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Kraaijvanger N, Raven W, van Dijken T, Gresnigt F. The PIRATE mnemonic: providing a structured approach in the care for intoxicated patients at the emergency department. Int J Emerg Med 2024; 17:30. [PMID: 38429763 PMCID: PMC10905834 DOI: 10.1186/s12245-024-00606-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/22/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Expertise in toxicology is essential for acute care providers, as intoxicated patients frequently present to Emergency Departments. These patients can be challenging for care providers because they often present with uncertain substance exposure and unknown dose and timing of these exposures. METHODS The Dutch Society of Emergency Physicians has developed an mnemonic to support treating physicians in a structured approach for the management of (undifferentiated) intoxicated patients. RESULTS The PIRATE mnemonic was developed, which includes the following aspects and sequence of care for the intoxicated patient: primary survey, investigation & identification, risk assessment, ADME (comprising pharmacokinetic therapeutic targets: absorption, distribution, metabolism, elimination), therapy and evaluation. CONCLUSION The toxicology section of the Dutch Society of Emergency Physicians developed the PIRATE mnemonic to provide a structured approach in the management of patients presenting with acute intoxications to Emergency Departments. It summarizes the essential steps and priorities required in the care of intoxicated patients. Further, it provides a common strategy for all specialties involved in the care of the acutely intoxicated patient, contributing to developing greater competence in poisoning management.
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Affiliation(s)
- Nicole Kraaijvanger
- Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands.
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands.
| | - Wouter Raven
- Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands
| | - Trudy van Dijken
- Diakonessenhuis, Bosboomstraat 1, Utrecht, 3582 KE, the Netherlands
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands
| | - Femke Gresnigt
- OLVG hospital, Oosterpark 9, Amsterdam, 1091 AC, the Netherlands
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands
- Medical toxicology at Dutch Poison Information Center, Utrecht, the Netherlands
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Verheij C, Haagsma JA, Koch BCP, Segers AEM, Schuit SCE, Rood PPM. Screening for hazardous alcohol use in the Emergency Department: Comparison of phosphatidylethanol with the Alcohol Use Disorders Identification Test and the Timeline Follow-back. Alcohol Clin Exp Res 2022; 46:2225-2235. [PMID: 36520053 PMCID: PMC10107187 DOI: 10.1111/acer.14958] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/10/2022] [Accepted: 10/07/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Up to 15% of all visits to the Emergency Department (ED) are alcohol related. Identification of problematic alcohol use is important in this setting because it allows for intervention and prevention efforts. This study investigated the correlation between the objective phosphatidylethanol (PEth) marker and the subjective Alcohol Use Disorders Identification Test (AUDIT) and Timeline Followback Questionnaire (TLFB) as screening methods for hazardous alcohol use in the general ED population. METHODS This prospective cohort study included 301 ED patients (57% male) who were seen in the ED and required to give a blood sample. The correlation between the values of PEth (PEth 16:0/18:1 and PEth 16:0/18:2) and the scores on the AUDIT and TLFB were analyzed using Spearman's rank correlation coefficient. Differences between risk categories of PEth and AUDIT were also examined. RESULTS The Spearman correlation coefficients between PEth 16:0/18:1|PEth 16:0/18:2 values and the AUDIT scores were moderate (PEth 16:0/18:1: 0.67, p < 0.001; PEth 16:0/18:2: 0.67, p < 0.001). Of the patients who scored 'low risk drinking/abstinence' according to the AUDIT questionnaire, respectively 1% and 4% had PEth 16:0/18:1|PEth 16:0/18:2 values indicating excessive alcohol use, and another 10% and 12% had PEth 16:0/18:1|PEth 16:0/18:2 values indicating moderate alcohol consumption. Of the 12 (PEth 16:0/18:1) and 25 (PEth 16:0/18:2) patients with high-risk values, respectively 25% and 40% scored in the lowest risk category on the AUDIT questionnaire. Spearman correlation coefficients between PEth 16:0/18:1|PEth 16:0/18:2 values and TLFB two-week scores were high (PEth 16:0/18:1: 0.74, p < 0.001; PEth 16:0/18:2: 0.82, p < 0.001). CONCLUSIONS AUDIT scores were moderately correlated with PEth values in the general ED population. In almost all cases where there was not a good correlation, patients had high PEth values with low AUDIT scores. We conclude that PEth identifies patients with problematic alcohol use who are missed by the AUDIT questionnaire and therefore PEth could be used as an additional screening method for hazardous alcohol use in this population.
