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An unconscious adult man with apparent alcohol intoxication
A
45-year-old m a n w a s b r o u g h t to t h e e m e r g e n c y d e p a r t m e n t b y a m b u l a n c e after b e i n g f o u n d s u p i n e on t h e s i d e w a l k , u n r e s p o n s i v e , a n d w i t h alcohol on his breath, P h y s i c a l e x a m i n a t i o n r e v e a l e d a n u n r e s p o n s i v e , u n k e m p t m a n . P r e s s u r e a p p l i e d to t h e nail b e d s failed to p r o d u c e a r e s p o n s e . His r e s p i r a tions w e r e noisy, t h e r e w a s n a s a l flaring, a n d blood w a s o o z i n g from his m o u t h . H e h a d p i n p o i n t pupils. B r e a t h s o u n d s w e r e p r e s e n t bilaterally; his a b d o m e n w a s soft a n d fiat. T h e r e w a s no o b v i o u s d e f o r m i t y of t h e h e a d , neck, chest, or e x t r e m i t i e s . H e d i s p l a y e d o b v i o u s p o s t u r i n g d u r i n g triage. Vital signs w e r e as follows: temperature, 35 ~ C rectally; pulse, 50 b e a t s / r a i n a n d regular; respirations, 14 per m i n u t e a n d labored; blood pressure, 210/74 m m Hg. What do you suspect? This m a n w a s r u s h e d into t h e t r a u m a r o o m for a n e m e r g e n c y e v a l u a t i o n b y t h e ED p h y s i c i a n . His n e c k w a s i m m o b i l i z e d w i t h a h a r d cervical collar, a n d r a p i d e n d o t r a c h e a l i n t u b a t i o n w a s c a r r i e d out. I n t r a v e n o u s a c c e s s w a s o b t a i n e d , a n d a b a t t e r y of l a b o r a t o r y t e s t s w a s ordered, i n c l u d i n g a t o x i c o l o g y s c r e e n i n g , w h i c h r e v e a l e d a blood alcohol level of 420 mg/dl. A s p u n h e m a t o c r i t of 31% i n d i c a t e d i n t e r n a l b l e e d i n g . B e d s i d e blood s u g a r t e s t i n g r e v e a l e d h y p o glycemia, and the patient was given intravenous d e x t r o s e , n a l o x o n e (Narcan), a n d t h i a m i n e . T h e r e w a s no r e s p o n s e to a n y intervention, a n d after s e v e r a l s t a n d a r d p r e o p e r a t i v e p r o c e d u r e s , a c o m p u t e d t o m o g r a p h i c s c a n of t h e h e a d w a s p e r formed. It r e v e a l e d a large s u b a r a c h n o i d h e m o r r h a g e . W i t h i n 1 hour a n d 15 m i n u t e s of arrival at t h e Carolene Barnes-Butler is staff nurse, Emergency Department, Elmhurst Hospital Center, Elmhurst, New York. Reprints not available from author. J Emerg Nuts 1996;22:468. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + O 18/1/75284
468
Volume 22, Number 5
e m e r g e n c y d e p a r t m e n t , t h e m a n w a s t r a n s f e r r e d to t h e n e a r e s t facility e q u i p p e d to surgically e v a c u a t e t h e h e m o r r h a g e , F o l l o w - u p reports i n d i c a t e d t h a t t h e s u r g e r y w a s successful.
Section Editor's teaching points T h e p r e s e n t a t i o n of this p a t i e n t to a n y e m e r g e n c y department would obviously warrant emergency e v a l u a t i o n a n d i n t e r v e n t i o n . However, s e v e r a l observ a t i o n s a b o u t this c a s e m a y i m p r o v e t h e efficiency of c a r e of similar p a t i e n t s . T h e s e e m i n g l y o b v i o u s clue to t h i s m a n ' s u n r e s p o n s i v e n e s s w a s t h e alcohol on his b r e a t h . However, t h e d i s p l a y of p o s t u r i n g should a l w a y s s u g g e s t t h e p o s s i b i l i t y of a n i n t r a c r a n i a l lesion. R e g a r d l e s s of a n y s i g n s of a h e a d injury, cervical s p i n e i m m o b i l i z a t i o n a n d i m m e d i a t e e s t a b l i s h m e n t of an a i r w a y are of t h e h i g h e s t priority. Of p a r t i c u l a r i n t e r e s t is t h e e v a l u a t i o n a n d m a n a g e m e n t of the p a t i e n t ' s metabolic state. Unconscious p a t i e n t s usually receive t h e "cocktail" of intravenous naloxone, dextrose, a n d thiamine. C o n c o m i t a n t a d m i n istration of t h i a m i n e a n d dextrose is critical in such c a s e s b e c a u s e p a t i e n t s w i t h alcoholic e n c e p h a l o p a t h y m a y b e c o m e irreversibly c o m a t o s e if t h e y do not receive t h i a m i n e with dextrose. B e d s i d e glucose testing is a s o m e t i m e s overlooked c o m p o n e n t of resuscitation a n d should b e i n c l u d e d as part of the s t a n d a r d m a n a g e m e n t of critically ill patients. Finally, it is important to note that p a t i e n t s w h o are in a n unconscious s t a t e should h a v e core t e m p e r a t u r e m e a s u r e m e n t s on arrival a n d every 15 to 30 m i n u t e s thereafter, with appropriate w a r m i n g m e a s u r e s in progress.
Cont~butions for this column sbouM be sent, typed double-spaced, one copy only, to Lisa Molitor, ARNP, RNC, MSN, CEN, CCRN, 8404 S.W. 128tb Place, Gainesville, FL 32607; phone (352) 331-1781.
