Blood alcohol measurements in the emergency department: who needs them?

Alcohol and the head-injured patient

Alcohol intoxication is a major predisposing factor for trauma in general and head injury in particular. The management of the head-injured patient is highly contingent on the accurate assessment of this patient’s consciousness, which is invariably impaired if the patient is intoxicated. This complicates the decision-making process and impedes the promptness needed in management when the head injury is severe. Furthermore, the prognosis of the head injury can depend on the patient’s degree and pattern of intoxication. This article presents some of the latest epidemiological data about the association of alcohol and head injury. It also highlights some of the challenges posed by alcohol intoxication in the management of head-injured patients, and examines the importance of documenting intoxication in head-injured patients.

Twenty per hour: altered mental state due to ethanol abuse and withdrawal

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.

Detection of problem-drinkers in an emergency department using a breathalyser and questionnaire

Over a 2-week period in January 1990 consecutive adult emergency attenders were breathalysed and screened for problem drinking using the WHO screening instrument. Results were compared with a similar study conducted 8 years previously. Of the patients tested, 12.5% had a positive alcohol in 1990 compared with 16% in 1982. Of those with positive alcohol results, the mean blood alcohol equivalent (BAE) concentration was significantly (p=0.0006) lower in 1990 (73.6+/-65.1; mg/100 ml; mean+/-SD) when compared to those levels found in 1982 (136.9+/-102.4 mg/100 ml). There was also significant reductions in 1990 of positive breath alcohol attenders both from road traffic accidents (p<0.03), and from head injuries (p<0.005) compared to 1982. In 1990 the questionnaire was positive in 23% of attendees. These studies suggest a trend towards less alcohol misuse in emergency department patients, but nevertheless indicate high rates of problem drinking. It is suggested that alcohol breathalysers be available in emergency departments to assist the detection of alcohol misusers and predict alcohol-associated medical problems.

Accuracy of an enzymatic assay device for serum ethanol measurement

OBJECTIVE

To determine the accuracy of an enzymatic assay of serum to measure blood ethanol levels in the emergency department.

METHODS

A blinded, prospective study of emergency department patients for whom a blood ethanol was ordered and performed. After skin prep with betadine, two blood samples were drawn into separate sodium fluoride-containing vacutainers. One sample was sent to the hospital laboratory for blood ethanol analysis. The other was centrifuged for 5 minutes and the serum was then assayed using the QED A350 Saliva Alcohol Test. Values were then compared by kappa statistic and Pearson's correlation. Sensitivity and specificity calculations were determined for the QED device to detect a blood ethanol > 100 mg/dL.

RESULTS

Sixty-six patients were enrolled. The kappa value for QED compared to lab blood ethanol was 0.93. The Pearson's correlation coefficient was 0.94. The QED, in general, tended to overestimate blood ethanol slightly. The QED was 100% sensitive and 82% specific in detecting a blood ethanol > 100 mg/dL.

CONCLUSIONS

Analysis of serum using a QED A350' is a sensitive and accurate index of low to moderate increases in blood ethanol appropriate to emergency department, but not legal, interpretation.

Predictive model to identify trauma patients with blood alcohol concentrations > or = 50 mg/dl

OBJECTIVE

To develop a simple model for identification of trauma patients who are likely to have a blood alcohol concentration > or = 50 mg/dL (BAC + 50).

METHODS

Demographic, clinical, and BAC data were collected from the clinical trauma registry and toxicology data base at a Level I trauma center. Logistic regression was used to analyze data from 11,206 patients to develop a predictive model, which was validated using a subsequent cohort of 3,523 patients.

RESULTS

In the model development cohort, alcohol was detected in the blood of 3,180 BAC-tested patients (28.7%), of whom 91.2% had a BAC + 50 status. Preliminary analysis revealed associations between a BAC + 50 status and sex, age, race, injury type (intentional vs. unintentional), and time of injury (night vs. day and weekend vs. weekday). A predictive model using four attributes (sex and injury type) identified patients at low, medium, and high risk for being BAC + 50. The model was validated using the second group of patients.

