Clinical Practice Guidelines for Assessment and Management of Patients with Substance Intoxication Presenting to the Emergency Department
Year: 2023
Type: article
Abstract: INTRODUCTION The International Statistical Classification of Diseases and Related Health Problems, revision 10 (ICD-10) describes intoxication as “a transient condition following the administration of alcohol or other psychoactive substance, resulting in disturbances in level of consciousness, cognition, perception, affect or behavior, or other psychophysiological functions and responses.”[1] Intoxication is generally an acute phenomenon, the intensity and effects of which wear off with time and disappear completely in the absence of further use of the substance. While most episodes of intoxication do not need medical attention, intoxicated patients may sometimes present to the emergency department.[1] The reasons for seeking medical attention may either be due to the substance use itself (e.g., extreme agitation or violent behavior that may endanger the patient or others around them) or due to an adverse consequence of substance use (e.g., head injury in a road traffic accident that occurred due to driving while intoxicated). Common substances of intoxication encountered in the emergency setting in India are alcohol, cannabis, opioids, and benzodiazepines. Cases of intoxication from other substances like inhalants, stimulants, hallucinogens, and newer psychoactive substances including synthetic cannabinoids and club drugs may also present to the emergency unit. Often the substance of intoxication may be unknown or falsely reported due to fear of legal ramifications or there may be use of more than one intoxicating substance, thereby complicating the clinical picture. Patients may present with decreased levels of consciousness, vomiting, seizures, or other symptoms that may resemble other medical or surgical emergencies. It is, thus, imperative that psychiatrists attending to patients in the emergency department be well-versed with identification, assessment, and management of patients with substance intoxication.[2] Caring for intoxicated patients in the emergency department comes with various other issues that require a psychiatrist’s time and effort. These patients may be brought into the emergency department against their wishes and refuse medical care. They may also be brought in for medical attention by law enforcement authorities with no available identification details and reliable history or even in association with an alleged crime or illegal activity, making it essential for the emergency care provider to be competent in dealing with the medicolegal aspects of intoxication and providing optimum medical services to the patient along with safeguarding the legal procedures. The present clinical practice guidelines deal with the assessment and management of patients with substance intoxication presenting to the emergency department. The guidelines present the general considerations while attending to a substance intoxicated patient, followed by general signs of intoxication. Thereafter, details of intoxication with specific substances are discussed, namely, alcohol, cannabis, opioids, benzodiazepines, and other substances. Features of intoxication, assessment, and management are discussed for each of these substances. Multiple substance intoxication is also discussed in the guidelines. Special populations are referred to in the guidelines, including children and adolescents, women, and the elderly population. The guidelines do not cover nicotine or caffeine intoxication (these are unlikely to be encountered in a clinical setting). Accidental ingestion of substances of use is not catered to in these guidelines. We also do not go into details of intoxication presenting with additional psychiatric and/or medical illnesses and each such case is likely to be unique with its own specific constraints and challenges in management. General considerations while attending to a substance intoxicated patient Patients with intoxication with a substance of abuse present several challenges during assessment and management [Figure 1]. One of the foremost concerns is the potential unreliability of history. Patients with substance intoxication may give inaccurate or unreliable history. This may be partly attributable to patients trying to minimize their substance use, not recollecting details adequately due to cognitive impact of the substance, concealment of the details of substance use from the family, or avoiding sharing details to prevent legal ramifications. Thus, multiple sources of information can be referred to obtain a more comprehensive account of the patient’s condition. Friends, family, and previous treatment records can be useful sources of collateral information about the patient. In some circumstances, physical examination and mental status examination of an uncooperative patient can be helpful to get a clearer clinical picture of the patient (e.g., injection track marks can hint at opioid overdose in an otherwise comatose patient).Figure 1: Challenges in assessment and management of patients with substance intoxicationAnother challenge that comes across in patients with intoxication is the occurrence of agitation or violence. Some of the intoxications with substances like alcohol and stimulants like cocaine may be associated to aggression. Aggression may be due to disinhibition and impaired judgement associated with substance use. Furthermore, substance use disorder may be associated with other psychiatric or medical illnesses that may individually contribute to the state of agitation or aggression. Addressing aggression promptly is required to prevent harm to the self and others. Other relevant guidelines of the Indian Psychiatric Society may be referred to while addressing aggression and violence when patients with substance intoxication present to the emergency department. A related issue is the consumption of substances or presentation with substance intoxication when the patient intends to kill themself. This may be a presenting feature in patients with overdose of opioids or