Identification of signs and symptoms related to alcohol misuse Recognition that ED attendance provides an opportunity for brief intervention and health promotion Provision of information on the health risks associated with alcohol misuse ID: 1039047
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1. March 2016ALCOHOL AND THE EMERGENCY DEPARTMENT
2. Identification of signs and symptoms related to alcohol misuseRecognition that ED attendance provides an opportunity for brief intervention and health promotionProvision of information on the health risks associated with alcohol misuseRecognition of the signs and symptoms of alcohol withdrawal Management of alcohol withdrawalLEARNING OUTCOMES
3. Alcohol costs the NHS £3.5billion per yearThere are over 1 million attendances at A&E each year as a result of excessive alcohol consumptionAlcohol intoxication and withdrawal are common in ED and prompt treatment is required to reduce mortality and morbidity40% patients attend ED in the day but 70% attend ED at night14% of road traffic accidents are related to illegal blood alcohol levels3-6% adults in England have alcohol dependence18% adults binge drinkCONTEXT
4. Department of Health Chief Medical Officers' guideline for both men and women(2016)RECOMMENDATIONShttps://www.gov.uk/government/consultations/health-risks-from-alcohol-new-guidelines
5. Harmful drinking: a pattern of drinking that causes health problemsAlcohol dependence: a subjective awareness of a compulsion to drink on a regular basis with resulting withdrawal if consumption stops (see DSM5 and ICD10 definitions)Binge drinking: >8 units for men and > 6 units for women on a dayDEFINITIONS
6. 1 unit of alcohol is equal to:Half a pint of regular strength beer, lager or ciderA single (25ml) measure of spirits 1.5 units is equal to:A small (125 ml) glass of standard strength wineA 35 ml measure of spirits UNITS OF ALCOHOL
7. PHYSICAL AND PSYCHOLOGICAL HEALTH
8. QUESTIONS TO ASK
9. Smell of alcoholSlurred speech and ataxiaLethargyVomitingErratic behaviour and emotional labilityIn severe cases, reduced Glasgow coma Score, and collapseAirway protection, intubation and ventilation may be necessaryAll patients should have a blood glucoseIf there is a head injury, a CT scan should be done CLINICAL SIGNS OF ACUTE ALCOHOL INTOXICATION
10. Has patient previous ED attendances related to alcoholPatients should be safely mobile prior to departure from EDPatients with head injury should have a CT brain Patients with sustained cuts, lacerations and abrasions should have tetanus status documented and receive appropriate immunization Blood alcohol levels do not influence management Consider all causes of GCS and do not automatically attribute it to alcoholAll patients should have and alcohol, tobacco and recreational drug history recorded and be given health promotion adviceCLINICAL INTOXICATION
11. Patients may not be reliable in reporting substance use due to confusion, poor memory, failing to recognise the connection between symptoms and substance useHistory should include prescribed and over the counter medications as well as alcohol, tobacco and illicit drugsSocial stigma may prevent patients being forthcomingPotential impact on employmentFear of police or social services involvement Patients may not present at the time of an injuryBARRIERS TO DETECTION
12. FAST – Fast alcohol screening testAUDIT – Alcohol use disorders identification testPaddington test – Paddington Alcohol TestSeverity of alcohol dependence questionnaire - SADQSCREENING TOOLS
13. Brief interventions in ED are effective in reducing alcohol related harmsIt aims to identify an alcohol problem and motivate someone to do something about itIt may take as little as 5minutesAll patients who report alcohol consumption above the recommended amounts should have a brief intervention prior to dischargeBRIEF INTERVENTION IN THE ED
14. Understanding how much someone is drinkingAny negative effects that may be the result of alcohol consumptionExploring the benefits of reducing or stopping alcohol Exploring barriers to changeDiscuss personal target i.e. reduction or cessationDiscuss what plans and support need to be put in place to achieve this targetBRIEF INTERVENTION
15. When alcohol dependent individuals reduce or stop drinking they are at risk of withdrawal symptomsThis may occur within a few hours of the last drinkWhen acutely intoxicated individuals sober up, withdrawal symptoms may followMild withdrawal included nausea, vomiting, tremor, anxietyModerately severe cases include hallucinations, tachycardia and pyrexiaSevere cases progress to seizures, delirium tremens, Wernicke’s encephalopathy ALCOHOL WITHDRAWAL
16. Patients who present following a seizure may require airway supportPatients who are confused, have had seizures or head injury should be discussed urgently with a senior colleague for CT scan to exclude intracranial bleedsConsider possibility of cervical spine injury in any patient with head injuryWhat may alternative cause for patient’s symptoms be? Sepsis, intracranial pathology, hypoglycaemia, psychiatric?Malnourishment may lead to electrolyte abnormalities which should be treated as they may lead to arrhythmiaALCOHOL WITHDRAWAL
