Management of Patients Presenting with Alcohol Intoxication and Polypharmacy Overdose PDF

Preview

Summary

Management of Patients Presenting with Alcohol Intoxication and Polypharmacy Overdose. Discussion and recommendation for use of toxidromes in pre-hospital settings....

Description

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Submission Date: Student ID: 486441

Management of Patients Presenting with Alcohol Intoxication and Polypharmacy Overdose

Introduction

The Australian Institute of Health and Welfare (AIHW) reported that approximately 25% of Australians exceeded the risk levels of alcohol consumption in 2019.(1) AIHW also found that in 2019, 14.1% and 4.2% of the population ingested illicit drugs or pharmaceuticals for non-medical use respectively.(1) Additionally, the Penington Institute found an increase of 123% of polypharmacy cases with 4 substances or more ingested.(2) Subsequently, the massive pharmacodynamic possibilities these statistics represent suggest any combination of alcohol consumption and drug ingestion, illicit or pharmaceutical, presents significant issues for the healthcare system.(3, 4)

The case under review in this paper details the St John Ambulance NSW Medical Emergency Response Team (MERT) activation, assessment, management, and handover to NSW Ambulance of a 17-year-old female who presented with an overdose of unknown substances. MERT, consisting of an anesthetist, paramedic, and a student paramedic, was on duty at the 2018/19 New Year celebrations in Bradfield Park, Milsons Point.

Evaluation of the MERT protocols and guidance against evidence-based practice is included with corresponding analysis and recommendations for improvement.

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Submission Date: Student ID: 486441

Case Synopsis Activation The initial activation of MERT came by way of a member of the public rapidly approaching a St John Ambulance NSW post whilst screaming “There is a young girl not breathing just up there!”. MERT were activated and responded accompanied by three responders to assist with equipment and patient management.

Assessment and Treatment On arrival, a young female was located on the ground in the prone position with abnormal breathing and unresponsive to voice or painful stimuli. Nearby were two other young females that claimed to be friends of the patient. Surprisingly, neither appeared concerned about the patient’s predicament.

The patient’s airway was found to contain fluid that was immediately drained with gravity by placing the patient in the recovery position with a head tilt. This action achieved airway patency however self-maintenance by the patient was unsuccessful necessitating the insertion of Naso-Pharyngeal Airway (NPA) and an emergency ambulance being called for assistance. Breathing remained abnormal prompting a switch of clinician positions placing the doctor at the airway as preparation for rapid sequence intubation (RSI) if required. Ventilatory support by way of Bag Valve Mask (BVM) ventilation with supplemental 100% oxygen at 15 litres/minute was initiated by the doctor. Further assessment revealed an odour of alcohol in the patient’s breath, a weak and bradycardic radial pulse, miosis with minimal pupil response, borderline hypotension, and a sinus bradycardia rhythm. Pulse oximetry was unable to be obtained due to thick nail polish on fingers and toes. Table 1 shows the initial set of vital signs taken.

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Vital Sign Pulse Blood Pressure

Submission Date: Student ID: 486441

Result 45-50bpm 103/55 Miosis (~2mm), minimal

Pupils

reaction to light

Electrocardiogram (ECG)

Sinus bradycardia

Respirations

Slow, abnormal

Glasgow Coma Scale (GCS)

Estimated at 8

Skin

Normal

Additional information Weak and difficult to accurately count Obtained using a LifePak 15 Patient’s eyes were manually opened 4 limb leads (wrists and ankles) using a LifePak 15 Unable to calculate at the time Patient position presented difficulty assessing flexion or extension No noticeable dryness or diaphoresis observed

Table 1: Initial vital signs taken during primary assessment.

History taking proved to be challenging as the patient was not responsive, and bystanders did not provide any meaningful information to assist with diagnosis. Suspicion of a combination of alcohol intoxication, opioid consumption, and/or benzodiazepine consumption was the working differential diagnosis and consequently, preparations for immediate extrication for resuscitation pending ambulance arrival were initiated.

Whilst ventilation assistance continued, the patient was canulated in the left hand and crystalloid fluids initiated. The paramedicine student prepared a 4mg in 4mL solution of naloxone. Immediately prior to the paramedic administering the naloxone, the doctor noticed movement and instructed for all treating members to pause and investigate a potential increase in the patient’s of level of consciousness. Reassessment revealed the patient was becoming combative and appeared less able to tolerate the NPA as observed by twitching in the nose. Respirations remained shallow though became less abnormal than previously observed. Ventilation support continued for approximately forty-five seconds when the ambulance arrived. Extrication was immediately initiated with the patient loaded onto the stretcher, fluid lines transferred, monitoring transferred, and oxygen transfer was completed as the patient entered the vehicle.

