Feb. 05, 2022
Casey M. Clements, M.D., Ph.D., an emergency medicine physician at Mayo Clinic's campus in Rochester, Minnesota, addresses an issue seen regularly in the emergency department and trauma bay: patients who are seemingly intoxicated yet may have a medical condition that is mimicking a substance on board. In the text that follows, Dr. Clements discusses this topic and offers tips for discernment and how to deal with this situation to provide the best medical care for each patient.
Do you see substance misuse in patients in the emergency department and trauma bay at Mayo Clinic?
Yes, it's extremely common. We see a wide range of things. We get people screaming, belligerent and altered with intoxication.
Drugs and alcohol increase the risk of trauma, and alcohol-related visits have gone up with the COVID-19 pandemic. Many people think you wouldn't see hard core drugs in sleepy little Rochester, but we see everything: methamphetamine, some cocaine, some heroin, hallucinogens, others.
Level 3 and 4 trauma centers will absolutely care for patients with drug and alcohol use in correlation with trauma.
Is it possible that some clinical conditions may mimic intoxication?
Yes. One of the first signs of severe head injury is agitation or confusion. It can be hard to weed out if it's drugs, alcohol or related to head injury, or if it's related to another condition outside of the trauma or some combination of these factors. Kidney disease, metabolic disease or low sodium — these can give a mixed picture of trauma, medical abnormality and substance-related impairment.
What would you say about potential intoxication and ability to consent?
In Minnesota, we're one of several states where intoxication doesn't immediately mean you can't consent. Yet, drugs and alcohol could cloud the patient's judgment.
If the patient is intoxicated but still understands, the patient can consent. Intoxication doesn't mean you can't make decisions, but the capacity issue is separate from that. This gets really complicated when it comes to trauma, which can cause altered mental status as well.
What would you suggest as a productive approach with a patient who appears impaired?
It's safest to bias ourselves toward the safety of a patient and pursue a trauma work-up if it is needed and document why we made this decision.
How would you suggest working with a patient who is agitated?
If a patient is not in their right mind and needs medical care, stabilize that situation with the patient's mental status to figure out what's going on. However, we can't let a patient delay the ability to identify a brain bleed or allow the patient to take a swing at us.
In the past, we used to use lorazepam or haloperidol to sedate a patient; however, these medications are slow acting and long lasting. For faster onset and efficacy, we now use midazolam and sometimes droperidol for undifferentiated agitation.
How would you work with a patient who seems severely intoxicated and clearly can't make decisions?
First of all, we should always be kind. That said, we cannot negotiate with a patient in such a state, especially if it will delay care. If you suspect a life- or limb-threatening situation, you don't want to put off addressing that.
What would you say about the impact of head injury on patients you see?
Head injury can mimic intoxication and cause agitation. I've seen patients with severe head injuries who appear intoxicated. It would have been horrible to write them off as "just drunk."
Do you have any written guidelines you follow with patients who appear potentially intoxicated or agitated?
Yes, we created a care pathway in the emergency department that has now been adopted or modified by other practices as well, including the medical intensive care unit and Mayo Clinic Ambulance Service, for addressing patients with undifferentiated agitation. This guideline focuses on upfront control of undifferentiated agitation that is placing the patient or the care team at risk, followed by identification and treatment of underlying causes.
For more information
Emergency Medicine Resources for physicians. Scroll to Undifferentiated psychomotor agitation care pathway. Mayo Clinic.
Refer a patient to Mayo Clinic.