Don’t miss substance abuse in trauma patients
A recent study in the Journal of the American Medical Association (JAMA) has added to the body of evidence that suggests a direct link between trauma patients and addiction. The study showed that more than half of trauma center patients are, or have been, substance abusers.1
Here are some tips to manage these patients effectively:
1. Don’t let a patient’s intoxication distract you from other symptoms.
Alcohol and other drugs may diminish pain, alter the patient’s ability to verbally respond, follow commands, or recall what may have caused their injury, so a thorough evaluation can be difficult, but it’s essential.
"These patients can never be taken lightly because the same substances also may mask serious injury," says Renee S. Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at Cincinnati Medical Center and immediate past president of the Emergency Nurses Association. This potential masking necessitates that the patient undergo CT and ultrasound scans, blood tests, and sometimes hours of observation.
If a patient smells of alcohol and has slurred speech, there is a tendency to write him or her off as "just drunk."
Carl A. Soderstrom, MD, FACS, director of physician education at the R. Adams Cowley Shock Trauma Center in Baltimore and principal investigator of the JAMA study, says, "There may be a lot going on with that patient that may not be readily apparent. We’ve had patients transferred from other institutions who weren’t getting better, and the CAT scan at Shock Trauma revealed a significant intracranial clot. Some of the decreased sensorium might have been attributed to alcohol, when really there was a head injury."
Never assume an intoxicated patient isn’t also sick or injured.
"There are times when an unruly patient may get pushed into a room to sleep it off, when in fact they have a brain injury which can lead to death or severe morbidity, says Pat Southard, RN, JD, associate hospital director for Oregon Health Sciences University in Portland. "You need to have a standard care for every single patient, and never deviate from it."
2. Look for signs of substance abuse.
Injuries can overshadow a substance abuse problem, causing it to go unrecognized.
"It’s difficult to tell when an alcoholic is intoxicated because they have tremendous tolerance. They can appear to function normally, with a blood alcohol level of 100 mg/dl [0.10] and higher," says Soderstrom. Consider whether the presenting injury could have been caused by substance abuse, he advises.
Possible signs of substance abuse include burns around facial hairs, rash around the nose or mouth from habitual inhalant use, track marks, powder in nasal hairs, symptoms of acute intoxication or drug withdrawal, and high tolerance to sedatives or analgesics.
"It can wreak havoc on your neurologic assessment and cause changes in level of consciousness, pupillary changes, and alter motor coordination and vital signs. These are hints which require additional investigation, but none can be attributed to drug use; you must rule out other causes," says Karen McQuillan, RN, MS, CCRN, CNRN, clinical nurse specialist at the Shock Trauma Center.
3. Don’t let prejudices get in the way of care.
"There’s a tendency for some caregivers to regard alcoholics or drug addicts as less than good people. Not only is that wrong, it can lead to problems in missing diagnoses," says Soderstrom. "We’re not judges of human behavior we need to be compassionate and realize that addictions are treatable diseases."
Still, there’s no denying that substance abusers are prone to violence. Patient and staff safety must be ensured, says Holleran. Chemical or physical restraints may be necessary, according to your facility’s policy and procedure.
4. Address the disease, not just the symptom.
In the ED, there is a tendency to treat the immediate problem and get the patient out the door, but that strategy is not appropriate with substance abusers.
"We need to create a new mindset that if an injured person has a drug or alcohol problem, chances are they’ll get hurt again and again, so we need to break that vicious cycle," advises Soderstrom.
If a substance abusing patient has been in the ED for injuries several times, clinical staff should make an effort to address the problem. "Every clearly intoxicated person should be referred to an on-call person or referred to a substance abuse counselor for a consultation after they leave the ED," says Soderstrom.
5. Use screening tests.
Verbal questionnaires that screen for alcohol and drug abuse can be effective in identifying substance abusers. If patient responses indicate a possible substance abuse problem, it’s a good idea for the nurse to ask a physician to order a substance abuse consult, says Soderstrom.
6. Talk to family members.
Interviewing family members about the patient’s social and medical history can provide clues to facilitate treatment. "But couch those questions so you’re not asking if the patient is an addict, because you’ll invariably get a "no" response," says McQuillan. Instead, ask pointed, direct questions that will give you the answers you’re looking for, such as the amount of substance taken in the last 24 hours.
If possible, talk to more than one family member. One person may be in denial about the extent of the problem, so try to validate information with another person, McQuillan advises.
7. Include nurse-to-nurse contact.
When transferring the patient out of the ED, inform the receiving nurse about the patient’s potential or actual substance abuse problem, Holleran says.
"DTs and some drug withdrawals can be life-threatening, and the nurse needs to ensure that the patient receives the appropriate care or is monitored closely," she says.
8. Take steps when you find drugs on a patient.
It’s not uncommon for nurses to discover stashes of cocaine, marijuana, or other illegal drugs in a patient’s possession. Most EDs don’t have formal policies on how to proceed in this situation.
"It’s a problem that many people are concerned about," notes Southard. "Most people will just dispose of it, instead of saying to the patient, By the way, here’s your crack back.’"
On the other end of the spectrum is reporting the found drugs to the authorities.
"Most people would say, You’re not in the business of trying to find contraband, you’re in the business of providing care,’" says Southard. "If you find vials of crack while undressing a patient and then turn them over to the police, I think that may constitute an unreasonable search and seizure."
ED nurses should work with in-house legal counsel to develop policies on this issue, she advises. (For more legal advice on treating patients with substance abuse, see story, p. 11.)
Reference
1. Soderstrom CA. Psychoactive substance use disorders among seriously injured trauma center patients. JAMA 1997; 277(22):1769-1774.
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