Original Contributions
Prospective Analysis of Mental Status Progression in Ethanol-Intoxicated Patients KEIR TODD, PA-C, WILLIAM A. BERK, ROBERT D. WELCH, MD, JOHN W. WILLIAMS, JAY FISHER, BS, ROBERT P. WAHL, PAMELA J. CLAPS, MD, W. RUSSELL FARRELL, RAYWIN HUANG, PHD, BROOKS F. BOCK, Distinguishing patfents with uncomplicated ethanol intoxication from intoxicated patients with other causes of mental status depression is a common clinical dilemma. The authors serially tested mental status in a group of ethanol-intoxfcated patients to determine the interval over which mental status changes could be attributed to uncomplicated intoxication. Study patients were identified by (1) admission breath ethanol 3100 mgldl; (2) ethanol-related impairment necessitating further observation or treatment: and (3) not critically ill or exhibiting focal neurologic signs. Mental status scores (sums of specific indices of alertness, orientation, and agitation) were determined initially, 1 hour after arrival, then every 2 hours. Causes of mental status depression other than acute intoxication were diagnosed in 16 patients, while another 16 failed to completely normalize mental status by the time of emergency department discharge or hospital admission. The remaining 71 with uncomplicated ethanol intoxication required (mean + SD) 3.2 & 3.6 hours to normalize mental status scores. A large proportion, however, took considerably longer to normalize mental status: 16 (21%) took 7 or more hours, and three (4%) took as long as 11 hours. Although patients with ethanol-associated depression of mental status lasting 3 hours after emergency department admission should be carefully evaluated for other causes of mental status abnormalities, the authors’ observations indicate considerable individual variation in the duration of mental status depression caused by uncomplicated ethanol intoxication. (Am J Emerg Med 1992;10:271-273. Copyright 0 1992 by W.6. Saunders Company)
The challenge of rapidly diagnosing other causes of central nervous system depression in patients with acute ethanol intoxication has been recognized for over a hundred years.’ More recently Galbraith reported that 16% of patients with traumatic intracranial hematomas at a teaching hospital had recognition of their head injuries delayed more than 12 hours due to ethanol overdose, and that 45% of those dying from From the Department of Emergency Medicine, Detroit Receiving Hospital and University Health Center; and the Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Ml. Manuscript received June 3,199l; revision accepted January 8, 1992. Supported by a grant from the Fund for Medical Research and Education, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Ml. Address reprint requests to Keir Todd, Emergency Department. Detroit Receiving tiosoital/Universitv Health Center, 4201 St Antoine, Detroit, Ml-4820i. Key Words: Alcohol intoxication. Copyright 0 1992 by W.B. Saunders Company 07358757/92/1004-0001$5.00/0
MD, BA, MD, MD, MD
undiagnosed head trauma had been intoxicated.’ Other causes of mental status changes in intoxicated alcoholic patients include concomitant drug ingestion, seizures, psychiatric disorders, and, less commonly, central nervous system infection and ingestion of ethanol substitutes such as methanol or ethylene glycol. Studies on the effects of ethanol intake have for the most part been done in normal volunteers3T4 or within the confines of well-controlled metabolic wards.5-8 To determine the duration of mental depression caused by uncomplicated ethanol intoxication, we studied prospectively 105 patients presenting to our inner-city emergency department with ethanol intoxication. METHODS
Our institution is a tertiary care facility and level one trauma center providing primary care for a largely indigent population. Emergency department census is approximately 80,000 annually. The study was conducted during designated periods on weekend and some weekday nights, when ethanol intoxication is common. Between 8 PM and midnight all patients admitted to the emergency department were evaluated by a study participant and entered if: (1) breath ethanol indicated a blood ethanol level greater than 100 mg/dL (Alcometer III, Intoximeters, Inc, St Louis, MO); (2) physical or mental impairment requiring further observation or care was present and attributable to ethanol intoxication in the opinion of a clinically experienced study participant; and (3) if the subject was not critically ill and exhibited no focal neurologic findings on initial presentation. The definition of intoxication included clinical signs in order to exclude patients with high blood ethanol concentrations but without impairment due to central nervous system tolerance to ethanol.’ Critically ill patients were considered those with initial blood pressure less than 90 mm Hg systolic, signs of shock, or problems requiring multiple procedures and/or emergency surgical care. All patients were evaluated with serial mental status and breath ethanol testing on admission, at 1 hour after admission, and thereafter every 2 hours until hospital admission, discharge from the emergency department, or breath ethanol was zero. Criteria for mental status scoring were indices of orientation, alertness, and agitation graded from 0 to 3 (Table 1). Scores were summed for each individual to produce an overall mental status score. Serum ethanol levels were 271
AMERICAN JOURNAL OF EMERGENCY MEDICINE I Volume 10, Number 4 n July 1992
272
TABLE 1.
