Your patient has had one too many of these. What would you do? a.observe the patient. b.give intravenous fluids.
Does IV saline therapy reduce alcohol intoxication in the ED? ACEM 4.10 Trainee Research Siegfried Perez, MD Gerben Keijzers, MBBS, MSc Michael Steele, PhD Josh Byrnes, PhD Paul Scuffham, PhD
Background Practice of giving IV fluids for alcohol intoxication continues among emergency physicians 1,2,3,4 Goal: accelerating resolution of signs of alcohol intoxication and decreasing emergency department length of stay (EDLOS) Previous experimental studies show no significant change in blood alcohol content 5
Objective To compare combined treatment using IV 0.9% saline with observation against observation alone in ED patients with acute uncomplicated alcohol intoxication
Main outcome measures ED length of stay (EDLOS) Treatment time Intoxication symptom scores - WHO Observed Assessment of Alcohol Intoxication (OAAI) tool 6 Breath alcohol levels Health economic analysis
Methods Single-blinded, randomized controlled trial One tertiary and one urban ED in Queensland, Australia Waiver of consent
Methods Age 18 to 50; acute uncomplicated alcohol intoxication Excluded: head injuries, overdose, admission Randomization Observation (n=72) Monitored bed Intoxication scores and BAL: arrival, 2 hours and discharge Treatment (n=72) 20ml/kg 0.9% saline bolus Monitored bed Intoxication scores and BAL: arrival, 2 hours and discharge Discharge: clinically fit or responsible adult available Discharge: clinically fit or responsible adult available
Flow Diagram Assessed for eligibility (n=164) Excluded (n=20) Randomized (n=144) Observation (n=71) Received IV fluids due to persistent tachycardia (n=1) Treatment (n=73) Refused IV Saline (n=1) Retrospective withdrawal of data (n=0) Retrospective withdrawal of data (n=0) Analysed (n=71) Analysed (n=73)
Baseline Characteristics Control Treatment No (%) male 42 (59%) 39 (53%) Age (years) 24.3 (7.39) 24.9 (8.38) Weight (kg) 70.7 (13.8) 70.2 (14.3) Standard drinks 10.8 (3.8) 11.1 (6.6) Intake of other drugs (%) 9/55 (16%) 7/55 (13%) Blood Alcohol Content (g/%) 0.185 (0.63) 0.195 (0.07) Total OAAI score at initial presentation 22.3 (9.58) 22.1 (10.46) Values are mean (SD) unless stated otherwise
EDLOS and Treatment Time Control (hours) Treatmen t (hours) P value EDLOS 4.6 (2.2) 4.8 (2.9) 0.61 Treatment Time 3.9 (1.9) 4.1 (2.4) 0.58 Values are mean (SD) unless stated otherwise
Intoxication Scores Rate of change of total OAAI score Control (points/hour) Treatment (points/hou r) P value 2 hours -3.2 (4.1) -4.9 (4.7) 0.16 Discharge -4.5 (3.1) -3.7 (3.1) 0.31 Values are mean (SD) unless stated otherwise
Rate of change (%/hour) of BAL Control (%/hour) Treatment (%/hour) P value 2 hours -0.01 (0.05) -0.02 (0.01) 0.19 Discharge -0.02 (0.02) -0.01 (0.04) 0.29 Values are mean (SD) unless stated otherwise
Health economic analysis Expenses per patient Price Control $151 Treatment $179 If no tests, no fluids given $69 Savings per patient Price Observation alone $110 Staff Nursing for Control Nursing for Treatment Medical for Control Medical for Treatment Ave time used (hour) Price equivalent 1.0 $47 1.1 $51 0.4 $21 0.9 $42 If all intoxicated patients in 2011 were observed only $410,000
Conclusion Intravenous fluids do not decrease length of stay, intoxication symptom scores and breath alcohol levels compared to observation alone Either approach is reasonable, and observation alone is less resource intensive
References 1. Sellaturay, S. et al. Management of Alcohol Intoxication and Aggressive Behavior: A Tale of Two Cities. Current Medical Research and Opinion. Jan 2007; 23, 1; Proquest Health and Medical Complete pg 77. 2. Yost, David, MD. Acute care for alcohol intoxication: Be prepared to consider clinical dilemmas. Postgraduate Medicine. Vol 12. No. 6. Decem 2002. http://www.postgradmed.com/issues/2002/12_02/yost1.htm 3. Levy, R. et al. Intravenous Fructose for the Treatment of Acute Alcohol Intoxication: Effects on Alcohol Metabolism. Archives of Internal Medicine. Vol. 137 No. 9, September 1977 4. Hindmarch, Paul N, Steven Land, and John Wright. Attitudes of Emergency Medicine Physicians in the North East of England Toward the Use of Intravenous Fluids to Treat Individuals Intoxicated with Ethanol Attending the Emergency Department Compared with the Scientific Evidence. European Journal of Emergency Medicine: Official Journal of the European Society for Emergency Medicine (November 29, 2011). http://www.ncbi.nlm.nih.gov/pubmed/22134421 5. Li, J et al. Intravenous saline has no effect on blood ethanol clearance. Journal of Emergency Medicine. Volume 17, Issue 1, 2 January 1999, Pages 1-5 6. WHO Collaborative Study on Alcohol and Injuries: Final Report. World Health Organization 2007.
Acknowledgments Our alcohol intoxicated patients of the Gold Coast Medical and nursing staff of the Gold Coast Hospital Emergency Department (Southport and Robina Campuses) Funded by the Queensland Emergency Medicine Research Foundation
Eligibility Inclusion Criteria Adults aged 18 to 50 years of age Uncomplicated alcohol intoxication (no injuries, overdose, or psychiatric conditions requiring ongoing investigation or treatment) Unremarkable physical examination Exclusion Criteria Age < 18 years or > 50, intellectual impairment, and pregnancy Aggressive behaviour beyond reasonable attempts at de-escalation and deemed a potential threat to staff safety Patients later found to have significant injuries (i.e head injury) or concomitant conditions (i.e overdose) requiring further investigation or treatment Airway support more than a nasopharyngeal airway or oropharyngeal airway (i.e. endotrachael or nasotrachael intubation)
Observed Assessment of Alcohol Intoxication Clinical signs *Severity (score) of each sign noted as None (0), Mild (1), Moderate (2), Severe (3) or Very Severe (4) Smell of alcohol on breath Conjunctival injection and/or flushed face Impairment of speech (e.g. slurring) Impairment of motor coordination Impairment of attention and/or judgment Elated (euphoria) or depressed mood Disturbances in behavioral response Disturbances in emotional responses Impaired ability to cooperate Horizontal gaze nystagmus General State of Intoxication Very severe alcohol intoxication (4) (Very severe disturbance in functions and responses, very severe difficulty in coordination, or loss of ability to cooperate) Severe alcohol intoxication (3) (Severe disturbance in functions and responses, severe difficulty in coordination, or impaired ability to cooperate) Moderate alcohol intoxication (2) (Smell of alcohol on breath, moderate behavioural disturbance in functions and responses, or moderate difficulty in coordination) Mild alcohol intoxication (1) (Smell of alcohol on breath, slight behavioural disturbance in functions and responses, or slight difficulty in coordination) Not intoxicated at all (0)