BACKGROUND
{mosimage}On physical examination, the patient has a blood pressure of 120/85 mm Hg and a heart rate of 92 bpm. His rectal temperature is 99.2°F (37.3°C). With the assistance of a ventilator, his respiratory rate is 12 breaths/min. A bleeding scalp laceration approximately 6 cm long is observed over the occipital region. The patient's pupils are 2 mm and symmetric with sluggish reflexes. The corneal reflex is intact. He does not open his eyes spontaneously or on command, though the patient is periodically and spontaneously moving all 4 extremities. His physical findings are otherwise unremarkable, with no other signs of injury.
Laboratory investigations demonstrate a blood alcohol level of 405 mg/dL. The patient's complete blood count (CBC), electrolyte panel, liver function, and coagulation profile are within normal limits. No other drugs of abuse, such as opiates, are detected. A nonenhanced computed tomography (CT) scan of the patient’s head reveals a 28-mm acute collection of blood extending from the frontal lobe to the temporal lobe, with 10-12 mm of midline shift and uncal herniation (see Image 1).
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{mosimage}What is the diagnosis, and what intervention is indicated given the patient's alcohol intoxication?
HINT
The intervention portion is effective and brief, and it involves a negotiation and an interview.
Authors:
Sarah Guzofski, MD,
Resident in Psychiatry,
University of Massachusetts Medical School, Worcester, MA
Ruben Peralta, MD,
FACS, Professor of Surgery,
Anesthesia and Emergency Medicine,
Senior Medical Advisor,
Board of Directors,
Program Chief of Trauma, Emergency
and Critical Care,
Consulting Staff,
Professor Juan Bosch Trauma Hospital,
La Vega, Dominican Republic
eMedicine Editor:
Rick G. Kulkarni, MD,
Assistant Professor,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery,
Attending Physician,
Medical Director,
Department of Emergency Services,
Yale-New Haven Hospital, Conn
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ANSWER
Subdural hematoma and a brief negotiated intervention: Substance use is the leading risk factor for traumatic injury and is a serious problem among patients with trauma. In some clinical studies, as many as 50% of patients admitted to a trauma service have positive results on screening tests for drugs or alcohol. Up to 36% of patients have a blood alcohol concentration greater than 100 mg/dL, and up to 23% test positive for cocaine or methamphetamine.8 As this case illustrates, patients with trauma who screen positive for drugs or alcohol can be at chronic risk for traumatic injury.5, 8
Substance use and repeated injury can be reduced, but success requires a proactive approach. A serious injury related to intoxication might convince a person to stop drinking; however, without intervention, patients usually return to their previous alcohol use within 4 months of injury.8 Successful substance-use reduction programs include systematic screening for drug and alcohol use followed by brief, standardized interventions. Short bedside interventions can reduce substance use for at least a year after discharge and decrease the recurrence of injury by 47% over 3 years.12 Every dollar spent on such efforts returns an estimated 4-fold savings in future healthcare costs.13 D’Onofrio and Degutis comprehensively reviewed the literature describing screening and brief intervention protocols and identified 30 randomized controlled trials and 9 cohort studies.4 Thirty-two studies showed positive outcomes, including reductions in morbidity or mortality, alcohol use, visits to the ED, hospitalizations, and social consequences of substance use, as well as increases in referrals to treatment for substance abuse.
Given the often hectic pace in the ED, clear and simple protocols for screening, intervention, and referral are necessary. Without established protocols, as few as 5-10% of eligible patients are referred to substance-abuse treatment centers at the time of discharge.8, 11, 15, 17 In 2003, the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention convened a multidisciplinary panel that called for simple screening and treatment-referral protocols to become standard practice at trauma centers. To allow for all institutions to benefit from the experience of those with demonstrated success, the CDC further suggested that investigators study the implementation of start-up manuals and practice guidelines, as well as track the effects of intervention on future injury.14
Ongoing research and clinical practices reflect a variety of approaches. Clinical suspicion alone is inadequate grounds to screen for intoxication or chronic substance-related problems; therefore, standardized and objective screening is needed.11 Methods range from laboratory toxicologic screening only to the incorporation of screening tools, examples of which include the alcohol questions recommended by the National Institute on Alcohol Abuse and Alcoholism; the "Cutting down, Annoyance at criticism, Guilty feeling, and Eye-openers" questionnaire, known as the CAGE questionnaire9; the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT alcohol consumption questions (AUDIT-C); and the Addiction Severity Index for other drug use.