Criteria for Serial Mental Status Scoring
Orientation
Alertness
Agitation
Score
Criterion
0
Oriented to self and place, knows year and month, and either weekday or date Any two of three for score of 0 Any one of three for score of 0 No answer Alert Responds slowly; lethargic Responds verbally only to painful stimuli, then lapses No verbal response to pain Absent Mild increase in motor activity Fidgets; restless Unable to remain at rest; thrashing
1 2 3 0 1 2 3 0 1 2 3
NOTE: Results for orientation,
alertness, and agitation were combined to produce overall mental status score.
determined for all patients at the time of initial evaluation. The medical records of all patients enrolled in the study were reviewed for causes of mental status depression other than ethanol intoxication while patients were enrolled in the study and in the emergency department. In addition, retrospective chart review was performed for admitted patients after discharge from a hospital ward. Patient care, including decisions relating to patient disposition, was provided independent of the study and its participants. The study protocol was approved by the Wayne State University Human Investigation Committee. The times from emergency department admission until normalization of mental status score were determined for each subject. Normalization was considered to have occurred when patients attained a score of “0”. Differences in continuous variables between two groups were tested with the unpaired two-tailed Student’s r-test. Binomial proportions were compared by x2 with continuity correction. Pearson correlation was used to test the relationship between continuous variables. Means are expressed as -t- standard deviation (SD) unless otherwise specified. Significance was taken as P s .05.
age (41 * 13 versus 40 * 13 years, P = .80), and gender (76% versus 79% male, P = .70). Figure 1 indicates the mental status course of both groups of intoxicated patients. For the 71 patients with uncomplicated ethanol intoxication, the mean time to normalization of mental status score was 3.2 2 3.6 hours. Figure 2 indicates the cumulative percentage of patients with normalization of mental status at increasing times from emergency department admission. Normalization took 7 or more hours for 15 patients (21%). while three patients (4%) required 11 hours to normalize mental status. For patients with uncomplicated ethanol intoxication, initial serum ethanol concentration correlated significantly with initial intoxication score (r = .25, P = .009) but not with time to normalization of mental status score (r = .17, P = .16). Compared with men, women with uncomplicated intoxication had similar initial intoxication scores (P = .89) and serum ethanol concentrations (men, 312 ? 109; women, 278 ? 108 mg/dL, P = .19). but took significantly longer to normalize mental status (men, 2.6 +- 3.5; women, 4.9 * 3.6 hours. P = .02). DISCUSSION Acute ethanol intoxication is by far the most common form of drug overdose in Western society.” Distinguishing uncomplicated ethanol intoxication from intoxication complicated by other causes of mental status depression, especially head injury 2.1’-‘4 is therefore a high priority for physicians caring for alcoholic patients. However, there are few data relating to the clinical course of acute ethanol intoxication and no previous studies to which we can directly compare our results. Previous work has largely been directed toward defining the dilemma of diagnosing head-injured patients with ethanol intoxication. Such studies have been unanimous in describing the increased risk of head injuries in intoxicated patients.‘.ll-‘4 A prospective study of 918 patients admitted with head injuries to a neurosurgical service concluded that
RESULTS The 105 patients entered into the study had a mean initial serum ethanol concentration of 303 * 109 mg/dL (range, 94 to 575 mg/dL); 81 were men. Sixteen had causes of mental status depression other than acute ethanol intoxication. These included serious head injury, defined as intracranial blood by computerized head tomography (n = 4); acute psychiatric problems requiring emergency care or hospitalization (n = 4); concomitant drug use or overdose (n = 4); generalized seizures (n = 3); and ethanol-associated hypoglycemia (n = 1). An additional 18 patients failed to normalize mental status by the time of emergency department discharge (n = 16) or admission to the hospital for further treatment of medical problems unrelated to abnormalities in mental status (n = 2). In comparison to the remaining 71 patients with uncomplicated ethanol intoxication, these 34 patients were, respectively, similar in initial serum ethanol concentration (298 2 109 versus 319 * 112 mg/dL, P = .35),
0
1
3
5
7
9
1’1
Hours after admission FIGURE 1. Mean and standard error of mental status scores of 7 1 patients with uncomplicated alcohol intoxication (thick line) compared with 34 with other causes of mental status depression (thin line). Differences were significant between the two groups by twotailed I-test at all times (P < ,005).
