1. Acute services & substance misuse: poisoning or overdose

2. What’s the problem? Harm from substance misuse (intentional or unintentional) including alcohol and drugs account for a high percentage of acute presentations although it is difficult to identify actual numbers as coding may identify them as assaults, accidents or unknown presentations. Alcohol-related admissions to hospital in 2012/13 alone amounted to over 1 million (HSCIC, 2014). Many individuals present as disoriented, confused or with an altered consciousness level. This makes assessment and management challenging. The importance of bystanders, friends, family, emergency services etc. for history cannot be underestimated. Safeguarding of individuals and on-going referral is critical to care.

3. Before reaching Accident & Emergency There should be concern regarding poisoning or overdose for anyone who appears drowsy, disoriented, behaving strangely or is physically unwell (sweating, headache, vomiting etc) and where there is reason to believe the person has taken a harmful substance. The most important first aid action should be to obtain specialist professional assessment for the person by phoning the emergency services. There are few other first aid actions necessary apart from calling for an ambulance. However, obtaining a history of what has been taken - what, how, when, how much - is very useful for the assessment process and risk management. Be aware that telephone triage is available. You will not be wasting ambulance service time if you are genuinely concerned. The operator will assess (triage) the seriousness of the person’s condition and advise you.

4. Case Study 1: Mandy Mandy is 24 and is brought to hospital by her friends who are concerned about her. She is disorientated, sweating profusely and is behaving strangely. She has consumed a lot of alcohol during the evening and her friends think she has also been taking pills that she purchased in a club. They have not taken any and don’t know what it is she has taken. Mandy is incoherent and unable to confirm or deny ingestion of any specific substances.

5. Case study 1: Mandy’s assessment Instigate the acute management process: Immediate assessment on arrival: Manchester Triage System (adopted by most UK emergency departments) has several flowcharts relating to this kind of presentation including behaving strangely, self-harm, and overdose. Whichever flowchart is followed, the priority is to ascertain as complete a history as possible and rule out life threatening issues or complications using a systematic approach.

6. The Manchester triage system IMMEDIATE VERY URGENT URGENT STANDARD NON- URGENT This system establishes the level of priority required:

7. Ruling out life threatening emergencies

8. ABCDE: a systematic approach to patient assessment A – AIRWAY B – BREATHING C – CIRCULATION D – DISABILITY E – ENVIRONMENT This is an effective way to assess the risk to the person. This can be done in the community during a crisis situation as well as in an acute care setting. The ABCDE system helps break down the assessment of threat to the person.

9. ABCDE: some examples associated with substance use Airway: an unconscious intoxicated person may vomit which blocks the airway. Or they may lie in an awkward position which impedes breathing. Breathing: opiate overdose causes respiratory depression: the person’s breathing may be slowed or arrested. Circulation: an unconscious person may lie for long periods on a limb and cut off circulation. Stimulant intoxication may bring on a cardiac or cerebral event. Disability: an unconscious person cannot defend themselves from harm. They may be at risk of accident, hypothermia or even hyperthermia. Environment: the person may be in an unsafe environment. As above, they may be at risk of hypothermia if outdoors, or being run over. If behaving strangely, they may take risks due to psychosis or a diminished sense of danger.

10. Assessment of Mandy: A & E process Airway - is it clear and patent? Record oxygen saturation. Breathing - is she breathing? Record respiratory rate and depth, colour of patient. Circulation - what is her heart rate, blood pressure, temperature and capillary refill time? Disability - how alert is she and are her pupils equal and reactive to light and what size are they (pupil size may indicate drug intoxication pinpoint is associated with opiates and dilated pupils are associated with amphetamine type drugs) Record blood glucose (to exclude diabetic coma). Environment – is she in the safest environment, are the right team members present? Has an accurate history been taken from the friends?

11. Assessment of Mandy Mandy has a raised temperature of 38.9, respiratory rate= 30, oxygen saturation is 92% on air, raised pulse= 110 regular, normal/low blood pressure = 100/60, capillary refill is 2 seconds, blood glucose is 5.2mmols, pupils are dilated but equal and reactive. She is agitated and is disorientated to time and place. There is no sign of obvious injury.

12. Assessment of Mandy (cont.) Differential diagnosis for Mandy: what else could be causing these signs and symptoms? ‘Behaving strangely’ may have a number of potential causes including: –Hypoglycaemia or ketoacidosis (from diabetic imbalance of sugar/insulin) –Raised intracranial pressure from a head injury –Post ictal (following a seizure) –Electrolyte imbalance/ acute dehydration from a range of acute conditions including sepsis –Acute psychiatric disorder –Alcohol withdrawal –Drug toxicity

13. Diagnosis for Mandy All these other possibilities need to be ruled out/in as substance toxicity can mimic several common conditions. Mandy is fortunate that her friends were able to give some history of her condition. However, no one knows exactly what she may have taken or how it may interact with the alcohol. With many new psychoactive substances (‘legal highs’) being used for recreational drug taking, the substance could be from a wide range of harmful chemicals. If the substance cannot be identified, staff can consult the National Poisons Information Service for advice. A new substance in circulation which causes problems needs to be identified and warnings issued to the community, police and health agencies.

14. Mandy’s immediate management needs Maintain the safety of Mandy and other individuals around her. Nurse in a quiet but easily observed environment. Give oxygen on admission 15 litres via non rebreathing mask if tolerated Cannulation for samples to test bloods urea and electrolytes, full blood count, glucose, blood alcohol and blood gases. Give intravenous fluids and monitoring urine output. Contact Mandy’s next of kin and identify as soon as possible any relevant medical history, allergies or medication. Observe and record observations (blood pressure, temperature, respiration rate, pulse) half hourly reporting any deterioration in Mandy’s conscious level or physiological status. If Mandy’s condition deteriorates she may require assessment by intensive therapy team.

15. Mandy: 4hrs after admission Mandy is observed for a period of four hours and in that time becomes less agitated and more alert. She is now able to tell staff that she had bought two pills believing them to be ‘Molly’ (MDMA/ecstasy) but she had not purchased anything from this individual before so couldn’t confirm exactly what she had taken. She admits to regular recreational drug use including cocaine, amphetamines and new psychoactive substances (NPS). Her clinical observations are within normal limits and staff can consider discharging her. Mandy: after stabilisation Once Mandy is stable and moved from immediate and very urgent care, blood and urine tests may establish what type of substance is involved. However, note that the immediate concern has been to ensure her immediate risks are managed and minimised.

16. References & additional resources Caroline N (2013) Emergency Care in the Streets. American Academy of Orthopaedic Surgeons, College of Paramedics. London, Jones & Bartlett. De Lacy J (2011) Improving the Assessment and Triage of Patients with Mental Illness attending the Accident and Emergency Department. Royal College of surgeons in Ireland. Available at: http://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1005&context=mscttheses http://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1005&context=mscttheses Downing P (Ed) (2009) Emergencies in Adult Nursing. Oxford. Oxford University Press. HSCIC (2014) Statistics on Alcohol England. Available at: http://www.hscic.gov.uk/catalogue/PUB14184 http://www.hscic.gov.uk/catalogue/PUB14184 National Poisons Information Service (NPIS) available at: http://www.npis.org/http://www.npis.org/