45-year-old m a n w a s b r o u g h t to t h e e m e r g e n c y d e p a r t m e n t b y a m b u l a n c e after b e i n g f o u n d s u p i n e on t h e s i d e w a l k , u n r e s p o n s i v e , a n d w i t h alcohol on his breath, P h y s i c a l e x a m i n a t i o n r e v e a l e d a n u n r e s p o n s i v e , u n k e m p t m a n . P r e s s u r e a p p l i e d to t h e nail b e d s failed to p r o d u c e a r e s p o n s e . His r e s p i r a tions w e r e noisy, t h e r e w a s n a s a l flaring, a n d blood w a s o o z i n g from his m o u t h . H e h a d p i n p o i n t pupils. B r e a t h s o u n d s w e r e p r e s e n t bilaterally; his a b d o m e n w a s soft a n d fiat. T h e r e w a s no o b v i o u s d e f o r m i t y of t h e h e a d , neck, chest, or e x t r e m i t i e s . H e d i s p l a y e d o b v i o u s p o s t u r i n g d u r i n g triage. Vital signs w e r e as follows: temperature, 35 ~ C rectally; pulse, 50 b e a t s / r a i n a n d regular; respirations, 14 per m i n u t e a n d labored; blood pressure, 210/74 m m Hg. What do you suspect? This m a n w a s r u s h e d into t h e t r a u m a r o o m for a n e m e r g e n c y e v a l u a t i o n b y t h e ED p h y s i c i a n . His n e c k w a s i m m o b i l i z e d w i t h a h a r d cervical collar, a n d r a p i d e n d o t r a c h e a l i n t u b a t i o n w a s c a r r i e d out. I n t r a v e n o u s a c c e s s w a s o b t a i n e d , a n d a b a t t e r y of l a b o r a t o r y t e s t s w a s ordered, i n c l u d i n g a t o x i c o l o g y s c r e e n i n g , w h i c h r e v e a l e d a blood alcohol level of 420 mg/dl. A s p u n h e m a t o c r i t of 31% i n d i c a t e d i n t e r n a l b l e e d i n g . B e d s i d e blood s u g a r t e s t i n g r e v e a l e d h y p o glycemia, and the patient was given intravenous d e x t r o s e , n a l o x o n e (Narcan), a n d t h i a m i n e . T h e r e w a s no r e s p o n s e to a n y intervention, a n d after s e v e r a l s t a n d a r d p r e o p e r a t i v e p r o c e d u r e s , a c o m p u t e d t o m o g r a p h i c s c a n of t h e h e a d w a s p e r formed. It r e v e a l e d a large s u b a r a c h n o i d h e m o r r h a g e . W i t h i n 1 hour a n d 15 m i n u t e s of arrival at t h e Carolene Barnes-Butler is staff nurse, Emergency Department, Elmhurst Hospital Center, Elmhurst, New York. Reprints not available from author. J Emerg Nuts 1996;22:468. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + O 18/1/75284
468
Volume 22, Number 5
e m e r g e n c y d e p a r t m e n t , t h e m a n w a s t r a n s f e r r e d to t h e n e a r e s t facility e q u i p p e d to surgically e v a c u a t e t h e h e m o r r h a g e , F o l l o w - u p reports i n d i c a t e d t h a t t h e s u r g e r y w a s successful.
Section Editor's teaching points T h e p r e s e n t a t i o n of this p a t i e n t to a n y e m e r g e n c y department would obviously warrant emergency e v a l u a t i o n a n d i n t e r v e n t i o n . However, s e v e r a l observ a t i o n s a b o u t this c a s e m a y i m p r o v e t h e efficiency of c a r e of similar p a t i e n t s . T h e s e e m i n g l y o b v i o u s clue to t h i s m a n ' s u n r e s p o n s i v e n e s s w a s t h e alcohol on his b r e a t h . However, t h e d i s p l a y of p o s t u r i n g should a l w a y s s u g g e s t t h e p o s s i b i l i t y of a n i n t r a c r a n i a l lesion. R e g a r d l e s s of a n y s i g n s of a h e a d injury, cervical s p i n e i m m o b i l i z a t i o n a n d i m m e d i a t e e s t a b l i s h m e n t of an a i r w a y are of t h e h i g h e s t priority. Of p a r t i c u l a r i n t e r e s t is t h e e v a l u a t i o n a n d m a n a g e m e n t of the p a t i e n t ' s metabolic state. Unconscious p a t i e n t s usually receive t h e "cocktail" of intravenous naloxone, dextrose, a n d thiamine. C o n c o m i t a n t a d m i n istration of t h i a m i n e a n d dextrose is critical in such c a s e s b e c a u s e p a t i e n t s w i t h alcoholic e n c e p h a l o p a t h y m a y b e c o m e irreversibly c o m a t o s e if t h e y do not receive t h i a m i n e with dextrose. B e d s i d e glucose testing is a s o m e t i m e s overlooked c o m p o n e n t of resuscitation a n d should b e i n c l u d e d as part of the s t a n d a r d m a n a g e m e n t of critically ill patients. Finally, it is important to note that p a t i e n t s w h o are in a n unconscious s t a t e should h a v e core t e m p e r a t u r e m e a s u r e m e n t s on arrival a n d every 15 to 30 m i n u t e s thereafter, with appropriate w a r m i n g m e a s u r e s in progress.
Cont~butions for this column sbouM be sent, typed double-spaced, one copy only, to Lisa Molitor, ARNP, RNC, MSN, CEN, CCRN, 8404 S.W. 128tb Place, Gainesville, FL 32607; phone (352) 331-1781.