Aspects of care to be considered during screening include regional and state legal confidentiality mandates and insurance practices in terms of denial of payment for injuries sustained during intoxication.7
Patients whose screening results are positive for substance use should undergo a standardized intervention. Many successful protocols are based on motivational interviewing, an established model that emphasizes preparing patients for change on the basis of their readiness rather than mandating specific changes. Intervention begins by addressing the patient’s immediate concerns. Patients must be reassured that the interviewer has the goal of helping them find options to improve their lives, not one of judging them or pressuring them to make changes.7 A nonjudgmental style minimizes the patient's defense mechanisms.
One effective technique is based on the stages-of-change model, which recognizes that people differ in their readiness to change their behavior and which tailors the conversation to a level appropriate to the patient’s current readiness.19 Stages of change begin with early precontemplation, in which patients may not recognize the adverse consequences of their substance use. At this point, the goal is to help them see the consequences and to create ambivalence about substance use. For patients who already recognize the negative aspects of their substance use, the goal is to explore the reasons for their substance use, to perceive the positive and negative effects, and to choose abstinence or a reduction in use.7, 18 The current model of brief interventions is effective for both harmful or at-risk drinkers and low-severity drinkers; different goals are set for each of these groups.4
Limitations in financial and workforce resources may pose challenges in staffing an intervention team. A variety of staffing models have been explored. Gentilello et al created an addiction intervention service in which a staff psychologist, along with trainees in psychiatry and psychology, perform the interventions.12 Other trauma centers involve nurses, social workers, and substance abuse specialists.7 Still others have trained existing faculty, residents, and physician associates in the ED to perform brief negotiation interviews (BNIs) and found this setup to be feasible.20 Authors suggest that the person performing the intervention need not be a substance-abuse specialist as long as the program includes a standard protocol and a patient-centered interviewing style.6
Staff from Project ASSERT (Alcohol Substance Abuse Services Education, Referral, and Treatment), with sites in Boston, Mass., and New Haven, Conn., found it cost-effective to involve health-promotion advocates and community-outreach workers to screen patients in EDs for substance use and other health risks.1 If they identified a patient at risk, the staff performed a BNI. If the patient was willing, they referred the patient to substance-abuse services. Of those who received this intervention, 50% reported contacting such services for follow-up treatment, and 56% reduced their alcohol use.
The patient faces many challenges after intervention, including the need for additional substance-abuse treatment after the patient leaves the hospital.12 Factors to consider are the patient's refusal of substance-abuse treatment, insurance barriers, concurrent needs for short-term physical rehabilitation, and inadequate availability of community treatment resources.3
The patient in our case underwent an emergency craniotomy and evacuation of the subdural hematoma. After surgery, a CT scan (see Image 2) of the head showed resolution of the hematoma. In general, his postoperative course was uncomplicated. After the patient's neurologic status improved, he was extubated and underwent treatment for alcohol withdrawal. Further consultation with the patient revealed a long history of alcohol abuse with resulting homelessness, an arrest for assault and battery, strained family relationships, and other trauma while intoxicated. Three months ago, the patient was admitted for a separate alcohol-related injury. Although he was referred for medical follow-up after discharge at that time, he did not request, and was not given, any counseling or referrals for alcohol-abuse treatment. The patient had been drinking about a liter of liquor per day since he was 15 years old without any sustained periods of sobriety. He ultimately recognized that drinking alcohol put him at risk for future injury and made it difficult for him to find housing and to financially support himself. After a few weeks of sobriety in the hospital, he contemplated maintaining abstinence. He was presented with a range of sober-living options, and he agreed to go to a halfway house and to follow up with mental health providers. Six months later, he had substantially decreased his alcohol intake, had no further injuries, and was in treatment with a primary care physician and a psychiatrist.
Substance-use disorders are often chronic illnesses, and change can be difficult; however, standardized and proven techniques (such as motivational interviewing) can change behaviors, especially when an injury occurs. Such interventions may raise the doubts and questions necessary to promote a turnaround, or they may present new options that eventually help even initially reluctant patients to change.
References
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