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Submission Date: Student ID: 486441

Handover Given the critical nature of the patient, the doctor continued treatment with one ambulance paramedic while the MERT paramedic initiated handover to the other NSW Ambulance paramedic. Handover consisted of the primary survey findings, immediate treatment initiated, known patient details (first name, gender, age), and our working differential diagnosis of a polypharmacy overdose. The unused naloxone was sent with the patient as a precaution in case of a toxin-induced cardiac arrest.

Discussion

Consideration of this case revealed the patient was mostly managed per protocol.(5) Specific issues of note concerned the accidental omission of blood glucose level (BGL) and temperature measurement during the vital sign survey. Blood glucose levels are of critical importance to confirming and/or eliminating hypoglycaemia in comatose patients and should always be measured.(6-8) Similarly, a patient’s core temperature can suggest agonism or antagonism of internal compensatory mechanisms triggered in response to the poisoning event.(6, 8, 9)

St John Ambulance and NSW Ambulance protocols stipulate primarily supportive management, continual patient monitoring, and symptomatic treatment where indicated. (5, 10) Consistency across these guidelines is paramount given the involvement of both services in emergency patients and the continuation of ongoing care en-route to the receiving facility.

Observed miosis correctly aroused further suspicion of polypharmacy poisoning and opioid involvement.(6, 9, 11) The decision to withhold naloxone as the patient’s increased level of consciousness (LOC) was considered appropriate and was agreed to be reviewed if required. Additionally, naloxone remained available in the case of LOC deterioration. Equally important to this patient was the lack of suspicion of parasympathetic nervous system innervation that could also explain aspects of her presentation.(8)

On reflection, whilst the patient was managed carefully and appropriately, focus on the signs and symptoms through the lens of toxidromes could have served as an advantage to the treating clinicians.(6, 8, 12) Given the lack of available history, a crucial aspect to the

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Submission Date: Student ID: 486441

assessment of intoxication, consideration of toxidromes may have provided a clearer context and framework for assessment, treatment, and handover.(6, 8, 12) The patient showed signs suggestive of Myorelaxation, Cholinergic, and Opioid toxidrome presentations as shown in Table 2.(11, 12) For clarity, the myorelaxation syndrome is also often referred to as the Sedative-Hypnotic toxidrome.(12, 13) Discussion of toxidromes during treatment, handover and debrief did not occur. The probability of that discussion having positively contributed to the team’s understanding and overall care through systematic suspicion or elimination of potential toxidromes is high. Inclusion of toxidrome identification is, therefore, a critical step in poisoning cases.(6, 8, 12)

Sign, Symptom

Result

Heart Rate Respiratory Rate Blood Pressure Temperature Pupils Skin Secretions

50bpm Slow 103/55 Not taken Miotic Normal Normal Initially

Mental Status

ECG

comatose progressing somnolent Sinus Bradycardia

Consistency with Toxidrome (High, Medium, Low) Alcohol Cholinergi Opioid Myorelaxation c Intoxication Medium High Medium High Medium High High Medium Low High Low Low Temperature not recorded Low High High Low Low Low High High Low Low High High

Medium

Medium

High

High

Low

High

Medium

Medium

Table 2: Consistency mapping between patient's signs, symptoms, and vital signs with relevant toxidromes.(6, 8, 9, 11-14)

Evidence and cases have continued to emerge that emphasise the priority of toxidrome consideration during the primary assessment over definitive identification of the specific agent in poisoning cases when a detailed history is unavailable.(6, 8, 12, 15)

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Submission Date: Student ID: 486441

Recommendations Optimisation of St John Ambulance NSW protocols and guidelines to include a specific framework detailing critical signs, symptoms, vital signs and an up-to-date toxidrome identification process would improve the assessment and management of poisoned patients. Consequently, the resulting enhanced data would assist clinicians in formulating a more informed differential diagnosis and corresponding treatment plan.(8, 12) Furthermore, in the context of St John Ambulance NSW, the level of criticality of the patient can be assessed based on evidence-based practice associated with toxidrome research. With this information, care escalation decisions can be expedited supporting the objective of maximising positive patient outcomes.(16)

Conclusion

Australia continues to experience high rates of alcohol intoxication, illicit drug use, and nonmedical pharmaceutical abuse.(1, 3, 4, 17) Polypharmacy overdose has increased by 123% since 2014 cementing it as a serious concern for paramedics and primary healthcare providers.(2) The continual emergence and evolution of substances, naturally occurring or synthetic, has created an overwhelming number of permutations of pharmacodynamics significantly complicating cases for front-line health workers.