sedative-hypnotics. Sometimes, patients may also consume large amounts of alcohol when they have an intent to die. Thus, self-harm be as a when patients present with substance intoxication, and assessment to self and the of psychiatric additional treatment be for the patient. A relevant of is to the the use of a substance or substance intoxication. in the substance intoxication as occurrence of disturbances in consciousness, cognition, perception, behavior, or that during or the consumption or there is a for the to is as One to is to clinical with a patient a history of substance use which in the mental or disturbances and are brought to the setting as these disturbances are by the and are to be be as The disturbances are as transient and and they are to with Patients with substance intoxication may have an issue related to their mental use may in of judgement or This may in of that is, the of the to a of and their This of a treatment that be and of It is generally that when a is not to be the can be the for the The treatment can also emergency treatment in the of the patient. Furthermore, substance intoxication is a emergency treatment is not one can for the patient to as the substance intoxication A clinical for patients with substance use is the use of substances This may to the clinical picture or by of intoxication or from substances. a patient with opioid may during intoxication. or alcohol are with opioids, the may be In such a patient, may the of intoxication from opioids, not the effects of benzodiazepines. intoxication from cocaine and other stimulants may to which may be by the consumption of than amounts of Thus, a to be to the of multiple substance consumption in a patient with substance intoxication. issue in the clinical management of patients with substance intoxication in the emergency setting is the potential of in the treatment Patients may be substances or it is that do not to or are not in a to to their own intoxication as and may be or due to the substance use disorder and may not be in with the care Thus, the available in the treatment of patients with substance intoxication may be Sometimes, or other may a patient with substance intoxication to the emergency and the of the patient may be unknown to Thus, may have to with information may be legal concerns with the consumption of substances illegal the and This may patients to use of some of the for psychiatrists also be about it be that can patients they are to get a reliable history of the patient. Thus, it be to information and while of the treatment records and providing about to the patient. It also be to or for substance a of of the It is unlikely that such treatment records are referred to by the legal a may need to present the relevant information to when due General signs of intoxication in the intoxication from one or more psychoactive substances may be in the following are disturbances in consciousness, perception, cognition, or behavior that during or the of the The symptoms are in with the effects of the substance. The intensity of the symptoms is related to the of substance The symptoms are and as the substance is from the The symptoms be by medical condition or psychiatric signs and symptoms of intoxication with 1: Features of intoxication with psychoactive management of intoxicated patients in the emergency setting patients presenting with intoxication may to behavior may be with other and A general management of a patient presenting with intoxication is in General management of intoxicated patients in an emergency is a psychoactive substance and in In of are attributable to than and injury are related to alcohol use. from the of which emergency department from in and that in of the emergency related to alcohol use. the alcohol related presenting to the emergency department in a with road traffic due to driving intoxication followed by acute alcohol which is as ingestion of a large of alcohol in a of of alcohol intoxication is a ingestion generally in of and to or In to in some of alcohol intoxication with alcohol are discussed in In of in of and while levels more than can be of alcohol and are likely to of intoxication at the than can from to a to to of alcohol of alcohol intoxication of a patient presenting with alcohol intoxication at the to the patient and and of alcohol use that may require management and care. alcohol intoxication may in several like and Thus, these may be required an can acute effects the such as and an may be discussed are the assessment for alcohol history details of of alcohol with other for details about previous of behavior or violence others. be to alcohol or use levels of may be and and with to patients may from an head injury that may be from It is to a for which is a clinical for may also be in alcohol Thus, may be required to management. In and in and for or for other physical and from the or status examination for and attention to and patient and and to time and and and other of such as and may be by including and and may be by and and from other substances benzodiazepines, and may be for and levels of in the levels than the The and are case considerations and clinical with some symptoms of alcohol intoxication and of or medical can be in medical are intoxicated be and further in a setting or care can be for acute alcohol is The is and of as due to alcohol intoxication may in as a thus, patients with signs of and and may be with is as with alcohol use disorder may have to be with use of is not for of alcohol intoxication. is for patients with alcohol to prevent the occurrence of Thus, may be to patients at of use of alcohol, mental and be at of for followed by It is to that in an emergency is to be that the is in as a of the which may A for management of alcohol intoxication in the emergency setting is in of alcohol intoxication in an emergency setting General management and to and be with level or with or with and one be for intoxicated patients and for with by can following alcohol be is intoxication the an be In the case of mental when a history be from the patient, a of the head can be for to the mental status (e.g., can also be for is psychiatric be and be as as in patients with is may be to for of and can be to be when of alcohol use is be in of or are of to the of alcohol alcohol levels may be required in medicolegal when reliable history is not available or when are of to the of alcohol levels may be in patients at of or to management aggression by a and be to as a injection of may be to the of alcohol in to from intoxication. 