Alcohol use in the prehospital setting: a diagnostic challenge in patients treated by a physician staffed mobile intensive care unit

Kauppila e al. Sp inge Plus (2016) 5:1247 DOI 10.1186/s40064-016-2921-y SHORT REPORT Alcohol use in he p ehospi al se ing: a diagnos ic challenge inpa ien s ea ed bya physician s a ed mobile in ensi e ca e uni Te hi Kauppila1, Janne Vi a2, Leena Lindg en1, Ilkka Vi kkunen3 and An i Kämä äinen2* Abs ac Backg ound: Alcohol use among eme gency pa ien s has been s udied ea lie , bu he da a ega ding alcohol use especially among c i ically ill and inju ed pa ien s ea ed in he p ehospi al se ing is sca ce. The aim o his s udy was o e alua e he incidence o alcohol use and he cha ac e is ics o cases a ended by a physician s a ed mobile in ensi e ca e uni (MICU). Findings: Du ing a 2 mon h pe iod, exhaled ai alcohol concen a ion—measu ed as a pa o ou ine pa ien exami- na ion in all adolescen and adul pa ien s ea ed by he MICU—was eco ded. The MICU encoun e ed 258 pa ien s, o which 82 could be es ed o alcohol use. O he es ed pa ien s 43 % ga e a posi i e b ea h es esul . P opo ion o male pa ien s p o iding a posi i e esul in he b ea h es did no di e signi ican ly hose o women. The p ima y eason o no o es he pa ien was a dec eased le el o consciousness in one- i h o he ini ial 258 pa ien s. Conclusions: A signi ican p opo ion (47 %) o he encoun e ed pa ien s could no be es ed due o hei c i ical condi ion. Alcohol use was obse ed in 43 % o hose capable o p o iding a b ea h es sample. The a e o posi i e es s seemed o be highe han hose epo ed om eme gency depa men s. No el diagnos ic me hods o de ec alcohol consump ion in non-coope a i e pa ien s a e wa an ed. Keywo ds: Alcohol, Diagnos ics, In oxica ion, P ehospi al, Ou -o -hospi al, Eme gency © 2016 The Au ho (s). This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. Backg ound Alcohol use among eme gency depa men pa ien s has been s udied o o e 30yea s. In a s udy by Hol e al. 40 % o pa ien s a ending he eme gency depa men o a la ge eaching hospi al we e unde he in luence o alcohol and he majo i y o hem we e men. A posi i e b ea h es as an indica o o alcohol use was mo e com- mon in cases o sel -poisoning, head inju y and majo auma han in gene al medical o su gical pa ien s. Fu - he mo e, 82 % o pa ien s p esen ing wi h a lowe ed le el o consciousness ga e a posi i e esul in he b ea h es (Hol e al. 1980). In ano he s udy, alcohol use was e i ied in app oxima ely one- hi d o auma pa ien s o wo king age admi ed o a casual y depa men o a uni e si y hospi al (An i-Poika and Ka aha ju 1986). As alcohol use p edisposes o inju ies and epea ed use o eme gency depa men (ED) se ices, i is impo an ha alcoholics and hea y consume s a e iden i ied by heal h ca e pe sonnel (An i-Poika and Ka aha ju 1986; Che pi- el e al. 1996). Howe e , he iden i ica ion o a d inking p oblem has p o en di icul and e.g. clinical signs such as slu ed speech and abno mal co-o dina ion un eliable indica o s o alcohol use (Hol e al. 1980; Che pi el e al. 1996). As a clinical aspec in an eme gency, alcohol use o he pa ien could a ec e.g. he e alua ion o auma ic b ain inju y (Shahin e  al. 2010), he deli e y o anaes hesia (Fassoulaki e al. 1993) o d ug me abolism (Wea he - mon and C abb 1999) ega dless o he ea men se ing. Despi e epo ed da a on alcohol use among ED pa ien s, da a ega ding pa ien s ea ed in he p ehos- pi al se ing is sca ce. Fu he mo e, o ou knowledge no Open Access *Co espondence: [email p o ec ed] 2 Eme gency Medical Se ices, Tampe e Uni e si y Hospi al, Tays, PL2000, Tampe e, Finland Full lis o au ho in o ma ion is a ailable a he end o he a icle Page 2 o 4 Kauppila e al. Sp inge Plus (2016) 5:1247 epo s ha