Is your patient injured, intoxicated, or both?
After a night out with friends, a young man was found on the living room floor in the morning. His family assumed he was intoxicated, but after a period of time 911 was called.
When he arrived at the ED, the patient had a CT scan of his brain and cervical spine, which revealed a fractured cervical spine with a large hemorrhage in his brain.
"His friend that he was with the night before arrived at the ED and explained to staff that he had gotten into a fight with the bouncer in a bar and was thrown to the street, striking his head," says Laura Aagesen, RN, BSN, MBA, trauma coordinator at Northwest Community Hospital in Arlington Heights, IL. Since the patient walked into his house, his friend assumed he was not injured.
"There may be a story behind your intoxicated patient, and without a proper evaluation, this could lead to further injury or even death," says Aagesen. "In this case, the patient did expire due to the delay in care."
Send up red flags
"We all have the same patients who come in night after night," says Aagesen. However, this group of patients should send up red flags instead of annoyance, she says.
This is group of patients is high-risk, as intoxication is the leading risk factor for injury, she explains. "Are they undressed? Is a thorough, head-to-toe assessment done on each one of these patients?" asks Aagesen. "A history of alcohol use should not eliminate the need to do a thorough physical examination."
Patients might display symptoms of heavy alcohol ingestion, when in reality their symptoms are caused by a head injury from a fall two days prior, adds Aagesen. "Due to their mental status, they may not be able to give you an accurate history," she says.
When treating an intoxicated patient in the ED, a communication barrier is present, says Danielle Savant, RN, BSN, associate nurse manager of emergency services at Beaumont Hospital Royal Oak (MI). "Much of our assessment relies on the patient's story and their response to palpation during an assessment," says Savant. "But when intoxicated, the patient may not recognize or report pain or tenderness in an area that is injured."
Assume head injury
Savant recommends placing all intoxicated patients with a known injury from a fall, assault, or motor vehicle accident in a cervical collar. "Treat as a possible head injury or bleed until proven otherwise," says Savant.
Keep the cervical collar in place until the patient is clinically sober and is cleared by a negative X-ray or physician examination, says Savant.
If you assume a patient is "only intoxicated," you might miss an injury ranging from broken bones to traumatic brain hemorrhage, warns Savant. "The process we follow includes assessing a patient head-to-toe for signs of injury when they present intoxicated," says Savant. "All intoxicated patients presenting with a known or suspected injury are cervical-collared, to protect the cervical spine from further injury, and have a head CT." (See clinical tip, below, on the importance of removing clothing.)
Always remove patient's clothing One of the homeless individuals who makes frequent visits to the ED at Beaumont Hospital Royal Oak (MI), arrived via emergency medical services on a winter night. The man usually arrived intoxicated. As the nurse was removing his several layers of clothes, she saw that two of his toes were so badly frostbitten they had become gangrenous. "When she asked him how his toes were, he stated, 'My toes are good, no problems there,'" says Danielle Savant, RN, BSN, associate nurse manager of emergency services. "His toes were amputated, and he was admitted for treatment. If the nurse would have left even one pair of his socks on, this would have been missed." Savant says, "It is imperative to assess intoxicated patients fully. Removing clothing allows for proper inspection for bruising, redness, lacerations, or changes in skin tone." |
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