Never assume ED patient is "just intoxicated again"

Medical emergency may exist

Paramedics arrive with a man you recognize instantly — from his many previous visits to your ED, always intoxicated. You learn that his vital signs are stable, and he was found on the ground by bystanders, says Tia Valentine, RN, CEN, clinical nurse educator for the ED at University of California-San Diego Medical Center.

"He had a fifth of vodka in his possession, half of it gone," says Valentine. "He is lethargic, but arouses to noxious stimuli."

The man is placed on a gurney in the hallway, close enough to be seen by staff, but not on any monitor, adds Valentine. "As the staff is very familiar with him, they leave him alone to 'sleep it off,' just as they have done many times before."

When the charge nurse goes to make rounds in the ED, however, she is unable to rouse the patient. "There is no response, his skin is cool," says Valentine. "She checks for a carotid pulse; there is none. CPR is immediately started, but despite a heroic attempt, the team is unable to obtain spontaneous return of circulation."

Does this sound like an improbable story? "In fact, it happens more times than one can imagine," says Valentine.

Mary Ellen Swanson, RN, a senior staff nurse in the ED at Hennepin County Medical Center in Minneapolis, MN, says that her ED has a designated area where assessments of intoxicated patients are done. "Intoxicated patients can be agitated and verbally abusive," she says. "Having a locked area allows us to maintain a safe environment and avoid using restraints."

Don't overlook this

Valentine says to ask yourself how many times you have assumed a patient just needs to "sober up." In fact, she says, your patient could be suffering from low blood sugar, a stroke, or a transient ischemic attack. Here are Valentine's recommendations to avoid missing a medical emergency in an intoxicated patient:

Check the patient's glucose level.

"He may be homeless, and not had a meal in a few days," says Valentine.

Place a portable monitor on the patient.

Obtain at least an oxygen saturation or end-tidal carbon dioxide, says Valentine. "A lot can be trended from these readings," she says. "You can actually see deterioration in numerical values before the patient gets into crisis mode."

Valentine notes that there are many different portable monitors available at a variety of cost. "From personal experience, I strongly recommend purchasing these devices for patients that may require a little more closer monitoring from a distance," says Valentine.

Avoid making assumptions.

"While caring for the same patient time and time again with the same complaint, it can certainly become run of the mill," says Valentine. "But that type of bias thought will tend to get a prudent nurse into a world of trouble." (See clinical tip on assessment, below.)

Source

For more information on caring for intoxicated ED patients, contact:

Mary Ellen Swanson, RN, Emergency Department, Hennepin County Medical Center, Minneapolis, MN. Phone: (612) 873-3573. E-mail: maryellen.swanson@hcmed.org.

Tia Valentine, RN, CEN, Clinical Nurse Educator, Emergency Department, University of California—San Diego Medical Center. E-mail: thooley@ucsd.edu.

Clinical Tips

Do serial exams for intoxicated patients

Serial examinations are very important with intoxicated patients, emphasizes Mary Ellen Swanson, RN, a senior staff nurse in the ED at Hennepin County Medical Center in Minneapolis, MN. "You don't just do a quick exam and that's the end of it," she says. "If someone walks in the door, their exam may look really good. Two hours later, you may not be able to get them to wake up at all, or their pupil shape is different."

Your "intoxicated" patient may, in fact, have a subdural hematoma, Swanson warns. "It is very easy to categorize people as homeless or intoxicated," she says. "You oftentimes don't know their history, and there may not be a visible injury. You don't have the common presenting portrait of somebody with an acute bleed."