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A of may be as the patient may not be with legal or information about consumption of cannabis, as in the and is in the for at in and for an even for One to be about for due to and drugs such as and of intoxication may intoxication with other substances of use like and synthetic a patient with psychiatric symptoms like or one for the of a psychiatric like acute and transient or of intoxication in the emergency setting of intoxication in the emergency setting can be with the patient in a and In most the intoxication in a The patient may be the patient is the or can be in such a the patient is or be for the management of agitation or violence. This may use of with or or and use of In of the patient be for or These may or or of of or with to or be the patient from intoxication, they be and providing information about associated with use. a use disorder is use or the patient be referred for further treatment of substance use are substances. generally in the of such as and and for like and Intoxication with opioids can be patient may be amounts of opioids to a more or as an to harm or patient may be to the of and may of are several for opioid intoxication or overdose that have reported in the These of opioids, of opioids and use of opioids a of and of like and intoxication is as a condition of transient and disturbances in consciousness, perception, behavior, cognition, or that during or the consumption or administration of followed by and impaired and is generally The intensity of these symptoms is related to the of opioids and in intoxication, may These symptoms are not by the of medical condition or of intoxication or of substance. intoxication can be as or the of the level of psychophysiological due to the opioids (e.g., in judgement or and of the level of overdose is a related condition by consumption of amounts of opioids, which is by and The of opioid intoxication and opioid overdose are in opioid intoxication and opioid overdose may be and the clinical of may be more when dealing with patients present to the emergency with and of large of Furthermore, generally opioid intoxication as followed by other of opioid intoxications may be and Some of the opioids are to the and and the patient may present with an of Features of opioid intoxication and opioid for opioid intoxication The assessment of patients with opioid intoxication at of the patient and of harm to the patient. In of opioid information is generally from or of the the of or injection the patient can be a helpful to the consumption of opioids by the patient. The and the intensity of the symptoms of intoxication to the of the opioid and the of for the of and are likely to present are likely to be more for and of may be for also be to the use of along with opioids for a patient. with the assessment of the patient, emergency need to be for the patient attention to the and are some that may be in patients present with of opioid These head or or other or and due to assessment and as be to or other of opioid intoxication in the emergency setting intoxication as a medical emergency and can be the patient is not The of is due to The in describes the management of patients with opioid intoxication. It be that treatment are available for the treatment of opioid intoxication in the emergency of opioid of management in the emergency setting be for the patient. be and the patient may need to be they are to the and or and may be required the patient or is than have a practice of a patient is and that may be as is a opioid that is an treatment for opioid intoxication. it the opioid and the signs and symptoms of opioid intoxication. 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The of assessment identification of intoxication along with and of details the use of the from and the patient, of and the with other psychoactive substances like alcohol, cannabis, opioids, or be to episodes of intoxication, in to identification of and physical or by benzodiazepines. about like driving or and a history of or signs including and level of consciousness, the may be present in of status examination General Patients may by and of or may be and are A examination is in elderly patients and with or history of and general condition. other of acute like head acute and of intoxication in the emergency setting of overdose is effects wear off in a for and in for benzodiazepines. and and may contribute to patient be may be required to The management be in with other Indian Psychiatric Society the General management and to prevent be be may be required for of status and functions may be may be to be for and other psychoactive substances. may be in of or of A may be for comatose patients or with to of of a of in of ingestion with with other substances like and the patient is brought than one like and be administration can The of administration is which may be as the patient is and is A of can be of the patient generally The and for may be to the and prevent injection is to the adverse effects associated with including seizures, and is and in India and is not for use. can be to of be in patients with history of and head of may be by its and other stimulants cocaine and other stimulants have not in their use is in of cocaine intoxication is in the of activity, impaired attention, and Some patients may of the effects and may in and are also by other stimulants and and these the of the Some patients may or due to or can be to in the of cocaine or intoxication is generally Patients can be in a Patients can be for symptoms and agitation or like can be or and as acute agitation and the patient may need a are not required in the absence of a disorder or patients may need Patients may be for and