Tapa: Awakening this man could agitate him, creating a difficult scenario for the entire ED staff. In a busy environment, it would be easy to let this man "sleep it off", but the responsibility is on the Emergency Physician to ensure there is no underlying pathology. It is imperative to attempt an initial examination, at the very least so as to have a baseline to compare to on later exams.
At a minimum, intial examination should include:
- Vital Signs and Fingerstick Blood Glucose
- A+O and Glasgow Coma Scale
- If possible, asking what/how much the person had to drink and if other substances were used as well (i.e. cocaine, prescription meds, etc.). Ask questions related to pain.
- Undress patient and examine completely for lacerations, abrasions, obvious deformities, and trauma (especially craniofacial).
- Check for PERRL.
- Perform Cardiac, Respiratory, Abdominal exams (note epigastric tenderness: think pancreatitis work-up)
- Make sure patient can move all 4 extremities, either by command or in response to pain.
If the above examination is unremarkable and you are fairly confident based on the clinical picture that the patient's altered mental status is secondary to Alcohol, the mainstay of treatment is observation & reassessment. IM Thiamine/Folate can be considered, but in general, labs, tox screens, and IV Fluids are unnecessary.
Alcohol is metabolized in the liver via Zero-Order Kinetics at a rate of approximately 1 drink/hour (faster in chronic alcoholics). Reassess the patient in several hours. If the patient is showing improved mentation, continue with your history & physical. If the patient has not improved, further workup including Head CT may be warranted.
The patient can be discharged when they are A+O x3, have a steady gait, and have no new complaints.
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