e been published on he opic o alcohol use in con ex o he mos c i ical p ehospi al eme gencies. The pu pose o his p ospec i e s udy was o e alua e he incidence o alcohol use using a b ea h analyze , he ea- sibili y o he b ea h es analysis i sel , as well as pa ien and mission cha ac e is ics o cases a ended by a physi- cian s a ed mobile in ensi e ca e uni (MICU) du ing a wo mon h pe iod. Me hods The s udy was conduc ed be ween 7 h Ap il and 8 h June 2012 in he physician s a ed MICU o Pi kanmaa coun y, Finland, co e ing a popula ion o 486,000. The MICU, s a ed wi h an anaes hesiologis and a pa a- medic, esponds o he mos c i ical eme gencies such as p esumed ca diac a es and high ene gy auma. As a pa o ou ine pa ien examina ion, exhaled ai alco- hol concen a ion is measu ed in all adolescen and adul pa ien s ea ed by he MICU—child en unde he age o 15 we e excluded om he s udy. Du ing he s udy pe iod, he esul s o his es we e p ospec i ely eco ded om he MICU un shee s and mission da a- base. Addi ionally, da a on pa ien age, gende , medical condi ion and he ype o eme gency we e eco ded. Alcohol use was examined ou o exhaled b ea h by using a single b ea h alcome e es e (D äge Alco es 3000, D äge Sa e y AG, Lübeck, Ge many). I he es e could no be used, he eason o his was eco ded in he MICU un shee . As he e was no new ea men o examina ion modali y in ol ed in he s udy se ing, and by he pe mission o he Depa men o Science Cen e o Pi kanmaa Hospi al Dis ic , he equi emen o pa ien consen and app o al o he egional e hics commi ee we e wai ed. S a is ical analysis was pe o med using he IBM SPSS S a is ics e sion 20.0. (IBM, A monk, NY, USA) wi h s a is ical signi icance se a p<0.05. Resul s Du ing he s udy pe iod, he MICU encoun e ed 258 pa ien s, ou o whom 161 (62%) we e men and 97 (38%) women. The mean age o he pa ien s was 51yea s ( ange 0–92). The mos common ypes o eme gency we e clas- si ied as; blun auma (n=48, 19%), neu ological cause (excluding p esumed ischemic s oke) (n=43, 17%), ca - diac a es (n=34, 13%) and in oxica ion (n=32, 12%). O he encoun e ed pa ien s, 82 (32 %) pa ien s, 52 men (63%) and 30 women (37%), could be es ed wi h he alcome e . The p ima y eason o ailed es ing was dec eased le el o consciousness in one- i h (n = 56, 22%) o he ini ial 258 pa ien s. Fu he mo e, 38 (15%) pa ien s we e in ca diac a es , and 26 (10%) pa ien s we e unable o pe o m he b ea h es due o sho ness o b ea h o a igue. Fi e pa ien s (2%) e used he b ea h es . O he encoun e ed pa ien s, 16 (6%) we e child en <15yea s and hus no es ed. Also, he b ea h es was o go en o wai ed due o an unknown eason by he MICU s a in 35 (14%) cases. Ou o he 82 pa ien s included in he inal analysis, 35 (43%) ga e a posi i e b ea h es esul . The cha ac e is- ics o hese pa ien s a e desc ibed in Table1. The p o- po ion o male pa ien s p o iding a posi i e esul in he b ea h es did no di e signi ican ly hose o women— 24 ou o 52 men e sus 11 ou o 30 women, wo ailed Fishe exac es 0.489. Also, he e was no signi ican di - e ence when compa ing he ype o eme gency be ween hose wi h a posi i e e sus wi h a nega i e b ea h es esul . O he 56 pa ien s ha could no be es ed due o low- e ed le el o consciousness, 19 (34%) p esen ed wi h a Glasgow Coma Scale (GCS) (Teasdale and Jenne 1974) sco e o 3, 23 (41%) sco ed 4–8 GCS poin s and 14 (25%) pa ien s 10–13 poin s. Due o he low a e o b ea h es s pe o med in he p ehospi al se ing, we pe o med a pos hoc analysis o he blood alcohol concen a ions measu ed in he ecei - ing eme gency depa men . O he 160 adul pa ien s in whom he b ea h es was no pe o med, 130 we e anspo ed o hospi al, whe ein blood alcohol concen- a ion was measu ed in 28 pa ien s. O hese pa ien s, 16 