TODD ET AL n ETHANOL-INTOXICATED PATIENTS
273
uating intoxicated patients for other causes of mental status depression. There are no simple rules or formulae to relieve the clinician of the responsibility for careful initial evaluation, and, for intoxicated patients without a clear indication for immediate intervention, of careful continuing evaluation for development of focal neurologic signs, deterioration of mental status, or simply failure to improve from admission. CONCLUSlON
-
-1
I
0
;
i
ii 7 Hours after admission
9
1’1
FIGURE 2. The percentage of patients with normalized mental status scores with increasing time from emergency department admission.
gross mental status changes should not be attributed solely to ethanol intoxication in patients with blood ethanol concentrations less than 200 mg/dL.” The question of management of patients with considerably higher concentrations, such as most of those in the current study, was not addressed. Our application of a mental status scoring scale to a group of patients with uncomplicated ethanol intoxication indicates that mean time to normalization of mental status is approximately 3.2 hours, but in certain individuals may be as long as 11 hours (Fig 2). Fully one quarter of our patients required 7 or more hours to regain baseline mental status. The considerable individual variations we observed in the duration of ethanol-induced changes in mental status are most likely secondary to differences in peak ethanol concentrations and degree of tolerance to the drug. Our finding that women took significantly longer than men to regain baseline mental status requires further study. Unfortunately, there were too few patients in the study with head injuries to allow meaningful comment on the relation of this problem specifically to ethanol intoxication. Our results should be applied with care to the clinical setting. We purposely excluded patients with focal neurologic findings on admission, since there is no dilemma in their management: further, urgent work-up is indicated. Patients with relatively low blood ethanol concentrations (
Prospective Analysis of Mental Status Progression in Ethanol-Intoxicated Patients KEIR TODD, PA-C, WILLIAM A. BERK, ROBERT D. WELCH, MD, JOHN W. WILLIAMS, JAY FISHER, BS, ROBERT P. WAHL, PAMELA J. CLAPS, MD, W. RUSSELL FARRELL, RAYWIN HUANG, PHD, BROOKS F. BOCK, Distinguishing patfents with uncomplicated ethanol intoxication from intoxicated patients with other causes of mental status depression is a common clinical dilemma. The authors serially tested mental status in a group of ethanol-intoxfcated patients to determine the interval over which mental status changes could be attributed to uncomplicated intoxication. Study patients were identified by (1) admission breath ethanol 3100 mgldl; (2) ethanol-related impairment necessitating further observation or treatment: and (3) not critically ill or exhibiting focal neurologic signs. Mental status scores (sums of specific indices of alertness, orientation, and agitation) were determined initially, 1 hour after arrival, then every 2 hours. Causes of mental status depression other than acute intoxication were diagnosed in 16 patients, while another 16 failed to completely normalize mental status by the time of emergency department discharge or hospital admission. The remaining 71 with uncomplicated ethanol intoxication required (mean + SD) 3.2 & 3.6 hours to normalize mental status scores. A large proportion, however, took considerably longer to normalize mental status: 16 (21%) took 7 or more hours, and three (4%) took as long as 11 hours. Although patients with ethanol-associated depression of mental status lasting 3 hours after emergency department admission should be carefully evaluated for other causes of mental status abnormalities, the authors’ observations indicate considerable individual variation in the duration of mental status depression caused by uncomplicated ethanol intoxication. (Am J Emerg Med 1992;10:271-273. Copyright 0 1992 by W.6. Saunders Company)
The challenge of rapidly diagnosing other causes of central nervous system depression in patients with acute ethanol intoxication has been recognized for over a hundred years.’ More recently Galbraith reported that 16% of patients with traumatic intracranial hematomas at a teaching hospital had recognition of their head injuries delayed more than 12 hours due to ethanol overdose, and that 45% of those dying from From the Department of Emergency Medicine, Detroit Receiving Hospital and University Health Center; and the Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Ml. Manuscript received June 3,199l; revision accepted January 8, 1992. Supported by a grant from the Fund for Medical Research and Education, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Ml. Address reprint requests to Keir Todd, Emergency Department. Detroit Receiving tiosoital/Universitv Health Center, 4201 St Antoine, Detroit, Ml-4820i. Key Words: Alcohol intoxication. Copyright 0 1992 by W.B. Saunders Company 07358757/92/1004-0001$5.00/0