17. Malnutrition is associated with vitamin deficiencies so high dose Vitamin B should be administered parenterally to reduce risk of Wernicke’s EncephalopathyExamine patient for stigmata of chronic liver diseaseAbdominal pain could be due to pancreatitis, gastritis, peptic ulcer, perforation of duodenal and gastric ulcers, spontaneous bacterial peritonitis, alcohol induced hepatitisConsider alcoholic ketoacidosis when patients are vomiting and perform blood gas acid-base disturbance ALCOHOL WITHDRAWAL
18. Score patients regularly according to Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) to guide treatmentFirst line treatment is benzodiazepinesLong acting eg chlordiazepoxide is preferredIn ED severe withdrawal may require intravenous benzodiazepines which should be discussed with a senior ED colleaguePatients with liver disease are at risk of toxicity from benzodiazepinesAll patients should have pulse oximetry, blood pressure, respiratory rate and GCS monitored to assess toxicityACUTE MANAGEMENT OF ALCOHOL WITHDRAWAL
19. Patients should have baseline blood tests eg FBC, renal profile, liver function tests, amylase, coagulation screen and magnesium levelsIf sepsis is considered, chest x-ray and urinalysis should be doneIf central infections are considered, CT and lumbar puncture should be consideredSuspicion of bacterial peritonitis may require an ascetic tap for microbiology, culture and sensitivityManage seizures according to Advanced life support guidelinesManage withdrawal with benzodiazepines and vitamins (see above)ALCOHOL WITHDRAWAL MANAGEMENT
20. Delirium tremens (DTs):Occurs in 5% patients with alcohol withdrawal after 2-3 days abstinenceUntreated has mortality rate of 15-20%Symptoms: sever tremor, altered consciousness, confusion, autonomic instability i.e. tachycardia and severe hallucinations Early treatment of withdrawal usually prevent onset of DTs*Society for Study Addiction Factsheet Alcohol Withdrawal https://www.addiction-ssa.org/factsheets/alcohol-withdrawalDELIRIUM TREMENS*
21. Triad of symptoms included acute confusion, ataxia and opthalmoplegia occurs in 10% patients onlyBe aware of distinction between withdrawal and Wernicke’s EncephalopathyDue to acute thiamine deficiencyTreatment involves rapid intravenous thiamine administration This is vital to prevent Korsakoff’s syndromeWERNICKE’S ENCEPHALOPATHY (see Alcohol withdrawal and Neurology)
22. Alcohol Concern (2014) The Alcohol Harm Maphttp://www.alcoholconcern.org.uk/for-professionals/alcohol-harm-map/Budd T. (2003) Alcohol –related assault: findings from the British Crime Survey http://www.dldocs.stir.ac.uk/documents/alcassault.pdfDepartment of Health (2106) UK Chief Medical Officers’ Alcohol Guidelines Review Summary of the proposed new guidelines https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795/summary.pdfDepartment of Health ( 2016) Updated alcohol consumption guidelines give new advice on limits for men and pregnant women https://www.gov.uk/government/news/new-alcohol-guidelines-showincreased- risk-of-cancerDepartment of Health (2010) White Paper: Healthy lives, healthy people: our strategy for public health in England. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/136384/healthy_lives_healthy_people.pdfDepartment of Health and National Treatment Agency for Substance Misuse (2006) Models of Care for alcohol misusers update 2006 http://www.dldocs.stir.ac.uk/documents/mocdmupdate2006.pdfDepartment of Transport (2016). Reported road casualties in Great Britain: Estimates for accidents involving illegal alcohol levels: 2014 (second provisional) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/497662/accidents-involving-illegal-alcohol-levels-2014.pdfEMCDDA (2106) Emergency department-based brief interventions for individuals with substance-related problems: a review of effectiveness http://www.emcdda.europa.eu/publications/papers/2016/emergencydepartment-based-brief-interventionsGhodse H.(2010) Ghodse’s Drug and Addictive Behaviour A guide to treatment 4th edn. Cambridge & New York: Cambridge University Press.Health and Social Care Information Centre (2015) Statistics on Alcohol- England 2015 http://www.hscic.gov.uk/catalogue/PUB17712/alc-eng-2015- rep.pdfHuntley JS, Blain C, Hood S, Touquet R. (2001) Improving Detection of alcohol misuse in the patients presenting to an accident and emergency department. Emergency Medicine Journal 2001;18:99-104 .http://emj.bmj.com/content/18/2/99.full?sid=44611469-d163-4f4d-82d1- 3cc4c9b31451References and useful resources
