Originally Published on RCEM Learning Podcast October 2017
As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast.
Author: Hack JB. Academic Emergency Medicine. July 2017.
Depending on where your department is located I would bet you either look after a lot of drunk patients, or an awful lot of drunk patients. They are difficult to assess and as such we have all missed or had delayed diagnosis of injuries in this population as we try to get the balance between over investigation and pragmatic emergency medicine practice. In addition, different patients handle their booze differently, some can have a blood alcohol of 0.25 (5 times the legal limit to drive) and look like theyve just had a quick pint as they complete the times crossword, others will be ‘on their arse’. In the UK, we rarely even measure blood or breath alcohol levels, favouring clinical judgement of sobriety, whereas here in Australia we measure it on everyone – though we’ll still make decisions based on clinical performance and ability. This paper looks at a novel objective score that can be performed and repeated at the bedside and give us a better idea of a patients real level of inebriation.
- Retrospective chart review over 24 months of patients assessed in ED for alcohol impairment or whose ED course ultimately included a period of observation for resolution of alcohol induced impairment.
- Patients were categorised as low frequency (1 visit), moderate frequency (2-5 visits) or high frequency (6 visits) over study period.
- Exclusion: co-intoxication with other substances, seizure activities, hypoglycaemia, or pre-existing conditions that would affect the assessment
- Intervention: Scores of 0-4 given for 5 tasks: speech quality and mentation, gross motor skills, eye movement, coordination with target pursuit, and fine motor skills. They got 0 if performed perfectly and 4 if they were unable to comply.
- Comparison: Ethanol levels by breathalyser or serum level were performed at discretion of treating team. Usual nursing assessment – informally structured and varied between nursing staff.
- 7526 visits from 2837 unique patients after exclusions
- Initial measured alcohol correlated poorly with both the HII score and the usual nursing assessment (and tended to be even less correlated in the more frequent attenders)
- HII score correlated well with the usual nursing assessment for alcohol intoxication.
- Serial HII scores declined predictably over time (1/16 point per hour), which also corresponded well to nursing assessment.
This score is another example of giving objective measurement to clinical gestalt but we think it could be an easy and useful method of formal assessment of the alcohol intoxicated patient. We particularly like the concept that there is a predictable improvement in the score over time. This could be of great use in the patients that we dont want to be biochemically sober – because they will be even less accessible if they are in acute withdrawal or at risk of seizing.