MD, BA, MD, MD, MD
undiagnosed head trauma had been intoxicated.’ Other causes of mental status changes in intoxicated alcoholic patients include concomitant drug ingestion, seizures, psychiatric disorders, and, less commonly, central nervous system infection and ingestion of ethanol substitutes such as methanol or ethylene glycol. Studies on the effects of ethanol intake have for the most part been done in normal volunteers3T4 or within the confines of well-controlled metabolic wards.5-8 To determine the duration of mental depression caused by uncomplicated ethanol intoxication, we studied prospectively 105 patients presenting to our inner-city emergency department with ethanol intoxication. METHODS
Our institution is a tertiary care facility and level one trauma center providing primary care for a largely indigent population. Emergency department census is approximately 80,000 annually. The study was conducted during designated periods on weekend and some weekday nights, when ethanol intoxication is common. Between 8 PM and midnight all patients admitted to the emergency department were evaluated by a study participant and entered if: (1) breath ethanol indicated a blood ethanol level greater than 100 mg/dL (Alcometer III, Intoximeters, Inc, St Louis, MO); (2) physical or mental impairment requiring further observation or care was present and attributable to ethanol intoxication in the opinion of a clinically experienced study participant; and (3) if the subject was not critically ill and exhibited no focal neurologic findings on initial presentation. The definition of intoxication included clinical signs in order to exclude patients with high blood ethanol concentrations but without impairment due to central nervous system tolerance to ethanol.’ Critically ill patients were considered those with initial blood pressure less than 90 mm Hg systolic, signs of shock, or problems requiring multiple procedures and/or emergency surgical care. All patients were evaluated with serial mental status and breath ethanol testing on admission, at 1 hour after admission, and thereafter every 2 hours until hospital admission, discharge from the emergency department, or breath ethanol was zero. Criteria for mental status scoring were indices of orientation, alertness, and agitation graded from 0 to 3 (Table 1). Scores were summed for each individual to produce an overall mental status score. Serum ethanol levels were 271
AMERICAN JOURNAL OF EMERGENCY MEDICINE I Volume 10, Number 4 n July 1992
272
TABLE 1.
Criteria for Serial Mental Status Scoring
Orientation
Alertness
Agitation
Score
Criterion
0
Oriented to self and place, knows year and month, and either weekday or date Any two of three for score of 0 Any one of three for score of 0 No answer Alert Responds slowly; lethargic Responds verbally only to painful stimuli, then lapses No verbal response to pain Absent Mild increase in motor activity Fidgets; restless Unable to remain at rest; thrashing
1 2 3 0 1 2 3 0 1 2 3
NOTE: Results for orientation,
alertness, and agitation were combined to produce overall mental status score.
determined for all patients at the time of initial evaluation. The medical records of all patients enrolled in the study were reviewed for causes of mental status depression other than ethanol intoxication while patients were enrolled in the study and in the emergency department. In addition, retrospective chart review was performed for admitted patients after discharge from a hospital ward. Patient care, including decisions relating to patient disposition, was provided independent of the study and its participants. The study protocol was approved by the Wayne State University Human Investigation Committee. The times from emergency department admission until normalization of mental status score were determined for each subject. Normalization was considered to have occurred when patients attained a score of “0”. Differences in continuous variables between two groups were tested with the unpaired two-tailed Student’s r-test. Binomial proportions were compared by x2 with continuity correction. Pearson correlation was used to test the relationship between continuous variables. Means are expressed as -t- standard deviation (SD) unless otherwise specified. Significance was taken as P s .05.