p o ided a nega i e sample, whe eas 12 a posi i e one (median 57mmol/l, ange 17–111mmol/l). Discussion In his e alua ion o p ehospi al alcohol use among pa ien s ea ed by a MICU, h ee key indings we e iden i ied. Fi s , a signi ican p opo ion (47 %) o he encoun e ed pa ien s could no be es ed using a b ea h es analyze due o c i ical illness o inju y. Al hough non-in asi e and o good co ela ion wi h blood alco- hol es s, he b ea h es me hod equi es co-ope a ion om he pa ien (De ogis e al. 1995). The e o e accu a e diagnos ic me hods o de ec alcohol consump ion e.g. in unconscious pa ien s a e wa an ed, such ha a e al eady a ailable o es ing o illici subs ances (Peh sson e al. 2011). Secondly, o he es ed pa ien s, alcohol use was obse ed in 43% o cases which is sligh ly highe han he a es epo ed in s udies om eme gency depa - men s (Hol e al. 1980, An i-Poika and Ka aha ju 1986). Thi dly, al hough he p opo ion o men in he whole pa ien ma e ial was highe , he e was no signi ican di - e ence be ween men and women in ega d o he a e o pa ien s p o iding a posi i e esul in he b ea h es . To ou knowledge, his is he i s p ospec i e s udy e alua ing he incidence and cha ac e is ics o alcohol use among eme gency medical se ice (EMS) pa ien s Page 3 o 4 Kauppila e al. Sp inge Plus (2016) 5:1247 ea ed by a physician s a ed MICU, hus ep esen ing a popula ion o pa ien s including he mos c i ical medical and su gical eme gencies. Compa ed o o he EMS sys- ems, he obse ed a e o alcohol use (43%) was highe han epo ed om Alaska by K iegsman and An hes (28%) (1998), simila o ha epo ed by McLaughlin (2010) om a Midwes e n college own (45%) and lowe han epo ed om Zu ich, Swi ze land (73%), (Holze e al. 2012). I is likely ha mo e cases o alcohol use could ha e been iden i ied wi h diagnos ic ools easible o use in he con ex o lowe ed consciousness— he pos hoc blood esul s analysis esul ed in u he 12 posi i e es esul s. The obse ed di e ences in compa ison o p e i- ous s udies om acciden and eme gency depa men s may e lec he policy ha no all pa ien s encoun e ed by he EMS a e anspo ed o hospi al, bu may also be anspo ed o shel e ca e o Police cus ody o e en le a he scene (Ross e al. 2013). Also, due o he na u e o he c i ical illness i sel and ongoing in ensi e ca e, in his pa ien popula ion ha m ul alcohol use is equen ly uniden i ied (Tomlinson e al. 2012) in he hospi al. Fu - he mo e, he da a om hospi al se ings do no e lec he bu den o alcohol use on EMS (K iegsman and An hes 1998). Howe e , i is necessa y o ema k ha no all alcohol use can be ca ego ically de ined as ha m ul pe se. In Finland, he a e o ha m ul alcohol use has been de ined o be equal o exceed se en daily o 24 weekly alcoholic be e ages o men and 5 daily o 16 weekly alcoholic be e ages o women. I has been es ima ed ha app oxima ely 500,000 inhabi an s exceed hese consump ion a es in Finland (Halme e  al. 2008). As ano he indica o o ha m ul alcohol use, d i ing unde he in luence (DUI) o alcohol is punishable by law in Fin- land i he alcohol concen a ion in exhaled ai exceeds 0.5‰ o 0.22mg/l. Wi h hese indica o s in mind, i can be obse ed ha all bu one pa ien wi h a posi i e es esul p o ided ei he a b ea h analysis o blood sample esul ha exceeded he minimum punishable DUI limi . This s udy ca ies weaknesses. Fi s , he e en ual sam- ple size o pa ien s pe o ming a b ea h es was small. This, howe e , e lec s he unsui abili y o he b ea h es Table 1 Alcohol b ea h es analysis esul s, cha ac e is ics o pa ien s andeme gency ypes NA no applicapble a =1‰ equals 1000mg/l o 21.7mmol/l o e hyl alcohol in blood Pa ien s by es esul o pe o mance n=258 Posi i e esul 35 (100%) Nega i e esul 47 (100%) No b ea h es 176 (100%) Alcohol concen