolled patients, 236 cases were ethanol-only and 173 were multisubstance cases. The three most common comorbidities in multisubstance patients showed significant gender differences: psychiatric disorders (43% males vs 61% females; p = 0.022), chronic ethanol abuse (55% males vs 32% females; p = 0.002) and drug addiction (44% males vs 17% females; p = 0.001). Gender differences were also found for the most frequently co-ingested substances: benzodiazepines (35% males vs 43% females; p = 0.014), cannabis (45% males vs 24% females; p = 0.006) and cocaine (24% males vs 6% females; p = 0.001). Male and female ethanol-only patients were transferred to the intensive care unit in 8% of cases. In multisubstance cases, 32% of male and 43% of female patients were transferred to the intensive care unit (no significant gender difference). The psychiatric ward referral rate in male (30%) and female (48%) patients with multisubstance abuse was significantly different (p = 0.028). No significant gender difference in psychiatric ward referral rates was observed for ethanol-only patients (12% males, 17% females).

CONCLUSION

Among emergency department patients admitted with ethanol intoxication, gender differences in comorbidities, substance use and psychiatric ward referrals were highly significant among patients who presented with multisubstance abuse. Rates of intensive care unit transfer for patients with ethanol intoxication are substantial for both genders, reflecting relevant disease burden and resource demand, as well as the need for further preventive efforts.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness

OBJECTIVE

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason.

METHODS

Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma.

RESULTS

In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively.

CONCLUSION

Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Aspiration risk in relation to Glasgow Coma Scale score and clinical parameters in patients with severe acute alcohol intoxication: a single-centre, retrospective study

OBJECTIVES

In alcohol intoxicated patients, the decision for or against airway protection can be challenging and is often based on the Glasgow Coma Scale (GCS). Primary aim of this study was to analyse the aspiration risk in relation to the GCS score and clinical parameters in patients with severe acute alcohol monointoxication. Secondary aim was the association between the blood alcohol level and the GCS score.

SETTING

Single-centre, retrospective study of alcoholised patients admitted to a German intensive care unit between 2006 and 2020.

PARTICIPANTS

A total of n=411 admissions were eligible for our analysis.

CLINICAL MEASURES AND ANALYSIS

The following data were extracted: age, gender, admission time, blood alcohol level, blood glucose level, initial GCS score, GCS score at admission, vital signs, clinical signs of aspiration and airway management measures. The empirical distribution of continuous and categorical data was calculated. Binary multivariable logistic regression analysis was used to identify possible risk factors for aspiration.

RESULTS

The mean age was 35 years. 72% (n=294) of the admissions were male. The blood alcohol level (mean 2.7 g/L±1.0, maximum 5.9 g/L) did not correlate with the GCS score but with the age of the patient. In univariate analysis, the aspiration risk correlated with blood alcohol level, age, GCS score, oxygen saturation, respiratory rate and blood glucose level and was significantly higher in male patients, on vomiting, and in patients requiring airway measures. Aspiration rate was 45% (n=10) in patients without vs 6% (n=3) in patients with preserved protective reflexes (p=0.0001). In the multivariate analysis, only age and GCS score were significantly associated with the risk of aspiration.

CONCLUSION

Although in this single-centre, retrospective study the aspiration rate in severe acute alcohol monointoxicated patients correlates with GCS and protective reflexes, the decision for endotracheal intubation might rather be based on the presence of different risk factors for aspiration.

Clinical profile and outcome of acute organophosphate poisoning in children of Upper Egypt: a cross-sectional study

Background

Organophosphates are one of the most common agents of poisoning in developing countries including Egypt. Due to lack of data about characteristics of organophosphates poisoning in our localities, we aimed to evaluate its clinical pattern and factors affecting outcome.

Methods

It was a cross-sectional study conducted in South valley University hospital between January 2019 and December 2019. It included all children ≤16 years of age presented with organophosphates poisoning. Diagnosis was performed from the history taken from the patient’s relatives and presenting symptoms. Demographic data, mode and route of poisoning, time from exposure to presentation, clinical symptomatology, grading and routine investigations were evaluated in addition to treatment taken and outcome.

Results

During the study period, 108 children; mean age was 7.95 ± 4.11 years (range 1. 5-16 years) presented with organophosphorous poisoning. Sixty five (60%) cases were females and 43 (40%) were males. Unintentional acts (87%) were detected more than suicidal (13%) and inhalation route (63.8%) more than ingestion (36. 2%). Miosis was the most frequent clinical sign (100%) followed by respiratory distress (77.7%). Regarding time of presentation to emergency department, 43 (40%) cases were presented within 6 h while others presented more than 6 h post-exposure. Mechanical ventilation (MV) was needed for 14 (13%) cases and 6 (5.5%) cases died due to respiratory failure. Duration of hospital stay, mean time interval from toxic exposure to hospital presentation, leucocytosis, need for MV and cumulative dose of pralidoxime were significantly higher in non survivors than survivors while Pao2 (partial arterial oxygen) and GCS (Glasgow coma scale) were significantly lower.

Conclusion

This study concluded that time consumed till presentation to hospital, low GCS, need for MV, leucocytosis, decreased PaO2 and increased cumulative dose of pralidoxime were independent risk factors of mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02563-w.