During the 2018/19 New Year celebrations in Bradfield, Milson's Point, a polypharmacy overdose presentation resulted in the activation of the Medical Emergency Response Team to a 17-year-old female.

Critical analysis of the MERT protocols for poisoning and envenomation patients against current evidence-based practice revealed multiple areas for improvement and provision of supplemental information aimed at accelerating diagnosis, treatment, and escalation of care.

Toxidrome identification is considered a necessary inclusion in paramedic training and practice as it represents well-established, evidence-based techniques to assist in the management of patients presenting with polypharmacy overdose.

CAA301 – Clinical Practice 4 Student Name: Richard Wessen

Submission Date: Student ID: 486441

　 References 1.

Australian Institute of Health and Welfare. National Drug Strategy Household Survey

2019. In: Australian Institute of Health and Welfare, editor. Canberra: AIHW; 2019. p. 104. 2.

Penington Institute. Australia’s Annual Overdose Report. Melbourne: Penington

Institute; 2020 2020 Sep 04. 3.

Cioccari L, Luethi N, Bailey M, Pilcher D, Bellomo R. Characteristics and outcomes

of critically ill patients with drug overdose in Australia and New Zealand. Critical Care and Resuscitation. 2017;19(1):14. 4.

Butler K, Reeve R, Viney R, Burns L. Estimating prevalence of drug and alcohol

presentations to hospital emergency departments in NSW, Australia: impact of hospital consultation liaison services. Public Health Res Pract. 2016;26(4). 5.

St John Ambulance Australia. Clinical Practice Guidelines for Heathcare

Professionals. Deakin WA: St John Ambulance Australia Ltd; 2019 [cited 2020 Dec 10]. 6.

Jung J. Poisoning and Toxidromes: Definitions, Types & Diagnosis. Germany:

Lecturio; 2018. 7.

Yaraghi A, Mood NE, Dolatabadi LK. Comparison of capillary and venous blood

glucose levels using glucometer and laboratory blood glucose level in poisoned patients being in coma. Adv Biomed Res. 2015;4:247-. 8.

Stefan AE, Desai R. Toxidromes. Clinical Reasoning. Osmosis.org2018. p.

https://www.osmosis.org/learn/Clinical_Reasoning:_Toxidromes. 9.

Mokhlesi B, Leiken JB, Murray P, Corbridge TC. Adult Toxicology in Critical Care*:

Part I: General Approach to the Intoxicated Patient. Chest. 2003;123(2):577-92. 10.

NSW Ambulance Service. 2018 Complete Protocol and Pharmacology. In: Integration

CS, editor. New South Wales: NSW Ambulance Service; 2018. p. 406. 11.

Boyer EW. Management of opioid analgesic overdose. N Engl J Med.

2012;367(2):146-55. 12.

Mégarbane B. Toxidrome-based approach to common poisonings. Asia Pacific

Journal of Medical Toxicology. 2014;3(1):2-12. 13.

Lam SW, Engebretsen KM, Bauer SR. Toxicology today: what you need to know

now. J Pharm Pract. 2011;24(2):174-88.

CAA301 – Clinical Practice 4 Student Name: Richard Wessen 14.

Submission Date: Student ID: 486441

Raheja H, Namana V, Chopra K, Sinha A, Gupta SS, Kamholz S, et al.

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review. Open Cardiovasc Med J. 2018;12:1-6. 15.

Su YJ, Lai YC. Treat the patient by the recognized toxidrome when the ingested

herbal juice is non-toxic. Int J Emerg Med. 2010;3(2):133-4. 16.

Patel R, Nugawela MD, Edwards HB, Richards A, Le Roux H, Pullyblank A, et al.

Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018;132:101-11. 17.

Cameron P, Jelinek G, Kelly A-M, Brown A, Little M. Textbook of Adult Emergency

Medicine. 4th ed: Churchill Livingstone Elsevier; 2015. 1077 p....