age (41 * 13 versus 40 * 13 years, P = .80), and gender (76% versus 79% male, P = .70). Figure 1 indicates the mental status course of both groups of intoxicated patients. For the 71 patients with uncomplicated ethanol intoxication, the mean time to normalization of mental status score was 3.2 2 3.6 hours. Figure 2 indicates the cumulative percentage of patients with normalization of mental status at increasing times from emergency department admission. Normalization took 7 or more hours for 15 patients (21%). while three patients (4%) required 11 hours to normalize mental status. For patients with uncomplicated ethanol intoxication, initial serum ethanol concentration correlated significantly with initial intoxication score (r = .25, P = .009) but not with time to normalization of mental status score (r = .17, P = .16). Compared with men, women with uncomplicated intoxication had similar initial intoxication scores (P = .89) and serum ethanol concentrations (men, 312 ? 109; women, 278 ? 108 mg/dL, P = .19). but took significantly longer to normalize mental status (men, 2.6 +- 3.5; women, 4.9 * 3.6 hours. P = .02). DISCUSSION Acute ethanol intoxication is by far the most common form of drug overdose in Western society.” Distinguishing uncomplicated ethanol intoxication from intoxication complicated by other causes of mental status depression, especially head injury 2.1’-‘4 is therefore a high priority for physicians caring for alcoholic patients. However, there are few data relating to the clinical course of acute ethanol intoxication and no previous studies to which we can directly compare our results. Previous work has largely been directed toward defining the dilemma of diagnosing head-injured patients with ethanol intoxication. Such studies have been unanimous in describing the increased risk of head injuries in intoxicated patients.‘.ll-‘4 A prospective study of 918 patients admitted with head injuries to a neurosurgical service concluded that
RESULTS The 105 patients entered into the study had a mean initial serum ethanol concentration of 303 * 109 mg/dL (range, 94 to 575 mg/dL); 81 were men. Sixteen had causes of mental status depression other than acute ethanol intoxication. These included serious head injury, defined as intracranial blood by computerized head tomography (n = 4); acute psychiatric problems requiring emergency care or hospitalization (n = 4); concomitant drug use or overdose (n = 4); generalized seizures (n = 3); and ethanol-associated hypoglycemia (n = 1). An additional 18 patients failed to normalize mental status by the time of emergency department discharge (n = 16) or admission to the hospital for further treatment of medical problems unrelated to abnormalities in mental status (n = 2). In comparison to the remaining 71 patients with uncomplicated ethanol intoxication, these 34 patients were, respectively, similar in initial serum ethanol concentration (298 2 109 versus 319 * 112 mg/dL, P = .35),
0
1
3
5
7
9
1’1
Hours after admission FIGURE 1. Mean and standard error of mental status scores of 7 1 patients with uncomplicated alcohol intoxication (thick line) compared with 34 with other causes of mental status depression (thin line). Differences were significant between the two groups by twotailed I-test at all times (P < ,005).
TODD ET AL n ETHANOL-INTOXICATED PATIENTS
273
uating intoxicated patients for other causes of mental status depression. There are no simple rules or formulae to relieve the clinician of the responsibility for careful initial evaluation, and, for intoxicated patients without a clear indication for immediate intervention, of careful continuing evaluation for development of focal neurologic signs, deterioration of mental status, or simply failure to improve from admission. CONCLUSlON
-
-1
I
0
;
i
ii 7 Hours after admission
9
1’1
FIGURE 2. The percentage of patients with normalized mental status scores with increasing time from emergency department admission.
gross mental status changes should not be attributed solely to ethanol intoxication in patients with blood ethanol concentrations less than 200 mg/dL.” The question of management of patients with considerably higher concentrations, such as most of those in the current study, was not addressed. Our application of a mental status scoring scale to a group of patients with uncomplicated ethanol intoxication indicates that mean time to normalization of mental status is approximately 3.2 hours, but in certain individuals may be as long as 11 hours (Fig 2). Fully one quarter of our patients required 7 or more hours to regain baseline mental status. The considerable individual variations we observed in the duration of ethanol-induced changes in mental status are most likely secondary to differences in peak ethanol concentrations and degree of tolerance to the drug. Our finding that women took significantly longer than men to regain baseline mental status requires further study. Unfortunately, there were too few patients in the study with head injuries to allow meaningful comment on the relation of this problem specifically to ethanol intoxication. Our results should be applied with care to the clinical setting. We purposely excluded patients with focal neurologic findings on admission, since there is no dilemma in their management: further, urgent work-up is indicated. Patients with relatively low blood ethanol concentrations (