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Affiliation(s)
- Carolien Verheij
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Juanita A Haagsma
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anne E M Segers
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Stephanie C E Schuit
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Board of Directors, University Medical Center Groningen, Groningen, The Netherlands
| | - Pleunie P M Rood
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Supervía A, Ibrahim-Achi D, Miró Ò, Galicia M, Ferrando JP, Leciñena MA, de L'Hotellerie MJV, Bajo ÁB, Martín-Pérez B, Burillo-Putze G. Impact of co-ingestion of ethanol on the clinical symptomatology and severity of patients attended in the emergency department for recreational drug toxicity. Am J Emerg Med 2021; 50:422-427. [PMID: 34482128 DOI: 10.1016/j.ajem.2021.08.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Investigate whether there are differences in the drugs involved, symptomatology and severity of drug intoxication in patients with co-ingestion of alcohol attended in hospital emergency departments (ED). METHOD Patients attended in 11 Spanish EDs due to drug intoxication were included. Sociodemographic and clinical characteristics were collected. A combined adverse event of cardiorespiratory arrest, need for intubation, and admission to intensive care or death was considered as the primary indicator of severity. The symptomatology and severity were compared adjusted for age, sex and type of drug based on whether or not ethanol had been co-ingested. RESULTS 3925 patients (alcohol co-ingestion: 2290, 58.3%) with a mean age of 33 (±11) years were included, and 25% were women. Co-ingestion of alcohol was observed in younger patients, in EDs in areas with high leisure tourism, on holidays and during the early morning hours. It was also more frequent in individuals intoxicated by amphetamine derivatives (66.2%) and cocaine (65.7%), and was more frequently associated with a reduction in consciousness (odds ratio [OR] = 2.13, 95% confidence interval [CI] 1.69-2.67) and agitation/aggressiveness (OR = 1.22, 95% = 1.04-1.43). A combined adverse event was observed in 114 patients (2.9%) with no differences between individuals co-ingesting or not ethanol (3.1% vs. 2.7%; OR = 1.11, 95% CI = 0.74-1.65). CONCLUSION Co-ingestion of alcohol is more frequent in individuals intoxicated by cocaine and amphetamines and predisposes a greater reduction in the level of consciousness or agitation, although there are no differences in the severity of the episodes of drug intoxication.
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Affiliation(s)
- August Supervía
- Emergency Department and Functional Toxicology Unit, Hospital del Mar, Barcelona, Spain
| | - Dima Ibrahim-Achi
- Emergency Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Òscar Miró
- Area of Emergencies, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Miguel Galicia
- Area of Emergencies, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | | | | | | | - Ángel Bajo Bajo
- Emergency Department, Hospital Clínico de Salamanca, Salamanca, Spain
| | | | - Guillermo Burillo-Putze
- Department of Physical Medicine and Pharmacology, Universidad de La Laguna, Tenerife, Spain.
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Panken S, Wauters L, Gijbels R, Quintens H, Dorette AAA, Verelst S. The 12 -year evolution of emergency department alcohol-related admissions in a student city. Acta Clin Belg 2021; 77:742-747. [PMID: 34412571 DOI: 10.1080/17843286.2021.1966582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate the trends in incidence of alcohol-intoxicated patients who present at the emergency department (ED), as well as the characteristics of these patients. METHODS Retrospective observational study based on data collected from 2008 until 2019 in two EDs in Leuven, Belgium. As a routine ED procedure, a blood alcohol concentration (BAC) test is ordered for all patients suspected of alcohol use as a primary presenting sign. Patients older than 10 years of age with a BAC ≥ 0.1 g/L were included. BAC levels, age, gender and proportion of repeat admissions were analysed. RESULTS The absolute number of patients with a positive BAC test increased from 1260 in 2008 to 1908 in 2019 (51.4%). Male-to-female ratio remained stable (2:1). In the University Hospital Leuven , the most represented age group shifted from 20-29 and 40-49 year olds (2008) to 50-59 year olds (2019). The most common age groups in Heilig Hart Leuven were 10-19 year olds and 20-29 year olds, which remained stable over the study period. The readmission rate was 18% within the entire study period with a range of 2 to 46 times. CONCLUSION Our study showed an annual increase in alcohol-related admissions. The highest rates of alcohol-related ED visits occurred in the age group 50-59. Patients with a repeat admission accounted for a large number of the total alcohol-related visits, placing a major burden on our healthcare system. It will be a challenge to timely detect patients at risk, regardless of their age, to prevent future ED admissions.
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Affiliation(s)
- Steffi Panken
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Ku Leuven - University, Leuven, Belgium
| | - Lina Wauters
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Ku Leuven - University, Leuven, Belgium
| | - Roos Gijbels
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Ku Leuven - University, Leuven, Belgium
| | - Hilde Quintens
- Department of Emergency Medicine, Regionaal Ziekenhuis Heilig Hart Leuven, Leuven, Belgium
| | | | - Sandra Verelst
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Ku Leuven - University, Leuven, Belgium
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Covino M, Di Nicola M, Pepe M, Moccia L, Panaccione I, Lanzotti P, Montanari S, Janiri L, Sani G, Franceschi F. Predictors of clinical severity in subjects attending the Emergency Department for substance use: a ten-year cross-sectional study. Am J Emerg Med 2021; 49:287-290. [PMID: 34175732 DOI: 10.1016/j.ajem.2021.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Substance-related referrals to the Emergency Department (ED) are rising. Multiple substance use is frequent, and psychiatric patients represent a high-risk population. Our study aimed at identifying risk factors for increased severity in ED attendances for substance use. METHODS We retrospectively evaluated consecutive patients attending the ED over ten years for substance-related problems, subdivided according to the triage code as having a life-threatening (LT), potentially life-threatening (P-LT), and non-life-threatening (N-LT) condition. RESULTS Substance/drug intake for deliberate self-harm was a risk factor for being classified as LT compared to both P-LT (OR = 6.357; p ≤ 0.001) and N-LT (OR = 28.19; p ≤ 0.001). Suicide attempts (OR = 4.435; p = 0.022) and multiple substance use (OR = 1.513; p = 0.009) resulted as risk factors for P-LT, compared to N-LT. Psychiatric diagnosis (OR = 1.942; p = 0.042) and multiple substance use (OR = 1.668; p = 0.047) were risk factors for being classified as LT rather than N-LT. CONCLUSIONS In our sample, self-harming overdoses were the strongest risk factor for highest overall severity in a real-world setting. Psychiatric disorders and multiple substance use also increased the risk for greater severity at presentation. Substance use worsens patients' clinical picture and management, suggesting the need for consultation-liaison psychiatry services in emergency contexts and highlighting the role of EDs as key sites for identification and early intervention.
