What medical school, the foundation programme, and by and large the ACCS curriculum does not prepare you for is how to manage the patient who is mashed (I think it should be a major presentation). These people who attend at a time when the department is at it’s busiest, and when we are at our weakest. These patients are clinically complex with an added legal dimension in terms of consent, and mental capacity, which sucks up a lot of ED resource.
In the coming few weeks I’m going to take you through a basic approach to patients who are intoxicated, and talk about some of the less well known/understood intoxicants. Much of the teaching and learning on the subject is based around the particular drug the patient has taken. This makes it difficult to apply at 3 am when ‘Harry’ has backed into the corner of one of your cubicles because he is convinced the Dynamap is going to devour him. He does not know what he has taken. He is not sure of his own name.
In the ED there are 2 syndromes that you can slide people into, this will give you an idea of what to expect, what to watch out for, and for how long. The key is often to be relaxed, have an easy friendly manner, and de-escalate as much as you can. Use the ‘up/down’ as a mental model, gain control/safety, and then go searching for causes. Know that time is normally on your side, most patients will finish their trip, and some will even apologise for wasting your time.
- ‘Just’ drunk / high / tripping is a diagnosis of exclusion.
- People do stupid things when drunk/high/tripping too, and may have injuries. Look for them.
Excited delirium (up)
These are the patients that can come in being held down by 2-3 police officers and couple of paramedics. The history is normally non-existent or vociferously denied by the individual who just wants to go. You can’t assume they have capacity, which is frustrating for them, and for you.
- ABCs, de-escalate.
- Glucose and a 12 lead is a good idea, but may be impractical. A temperature is also useful.
- D look at the pupils (BIG: amphetamines, MCAT, anticholinergics, serotinergic, neuroleptics. SMALL: opiates, alcohol)
- If de-escalation, bargaining, and brute force aren’t working consider something to make the situation a little calmer – midazolam, diazepam, or propofol all work well when used in experienced hands. This lets you work out if there is anything wrong, and also keeps you and your colleagues safe.
People who are screaming and shouting and fighting off police officers and nurses may have serious pathology (I have found a frontal lobe tumour in a guy fighting off police officers). Rapidly expanding space occupying lesions can make some people get very fighty. Don’t assume they are just being annoying.
If someone can’t calm down enough for you to have a conversation with them, they probably don’t have capacity.
Hypoactive delirium (down)
These patients are brought in cold often being ‘found’ by some unlucky member of the general public. Sometimes the police bring them in, sometimes ‘friends’.
- Glucose, 12 lead, temp.
- GCS – A GCS of <8 only counts if it’s done by an ED sister or ED spr. We are brutal. We will teach you our tricks if you ask nicely, or give us cake.
- Pupils: BIG: amphetamines, MCAT, anticholinergics, serotinergic, neuroleptics. SMALL: opiates, alcohol
Be more concerned with patients with big pupils and hypoactive delirium, this means they’ve taken A LOT, and are closer to the final common pathway of all toxicology which is SEIZURE->COMA->DEATH.
Next week MCAT!