CONCLUSION

Injured patients with a high probability of being alcohol positive can be identified using a simple scoring system based on readily available demographic and clinical information.

Utilisation of hormone replacement therapy by women doctors

OBJECTIVES

To ascertain the prevalence and duration of use of hormone replacement therapy by menopausal women doctors.

DESIGN

Postal questionnaire.

SETTING

General practices in the United Kingdom.

SUBJECTS

Randomised stratified sample of women doctors who obtained full registration between 1952 and 1976, taken from the current principal list of the Medical Register.

MAIN OUTCOME MEASURES

Prevalence and duration of use of hormone replacement therapy; menopausal status.

RESULTS

Overall, 45.7% (436/954) of women doctors aged between 45 and 65 years had ever used hormone replacement therapy. When the results from women still menstruating regularly were excluded, 55.2% (428) were ever users and 41.2% (319) current users. The cumulative probability of remaining on hormone replacement therapy was 0.707 at five years and 0.576 at 10 years.

CONCLUSIONS

Women doctors have a higher prevalence of use of hormone replacement therapy than has been reported for other women in the United Kingdom, and most users seem to be taking hormone replacement therapy for more than five years. The results may become generalisable to the wider population as information on the potential benefits of hormone replacement therapy is disseminated.

Effects of alcohol intoxication on the initial assessment of trauma patients

STUDY OBJECTIVES

To evaluate the influence of alcohol intoxication on the initial assessment and treatment of trauma patients.

DESIGN

A prospective study of 2,237 trauma patients 18 years of age or older admitted to a Level I trauma center over a 19-month period.

RESULTS

The study population was primarily male (78%) and white (73%) and had sustained blunt trauma (79%). One thousand fifty-three patients (47.1%) had positive blood alcohol concentration (BAC); median BAC in patients with any detectable alcohol was 179 mg/dL. When stratified by injury severity categories and compared with nonintoxicated (BAC less than 100 mg/dL) patients, intoxicated patients with an Injury Severity Score (ISS) of 1 to 15 were more likely to undergo the following: field and/or ED intubation (relative risk [RR], 2.22; 95% confidence interval [CI], 1.7 to 2.7); diagnostic peritoneal lavage (RR, 1.83; CI, 1.43 to 2.3); head computed tomography scanning (RR, 1.18; CI, 1.0 to 1.4); and intracranial pressure monitoring (RR, 1.41; CI, 0.74 to 2.7). The effects were less pronounced for those patients with an ISS of more than 15, except for intracranial pressure monitoring where patients with an ISS of more than 15 were 47% more likely to have intracranial pressure monitoring if intoxicated (RR, 1.47; CI, 1.2 to 1.9).

CONCLUSION

Acute intoxication appears to alter the initial assessment of injury severity, resulting in an increased use of invasive diagnostic and therapeutic procedures.

Refusal of care and discharging 'difficult' patients from the emergency department

Patients generally have the right to refuse medical care, a right based on certain legal precedents. Its application in the emergency department leads to difficult decisions for the emergency physician. A model that allows the emergency physician to determine the capacity of a patient to refuse care is presented. Certain types of patients regularly present problems in their treatment. These include psychiatric patients, narcotics abusers, alcoholics, "street people," and some patients with migraine headaches. They represent some of our most difficult decisions because the treatment required for the patient is often clear and the patient refuses care or demands inappropriate care.

Written case simulations: do they predict physicians' behavior?

Written case simulations are often used to investigate physicians' decision making and clinical competence. Their use rests on the assumption that physicians' responses to written simulations closely agree with their responses to actual clinical encounters, yet this assumption of criterion validity has received little attention. To determine the ability of written case simulations to predict actual clinical behavior, we applied methodologic criteria to published articles that used written simulations. Only 11 (15%) of 74 articles included an assessment of the criterion validity of their written case simulations. Only 2 of those 11 studies were designed and executed in such a way that criterion validity could be fully interpreted. No clear consensus emerged from an examination on the 11 studies on how well responses to written case simulations perform as proxy measures of actual behavior. More work is needed before assuming that written case simulations measure actual behavior.