Last call? Alcohol intoxication in the emergency department.

SICK OR JUST ONE TOO MANY?

Across a wide variety of practice environments, emergency departments (EDs) worldwide are receiving centers of excellence when it comes to caring for intoxicated patients. Despite the near ubiquitous presence of these patients, it can be difficult to provide these patients with consistent, evidence‐based high‐quality care. Timely recognition of critical illness in this demographic can be difficult given chronic medical complexities, lack of clinical history and patient compliance with examination, and false reassurance of abnormal vital signs and mental status changes due to acute intoxication. As clinicians we often feel this tension between our duty to diagnose and treat acute emergencies and our hesitancy to work someone up excessively who at the end of the day is simply intoxicated. In April's JACEP Open Podcast we tiptoe through the minefield that can exist when evaluating intoxicated patients in the ED.

NEED TO STAY OR TIME TO GO?

Short of finding a rapid reversal agent for ethanol intoxication, the “holy grail” for this cohort of patients would be a rapidly available diagnostic test that would let us risk stratify intoxicated patients without pursuing an extensive workup. Previous studies have looked at role that serum lacate could play in evaluating patients who are intoxicated, but these studies have focused exclusively on trauma patients who are intoxicated and have had inconsistent and, at times, conflicting conclusions. Recently in JACEP Open, Akhavan et al. published a 7‐year retrospective study describing the relationship between serum lactate levels and short term mortality in patients who were intoxicated in the ED. Contrary to previous studies showing an association between elevated lactate and increased morbidity and mortality, Akhavan et al. failed to find an association between lactates <6 mmol/L, suggesting that this subset of intoxicated patients may represent a “lower risk” cohort. Although this finding is novel and may help in certain clinical scenarios, unfortunately it may not help us streamline our evaluation of intoxicated patients.

THINGS LOOK GOOD FOR NOW?

One of the biggest limitations of this and other similar studies is that when we attempt to risk‐ stratify intoxicated patients we may be looking for short‐term reassurance without fully appreciating the long‐term risk associated with this population. From a cohort of over 2 million patients, Kendler et al. reported that patients with alcohol use disorder (AUD) had a nearly 6‐fold mortality hazard ratio both as a direct result of their AUD and also secondary to the conditions that may have predisposed them to develop AUD. Other studies have found similarly increased rates of both short‐ and long‐term adverse events in patients who are experiencing homelessness, mental health disorders, and substance abuse. Ultimately, when treating intoxicated patients, it is crucial to focus on both the immediate issues while also anticipating risks that may lie on the patient's horizon.