23. Institute of Alcohol Studies (2013) Alcohol and older people: Health impacts:Hospital admissions. http://www.ias.org.uk/Alcohol-knowledgecentre/alcohol-and-older-people/Factsheets/Health-impacts-Hospitaladmissions.aspxInstitute of Alcohol Studies (2013). UK Alcohol- related crime statistics. http://www.ias.org.uk/Alcohol-knowledge-centre/Crime-and-socialimpacts/Factsheets/UK-alcohol-related-crime-statistics.aspxKohler ,S . & Hofmann, A. (2015) Can Motivational Interviewing in Emergency Care Reduce Alcohol Consumption in Young People? A Systematic Review and Meta-analysis. Alcohol & Alcoholism. 50: 107-117.Mann C.J. (2016) The burden of alcohol Emerg Med J;33:174-175 doi:10.1136/emermed-2015-205295Mayo-Smith MF.(1997) Pharmacological treatment of alcohol withdrawal. A meta-analysis and evidence based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1;278(2):144-51NHS (2012): Your Drinking and You: The Facts on alcohol and how to cut down. http://www.alcohollearningcentre.org.uk/_library/Change4Life/408723_Your_Drinking_And_You.pdfNICE (2011) Alcohol Dependence and harmful alcohol use quality standard. http://www.nice.org.uk/guidance/QS11/chapter/introduction-and-overviewNICE (2010) Clinical Guideline CG100Alcohol-use disorders: Diagnosis and Clinical Management of alcohol-related physical complications. http://www.nice.org.uk/guidance/CG100NICE (2011) Clinical Guideline CG115 Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence. http://www.nice.org.uk/guidance/CG115NICE (2014) CG 176 Head Injury: Triage, assessment, investigation and early management of head injury in children, young people and adults. http://www.nice.org.uk/guidance/CG176Parkinson K et al (2016), Prevalence of alcohol related attendance at an inner city emergency department and its impact: a dual prospective and retrospective cohort study. Emerg Med J;33:187-193 doi:10.1136/emermed-2014-204581Patient.co.uk (20152) Alcohol and sensible drinking http://www.patient.co.uk/health/alcohol-and-sensible-drinkingPublic Health England Alcohol Learning Centre (2012).Emergency medicine topic- screening tools http://www.alcohollearningcentre.org.uk/Topics/Browse/Hospitals/EmergencyMedicine/Public Health England (2014) Alcohol treatment in England 2013-14 http://www.nta.nhs.uk/uploads/adult-alcohol-statistics-2013-14-commentary.pdfRoyal College of Physicians (2001) Alcohol- Can the NHS afford it? Recommendations for a coherent alcohol strategy for hospitals. http://www.alcohollearningcentre.org.uk/_library/alcoholNHS_afford_it.pdfReferences and useful resources
24. NHS (2012): Your Drinking and You: The Facts on alcohol and how to cut down. http://www.alcohollearningcentre.org.uk/_library/Change4Life/408723_Your_Drinking_And_You.pdfNICE (2011) Alcohol Dependence and harmful alcohol use quality standard. http://www.nice.org.uk/guidance/QS11/chapter/introduction-and-overviewNICE (2010) Clinical Guideline CG100Alcohol-use disorders: Diagnosis and Clinical Management of alcohol-related physical complications. http://www.nice.org.uk/guidance/CG100NICE (2011) Clinical Guideline CG115 Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence. http://www.nice.org.uk/guidance/CG115NICE (2014) CG 176 Head Injury: Triage, assessment, investigation and early management of head injury in children, young people and adults. http://www.nice.org.uk/guidance/CG176Parkinson K et al (2016), Prevalence of alcohol related attendance at an inner city emergency department and its impact: a dual prospective and retrospective cohort study. Emerg Med J;33:187-193 doi:10.1136/emermed-2014-204581Patient.co.uk (20152) Alcohol and sensible drinking http://www.patient.co.uk/health/alcohol-and-sensible-drinkingPublic Health England Alcohol Learning Centre (2012).Emergency medicine topic- screening tools http://www.alcohollearningcentre.org.uk/Topics/Browse/Hospitals/EmergencyMedicine/Public Health England (2014) Alcohol treatment in England 2013-14 http://www.nta.nhs.uk/uploads/adult-alcohol-statistics-2013-14-commentary.pdfRoyal College of Emergency Medicine (2015) Alcohol Related Harm Position Statement http://www.rcem.ac.uk/Shop-Floor/ Clinical%20Guidelines/College%20Guidelines/References and useful resources
25. Royal College of Emergency Medicine (2015) A toolkit for improving care http://www.rcem.ac.uk/Shop Floor/Clinical%20Guidelines/College%20Guidelines/Royal College of Physicians (2001) Alcohol- Can the NHS afford it? Recommendations for a coherent alcohol strategy for hospitals. http://www.alcohollearningcentre.org.uk/_library/alcoholNHS_afford_it.pdfSiva N ( 2015) Tackling the UK's alcohol problems. The Lancet Vol 386, p121-122 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2961228-4/fulltextSociety for Study Addiction Factsheet Alcohol Withdrawal https://www.addiction-ssa.org/factsheets/alcohol-withdrawalSullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. (1989)Assessment for alcohol withdrawal: the revised clinical institute withdrawal assessments for alcohol scale (CIWA-Ar) Br J Addict 1989;84(11):1353-7Turner RC, Lichstein PR, Peden JG, Busher JT, Waivers LE.(1989) Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation and treatment. J Gen Int Med;4 (5):432-44Wyatt J, Illingworth R, Graham C, Hogg K (2012). Oxford Handbook of Accident and Emergency Medicine. 4th ed. Oxford University Press References and useful resources