ALCOHOL AND THE EMERGENCY DEPARTMENT.

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ALCOHOL AND THE EMERGENCY DEPARTMENT.

• LUCY HARRISON
• Alcohol CNS
• Ext 21487, bleep 6110
• July 2014

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AIMS OF SESSION

• 1. To understand why we need to ask all patients
  who attend the ED about their alcohol use.
• 2. Who has problems with alcohol?
• 3. How do we ask people about their alcohol use?
• 4. How to detect possible dependence to alcohol?
• 5. How do we manage alcohol dependant patients in
  the ED?
• 6. Non dependant patients.

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WHY WORRY...
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WHY WE SHOULD WORRY ABOUT ALCOHOL...

• Alcohol costs the NHS 2.7 billion per year.
• Recent reports indicate that 10.5 million adults
  drink above the recommended limits.
• Alcohol is the 3rd leading cause of disease
  burden in developed countries.
• There are over a million hospital admissions due
  to alcohol each year in England. In 2009/10
  20,032 individuals in Bristol were admitted to
  hospital either wholly or partly due to alcohol.

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• WHAT SORT OF ED PRESENTATIONS COULD BE ALCOHOL
  RELATED?

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TOP 10 ALCOHOL RELATED PRESENTATIONS

• Fall
• Accident
• Collapse
• Head Injury
• Assault
• Unwell
• Gastro Intestinal
• Cardiac
• Psychiatric ( including OD/DSH)
• Repeat attendee
  Touquet et al (2009)

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• Who has problems with alcohol?

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• ACCORDING TO GOOGLE
• Jonny Depp, Russell Brand, Michael J Fox,
  Davina McCall, David Hasselhoff, Mel Gibson,
  Robin Williams, Steven King, Tara
  Palmer-Tomkinson, Florence Welch, Kelly Osbourne,
  Frank Skinner, Ben Affleck, Denzel Washington,
  Ewan McGregor, Diana Ross, Matthew Perry, Eminem,
  Christina Ricci, Simon Pegg, Kate Moss, Daniel
  Radcliffe, Jada Pinket-Smith, Kristin Davis, Drew
  Barrimore, Eva Mendes, Micha Barton, Angelina
  Jolie, George Clooney, Sadie Frost, Katie Perry,
  Anne Robinson, Kirsten Dunst, Demi Moore, Charlie
  Sheen, Tara Reid, Oprah Winfrey, Mike Tyson,
  Damien Hurst, Nicole Ritchie, Winona Ryder, Cory
  Monteith, Jamie Lee-Curtis, Jemima French, Jim
  Carey, Mark Owen, Tom Chaplain, Toby Maguire,
  Naomi Campbell, Alex James, Gerard Butler, Gazza,
  Pearl Lowe, David Bowie, Shaun Ryder, Colin
  Farrell, Brittany Spears, Anthony Hopkins, Pete
  Doherty, Robbie Williams, Sarah Harding, Graham
  Coxon

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WHY DO WE NEED TO ASK ABOUT ALCOHOL USE?

• To be able to manage patients care safely while
  in the department.
• To be able to offer support/ advice etc around
  patients alcohol use if they feel it is
  required. This can help to reduce further
  hospital attendances in the long run.
• The ensure that patients are aware of the risks
  involved in regularly drinking more than the
  recommended amounts.

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HOW DO WE ASK PEOPLE ABOUT THEIR ALCOHOL USE?

• Use of the Paddington Alcohol Test (PAT).
• Consists of three questions.
• Takes very little time to do.
• Anyone can complete it.
• Anyone who is PAT positive should be asked if
  they would like to see the alcohol nurse
  specialist.
• Anyone who is PAT positive leads you to consider
  more questions about a patients alcohol use eg,
  is there concern that there maybe a dependence to
  alcohol?

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RECOGNISING ALCOHOL DEPENDENCE

• Patients who experience 3 or more of the
  following symptoms are likely to have alcohol
  dependence
• A strong desire or compulsion to drink.
• Difficulty in controlling levels of alcohol use.
• Experience of physical withdrawal on stopping
  alcohol use.
• Increased tolerance to alcohol.
• Neglect of other interests eg eating or washing.

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SYMPTOMS OF UNCOMPLICATED ALCOHOL WITHDRAWAL

• Tremor
• Fever
• Anxiety
• Insomnia
• Sweating
• Nausea/ vomiting
• Agitation/ irritability
• Tachycardia
• Hallucinations
• Mild systolic hypertension
• Symptoms of withdrawal can be seen within 6-8
  hours of the last alcoholic drink. They peak at
  10-30 hours, and usually begin to stop at 30-40
  hours.

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DELIRIUM TREMENS (DTS)

• DTs only occur in around 5 of patients
  experiencing alcohol withdrawal, but account for
  a high rate of mortality. DTs represent a
  medical emergency, and usually have an onset 2-3
  days post the last alcoholic drink.
• Symptoms of DTs
• Auditory and visual hallucinations.
• Confusion and disorientation
• Severe tremors
• Delusion
• Agitation
• Tachycardia
• Fever
• Hypertension

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ALCOHOL RELATED SEIZURES

• Seizures can be another symptom of alcohol
  withdrawal, but are rare beyond 48 hours after
  the last alcoholic drink. Consider admission if
  it is the first ever instance, otherwise base
  treatment on the severity of the seizure and
  observed recovery.

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MANAGING ALCOHOL WITHDRAWAL

• Chlordiazepoxide is used to treat alcohol
  withdrawal.
• 20-40mg of chlordiazepoxide QDS depending on
  level of alcohol use. Additional PRN
  chlordiazepoxide should be considered, up to
  240mg in total can be given in a 24 hour period.
• If symptoms persist, consider lorazepam or
  haloperidol.
• (prescribing guidance for chlordiazepoxide is on
  the DMS)

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WERNIKES ENCEPHALOPATHY

• Wernikes encephalopathy is caused by thiamine
  deficiency, but can be reversible if treated
  early. It is also very difficult to diagnose,
  especially if the patient is intoxicated. As
  there is no simple test for wernikes
  encephalopathy, all patients with evidence of
  chronic alcohol misuse should be prescribed
  pabrinex.
• IV Pabrinex 1and 2, 2 pairs TDS.
• (Prescribing guidance is on DMS)

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??TTA CHLORDIAZEPOXIDE??

• TTA chlordiazepoxide should not be prescribed to
  patients being discharged from the ED.
• Once discharged from the ED, patients should be
  advised to contact their GP and offered an
  appointment with the alcohol nurse specialist.
  They should be advised to continue drinking until
  they have the support of specialist services to
  help them detox safely. They should be advised of
  the risks of stopping drinking suddenly. Please
  give out the advice leaflet on this.

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NON DEPENDANT PATIENTS

• Alcohol can still cause harm and be problematic
  even if the patient is not alcohol dependant...
• They can still benefit from our advice and
  support.

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THINK ABOUT THE BIGGER PICTURE

• Does alcohol have an impact on your patients
  health and wellbeing, is it likely to in the
  future?
• Is alcohol stopping your patient from meeting
  their own basic needs?
• (Maslows Hierarchy Of Needs)
• Remember to consider the effect alcohol may be
  having on others too

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• Please refer to the drug and alcohol connect site
  for advice/ information and for links to alcohol
  related information leaflets.
• There is a Smart Recovery group run by the drug
  and alcohol nurses every Wednesday evening
  (Queens building, level 4, clinic 9).