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Affiliation(s)
- Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Marco Di Nicola
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy.
| | - Maria Pepe
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Lorenzo Moccia
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Isabella Panaccione
- Mental Health Department, ASL Roma 1, Piazza Santa Maria della Pietà, 5, 00135 Rome, Italy
| | - Pierluigi Lanzotti
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Silvia Montanari
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Luigi Janiri
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Gabriele Sani
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, L.go Francesco Vito, 1, 00168 Rome, Italy
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Piccioni A, Cicchinelli S, Saviano L, Gilardi E, Zanza C, Brigida M, Tullo G, Volonnino G, Covino M, Franceschi F, La Russa R. Risk Management in First Aid for Acute Drug Intoxication. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218021. [PMID: 33143348 PMCID: PMC7663746 DOI: 10.3390/ijerph17218021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
Drug abuse (cannabis, cocaine, opiates, and synthetic drugs) is an increasing phenomenon, especially in the younger population, thus leading to more cases of intoxication requiring evaluation in the emergency department and subsequent hospitalization. In 2017, 34.2% of students reported having used an illegal psychoactive substance in their lifetime, while 26% reported having done so over the past year. We made a review about the effectiveness of the role of the temporary observation unit in the emergency department to improve management of acute drugs intoxication. We checked medical literature from the last 10 years (2009-2019). The following electronic databases were systematically searched: MEDLINE-PubMed, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials. Then, a systematic review was carried out according to the Preferred Reporting Items for Systematic Review standards. Intoxicated patients usually display a favorable medical course, few diagnostic and therapeutic interventions, a short stay in the hospital, and, when hospitalization is needed, semi-intensive therapy is a feasible solution; therefore, intoxicated patients are ideal candidates for a temporary observation unit. The emergency department is very important to manage intoxicated patients; however, the hospitalization of these patients is often not necessary.
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Affiliation(s)
- Andrea Piccioni
- Emergency Medicine Department, University Polyclinic Foundation A. Gemelli, IRCCS (Scientific Institute for Hospitalization and Treatment), 00168 Rome, Italy; (A.P.); (S.C.); (L.S.); (M.B.); (G.T.); (M.C.)
| | - Sara Cicchinelli
- Emergency Medicine Department, University Polyclinic Foundation A. Gemelli, IRCCS (Scientific Institute for Hospitalization and Treatment), 00168 Rome, Italy; (A.P.); (S.C.); (L.S.); (M.B.); (G.T.); (M.C.)
| | - Luisa Saviano
- Emergency Medicine Department, University Polyclinic Foundation A. Gemelli, IRCCS (Scientific Institute for Hospitalization and Treatment), 00168 Rome, Italy; (A.P.); (S.C.); (L.S.); (M.B.); (G.T.); (M.C.)
| | - Emanuele Gilardi
- Emergency-Admission Department, Biomedical Campus, 00128 Rome, Italy;
| | - Christian Zanza
- Department of Anesthesia, Critical Care and Emergency Medicine, Pietro and Michele Ferrero Hospital, 12051 Verduno, Italy;
| | - Mattia Brigida
- Emergency Medicine Department, University Polyclinic Foundation A. Gemelli, IRCCS (Scientific Institute for Hospitalization and Treatment), 00168 Rome, Italy; (A.P.); (S.C.); (L.S.); (M.B.); (G.T.); (M.C.)
| | - Gianluca Tullo
- Emergency Medicine Department, University Polyclinic Foundation A. Gemelli, IRCCS (Scientific Institute for Hospitalization and Treatment), 00168 Rome, Italy; (A.P.); (S.C.); (L.S.); (M.B.); (G.T.); (M.C.)
| | - Gianpietro Volonnino
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, 00161 Rome, Italy;
| | - Marcello Covino
- Emergency Medicine Department, University Polyclinic Foundation A. Gemelli, IRCCS (Scientific Institute for Hospitalization and Treatment), 00168 Rome, Italy; (A.P.); (S.C.); (L.S.); (M.B.); (G.T.); (M.C.)
| | | | - Raffaele La Russa
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, 00161 Rome, Italy;
- Correspondence:
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