What is the best approach to manage a patient with intoxication in the emergency department, particularly when faced with an ethical dilemma?

From the Guidelines

The best approach to managing a patient with intoxication in the emergency department, particularly when faced with an ethical dilemma, involves a systematic assessment and stabilization of vital functions, followed by administration of specific treatments such as naloxone for opioid overdose or benzodiazepines for alcohol withdrawal, while balancing medical necessity with respect for patient autonomy. When managing an intoxicated patient, it is crucial to begin with stabilization of vital functions, including airway management, breathing support, and circulatory assessment. For opioid overdose, the most recent and highest quality study recommends administering naloxone 0.4-2mg IV, IM, or intranasal, repeating as needed, as outlined in the American Heart Association guidelines 1.

Key Considerations

• For alcohol intoxication, supportive care is primary, with IV fluids like normal saline at 1-2 liters for dehydration, thiamine 100mg IV to prevent Wernicke's encephalopathy, and benzodiazepines such as diazepam 5-10mg IV or lorazepam 2-4mg IV for withdrawal symptoms or seizures.
• When ethical dilemmas arise regarding treatment refusal, assess decision-making capacity by evaluating the patient's understanding of their condition, treatment options, and consequences of refusal.
• If the patient lacks capacity but requires immediate intervention for life-threatening conditions, proceed with necessary treatment under implied consent or emergency exception doctrine, as recommended by general medical principles and supported by guidelines for managing psychiatric patients in the emergency department 1.

Ethical Considerations

• The approach should balance the ethical principles of beneficence (providing needed care) and autonomy (respecting patient choices) while fulfilling the duty to protect patients from harm when their judgment is impaired by intoxication.
• Document all assessments, interventions, and decision-making processes thoroughly to ensure transparency and accountability in the management of the patient.

From the FDA Drug Label

WARNINGS Risks from Concomitant Use with Opioids Concomitant use of benzodiazepines, including lorazepam injection, and opioids may result in profound sedation, respiratory depression, coma, and death. Abuse, Misuse, and Addiction The use of benzodiazepines, including lorazepam injection, exposes users to the risks of abuse, misuse, and addiction, which can lead to overdose or death

The best approach to manage a patient with intoxication in the emergency department, particularly when faced with an ethical dilemma, is to assess each patient's risk for abuse, misuse, and addiction and to monitor patients closely for respiratory depression and sedation. It is also crucial to use a gradual taper to discontinue lorazepam injection to reduce the risk of withdrawal reactions. Additionally, concomitant use of CNS depressants and other substances associated with abuse, misuse, and addiction should be avoided or minimized. If a substance use disorder is suspected, the patient should be evaluated and instituted (or referred for) early treatment, as appropriate 2.

• Key considerations:
  • Monitor for signs and symptoms of abuse, misuse, and addiction
  • Avoid concomitant use of opioids and other CNS depressants
  • Use gradual taper to discontinue lorazepam injection
  • Evaluate and treat suspected substance use disorder
  • Inform patients about the risks of benzodiazepine abuse, misuse, and addiction 2.

From the Research

Management of Intoxication in the Emergency Department

The management of patients with intoxication in the emergency department (ED) is a complex issue that requires a comprehensive approach. Key aspects of management include:

• Decontamination processes and basic supportive care 3
• Use of specific antidotes when available and/or applicable 3
• Removal of chemicals and drugs from the body by means of hemodialysis or hemoperfusion while treating vital sign abnormalities and electrolyte and acid-base disturbances 3
• Comprehensive assessment, including medical and psychiatric evaluation 4
• Treatment of diagnosed disorders, including withdrawal, intoxication, and clinical features that characterize an emergency 4

Ethical Dilemmas in the Emergency Department

When faced with an ethical dilemma in the ED, healthcare professionals must consider the best approach to manage the patient. This may involve:

• Balancing the need to provide medical treatment with the need to respect the patient's autonomy 5
• Ensuring that patients receive comprehensive assessment and treatment, including awareness of the patient to carry out treatment if necessary and referral 4
• Providing evidence-based interventions for patients with substance use disorders 4
• Managing agitation and aggression in patients with intoxication, including the use of sedating medications and physical restraints 6

Medical Interventions for Intoxicated Patients

Intoxicated patients in the ED often require medical interventions, including:

• Sedating medications 6
• Physical restraints 6
• Imaging studies 6
• Laboratory testing 6
• Airway interventions, including intubation, nasal airway, and supplemental oxygen 6
• Repositioning to protect the airway 6
• Referral to treatment, including detoxification or sobering facilities 5

Standardized Approaches to Management

Standardized approaches to managing intoxication in the ED can improve patient outcomes, including:

• Decreasing the use of benzodiazepines 7
• Avoiding undertreatment of adrenergic hyperactivity and delirium 7
• Decreasing the need for sitters and physical restraints 7
• Reducing hospital length of stay 7