are for related to Patients with cocaine or intoxication a of to a of the intoxication, the patient may be referred for treatment of the use may of intoxication, and these and of intoxication such as and like or impaired and of Patients may and of intoxication is The effects generally wear off a or the patient in a with The patient be Sometimes, like or can be the patient is to these can be or can be and physical need to be for such of the intoxication, the patient be and to treatment are are a of that are by These and Psychiatric effects of are and for In and are are generally by children and adolescents, also consume these substances. The of intoxication impaired and or and Patients may and may also in agitation and and of Some patients may have intoxication with inhalants, and an may be useful for such of patients with intoxication is of and is along with the and can be for some of the patients as like can be for agitation or The intoxication generally a of and the patient of be further referred for use in emergency may patients with a history of use, which consumption of more than one at The substances be drugs or a of benzodiazepines, and are substances in with other psychoactive substances. Multiple substances are generally with the of the psychoactive the adverse and the of intoxication and overdose is when multiple substances are This be either due to of effects or due to consumption of amounts of substances in an intoxicated Thus, intoxication with multiple substances may sometimes present with a clinical picture and may Common symptoms of intoxication can the and to and when multiple stimulants have vomiting, and or and that is or and to of intoxication with multiple substances in an emergency setting are no guidelines for the treatment of intoxication with multiple and the is required to assessment, and in to prevent of be from the patient, and It is to to medical for relevant information history of substance use and episodes of overdose or be examination may to substance for to from or track or other signs that may the substances a examination with attention to and is A may be useful to the substances of use in the emergency department at and of consumption of multiple psychoactive substances. While management from case to case the of some are as signs and with by the patient in when or may be management of the of substances may be to like and may be with to effects of substances with psychoactive for at may be for effects and It is to such as or for assessment the patient is and This may a for and with treatment intoxication in populations use as a with no to its require unique considerations while substance intoxication in emergency and in treatment services due to their unique and In of such children and than women, and elderly and and a in the of substance use due to the that they have making a of substance psychoactive and a which may be at of adverse effects when to psychoactive substances. substance use is in substances of are alcohol, cannabis, and and may present with intoxication symptoms to in with amounts of substances a of The essential of treatment are to with some of the to be into in the management of children and with substance intoxication. One can also to the related to substance use children and General considerations in the management of children and with substance alcohol, and drugs are during due to potential harm to the and the in to in the of making most and psychoactive substances of substance use is about with intoxication present a for the emergency as the and the are in need of medical attention, and need to be with General considerations for management of an intoxicated in the emergency setting are in General considerations for management of an intoxicated in The elderly some unique for substance intoxication. They have a of to of psychoactive substances. of drugs from the These to of intoxication at of the substances. Some sometimes have a of and One may need to from symptoms of which as and of Sometimes, of the may also in of substance A to while elderly patients with substance intoxication in emergency are in for the management of elderly patients with substance intoxication in the emergency to the of a substance use disorder along with a psychiatric condition. that substance use are related to to the emergency department across multiple of patients with psychiatric (e.g., and are associated with substance use. to the emergency may be required due to overdose or overdose with a for substances and may to in of and present with symptoms of the clinical picture in an emergency history along with to the patient’s medical records with details of the may to the of intoxicating drugs and are helpful in the of psychiatric services along with care be referred to in such a at the The psychoactive is for a of that are for their psychoactive that are not the psychoactive substances may to associated with substances and in the of drugs benzodiazepines, stimulants, they are the they present to may or be associated with may from trying an unknown or a substance with unknown or unknown In an emergency associated with use, history of may not these and may not have for While the emergency management the care be to as information about the as for an psychiatric services along with care be intoxication is a for seeking emergency care. Some substance intoxications alcohol, or can be A of clinical is required to substance intoxication, when the patient is not with intoxication to be the of medical and psychiatric status of the patient, history available and examination and available Intoxication may in and substance The of management the of the patient, their they are in a the symptoms and signs of intoxication the medical or psychiatric and to further services as may be helpful in the emergency setting as have an to in the management of patients with substance intoxication, and with emergency in the care of patients may to patient and of are no of
Source: Indian Journal of Psychiatry
Authors: Siddharth Sarkar, Gayatri Bhatia, Anju Dhawan
Language: English
Subfield: Emergency Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4318455394