a ion in he b ea h es (‰)aReason o ailed es ing Impai ed consciousness 56 (22 %) <1 1 (3 %) NA Ca diac a es 38 (15 %) 1–2 14 (40 %) NA Sho ness o b ea h 26 (10 %) 2–3 14 (40 %) NA Pedia ic 16 (6 %) 3–4 5 (14 %) NA Re used 5 (2 %) >4 1 (3 %) NA Unknown 35 (14 %) Pa ien cha ac e is ics Male 24 (69 %) 27 (57 %) 108 (61 %) Female 11 (31 %) 20 (43 %) 68 (39 %) Age (yea s) <15 NA NA 16 (9 %) 15–20 2 (6 %) 5 (11 %) 6 (3 %) 21–30 9 (27 %) 8 (17 %) 13 (7 %) 31–40 7 (20 %) 4 (9 %) 11 (6 %) 41–50 8 (24 %) 7 (15 %) 24 (14 %) 51–60 6 (17 %) 6 (13 %) 25 (14 %) >60 3 (6 %) 17 (36 %) 81 (46 %) Type o eme gency Blun auma 11 (31 %) 8 (17 %) 29 (16 %) In oxica ion incl. subs ance abuse 11 (31 %) 5 (11 %) 15 (9 %) Pene a ing auma 5 (14 %) 3 (6 %) 2 (1 %) Neu ological (excluding ischaemic s oke) 4 (11 %) 8 (17 %) 31 (18 %) Respi a o y 2 (6 %) 1 (2 %) 19 (11 %) O he 2 (6 %) 22 (47 %) 80 (45 %) Page 4 o 4 Kauppila e al. Sp inge Plus (2016) 5:1247 me hod in c i ically ill pa ien s. Second, he s udy was conduc ed in a physician s a ed MICU, which esponds only o he mos c i ical p ehospi al eme gencies. The e- o e his ma e ial can be ega ded as selec ed o ocus on he c i ically ill o inju ed. S ill—in con as o p e ious s udies—all ypes o eme gency and adul pa ien age g oups we e included in a p ospec i e manne , expand- ing he insigh o he ex en o alcohol use among p ehos- pi al pa ien s. Finally, he deg ee o alcohol in oxica ions o alcohol use in gene al we e no con i med wi h blood es s in he whole pa ien popula ion, as he ocus o he s udy was limi ed o he p ehospi al se ing. O e - all, based on hese sho comings in da a collec ion he conclusions on p e alence and compa isons o p e ious epo s and o he me hods o alcohol use de ec ion need o be ca e ul. F om an e hical iewpoin , i could be deba ed whe he ou ine b ea h es ing o alcohol is jus i ied. Dunham and Chi ichella (2012) ha e app oached he subjec p e- iously and concluded ha es ing is jus i ied a leas in he mos se e ely inju ed pa ien s. Also, in an eme gency se ing, alcohol use o he pa ien could a ec e.g. he e alua ion o auma ic b ain inju y (Shahin e al. 2010), he deli e y o anaes hesia (Fassoulaki e al. 1993) by he p ehospi al o eme gency depa men physician, o d ug me abolism (Wea he mon and C abb 1999). In p ehospi- al pa ien s wi h pe sis ing impai ed le el o conscious- ness mo ali y is conside able (Bjö kman e al. 2015) and ea ly diagnosis and ea men o he cause is impo an — such as uling ou alcohol in oxica ion. I has been p e- iously ecognized ha eme gency depa men pa ien s do no spon aneously epo alcohol abuse hemsel es (Richoux e  al. 2011) and he e o e—due o pa ien sa e y—we con inue o ind he me hod o ou ine es ing o be app op ia e a leas in he mos se e ely inju ed o ill pa ien s ea ed by de ini ion by he physician s a ed MICU. In conclusion, in pa ien s o whom a physician s a ed MICU was dispa ched due o a p esumed high- isk eme - gency, alcohol use was obse ed in 43% o hose capa- ble o p o iding a b ea h es sample. Impo an ly, almos hal o (47%) o he encoun e ed pa ien s could no be es ed due o a c i ical condi ion. No el diagnos ic me h- ods o quan i a i ely de ec alcohol consump ion in non- coope a i e pa ien s and u he s udies on he bu den o alcohol use on he eme gency medical se ices a e necessi a ed. Au ho s’ con ibu ions All au ho s con ibu ed o he design and concep ion o he s udy. TK, IV, JV and AK con ibu ed o he acquisi ion o da a, TK and AK analyzed he da a. All au ho s con ibu ed o in e p e a ion o he da a. All au ho s con ibu ed o he d a ing and e ising o he manusc ip , and ag eed upon submission o he manusc ip . All au ho s ead and app o ed he inal manusc ip . 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