Article

L’orientation du patient alcoolisé aux urgences : état des lieux et perspectives

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Abstract

Résumé La consommation d’alcool apparaît comme un facteur de risque de consultation aux urgences comme l’atteste la prévalence importante de patients alcoolisés ou présentant un trouble lié à l’usage d’alcool dans les services d’accueil et d’urgence (SAU). Malgré l’existence de recommandations, depuis 2001, précisant la prise en charge et l’orientation de l’intoxication éthylique aiguë admise au SAU, et bien que la clinique soit bien définie, les patients en difficulté avec l’alcool sont peu captés en raison de la grande variabilité des modes de présentation et l’absence de filière spécifique d’orientation facilement identifiable. Un groupe réunissant urgentistes, addictologues et psychiatres s’est constitué afin de discuter et de proposer des stratégies pratiques pour guider la création de filières de soins addictologiques dont la porte d’entrée serait le SAU. Trois axes principaux ont été identifiés : la proximité entre équipes des services d’urgence et équipes de liaisons et de soins en addictologie (ELSA) favorise les échanges cliniques et stimule les actions de formation ; la pertinence de lits dédiés d’addictologie aiguë ou de crise addictologique ; l’intérêt de consultations d’addictologie ambulatoire de post-urgence. Pour être pertinent, la constitution d’un réseau structuré autour des ressources locorégionales articulera urgentistes, addictologues, services de médecine et de psychiatrie et s’appuiera sur des procédures décisionnelles simples et partagées. La construction d’une filière d’addictologie aiguë réactive, au-delà des enjeux de santé publique auxquels elle répond, pourrait avoir un grand intérêt médico-économique.

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... « La prise en charge idéale du patient alcoolisé repose sur une surveillance médicale pendant quelques heures » [11], le plus habituellement en unité d'hébergement de courte durée (UHCD) au service des urgences [4,9]. Ce n'est dans la réalité proposé qu'aux formes compliquées, pathologiques ou les plus sévères avec altérations comportementales. ...
... Une IEA motivant le recours aux urgences constitue en elle-même un mésusage d'alcool (ANAES grade B), et témoigne d'une situation à problème [8,9]. C'est une occasion d'échanger, d'évaluer les consommations d'alcool ou d'autres substances, dans un discours du lendemain de l'IEA [4,5,17]. Plutôt qu'un aléa dans un parcours de consommations, une IEA amenant à rencontrer des soignants est une opportunité de soin, d'écoute de la souffrance associée au mésusage d'alcool, qui est identifiée dans plus de 90 % des IEA hospitalisées [5,10,12], initialement à l'hôpital, avec l'appui des équipes de liaison et de soins en addictologie (ELSA) [18], puis secondairement avec les soignants de proximité, parmi lesquels le médecin traitant à un rôle central. ...
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Article
L’intoxication éthylique aiguë (IEA) est fréquente en médecine générale, d’urgence et parfois en addictologie. L’IEA est modélisée entre des formes simples où se succèdent l’excitation psychomotrice, l’ébriété puis le coma, et des formes pathologiques. D’évolution le plus souvent spontanément favorable, l’IEA peut être émaillée de complications qu’il faut connaître pour les traiter précocement. Les soins de l’IEA sont d’abord symptomatiques, parfois hospitaliers et se prolongent par la proposition d’une rencontre au lendemain, utile et recommandée. La place de tout soignant est alors possible, parmi lesquels les médecins traitants, pour évaluer la situation avec l’alcool, d’éventuelles addictions associées et soutenir l’orientation vers des soins spécialisés lorsqu’ils sont requis.
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Acute Alcoholic Intoxications in Hospital: Trends for 26 years at Mâcon Hospital (France) Hospital is a privileged place to observe alcohol induced damage and acute alcohol intoxications (AAI), which are there one of the main grounds for recourse. Faced with this, hospital addictology has developed ways of meeting upstream of a care request, in a linkage and outreach activity, which finds its entire place there. This survey observed the positive blood alcohol concentration assay, carried out in a hospital between 1992 and 2017. It considered the evolution of this population: stability of the number of AAIs, growing part of the younger ones, associated with an overall ageing of this population, as well as its increasing feminisation, for average values of inversely decreasing alcohol blood level. These data can help to adapt an offer of speech from the day after the drunkenness, the most congruent to concerned people, in order to promote their access to care and to improve their quality of life.
Thesis
Les intoxications éthyliques aiguës (IEA) représentent une part non négligeable de l’activité globale des services d’accueil des Urgences. Afin d’améliorer la prise en charge de ces patients, nous avons élaboré un protocole de prise en charge, regroupant à la fois la démarche clinique, diagnostique et thérapeutique de l’IEA et de ses complications, mais également les éléments nécessaires à la réalisation de l’intervention brève qui a démontré son utilité dans la réduction de la consommation d’alcool. Dans une première partie nous nous sommes efforcés de faire un rappel le plus exhaustif possible de l’épidémiologie, des différentes classifications, et des complications de l’IEA, ainsi que des examens biologiques ou radiologiques nécessaires au diagnostic de l’IEA, de ses complications ou de ses diagnostics différentiels. Ces différents éléments ont servi d’éléments fondamentaux à la rédaction d’un protocole de prise en charge de l’IEA. Dans une seconde partie, afin de déterminer si la création et l’utilisation de ce protocole avait un intérêt, nous nous sommes intéressés à l’avis des soignants de notre service. Sous forme d’un questionnaire nous avons sollicité l’ensemble de l’équipe médicale et paramédicale de notre service d’Urgences. Pour 94.7% la création et l’utilisation d’un protocole présente un intérêt, et pour un tiers des répondants ce protocole a déjà apporté une amélioration concernant la prise en charge de ces patients. Près de 40% des membres de notre équipe ne réalisent pas d’intervention brève, parce qu’ils ne se sentent pas formés à son utilisation. Ces résultats ouvrent des perspectives intéressantes quant à l’utilité d’un protocole de soins standardisé. Des efforts restent à fournir afin d’améliorer les compétences de chacun, mais les premiers résultats semblent encourageant
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Le développement des soins aux sujets relevant de troubles de l’usage de substance a, en France, un versant hospitalier, dont l’activité de liaison est un pilier. Développée sur le modèle de la psychiatrie de liaison, l’alcoologie de liaison est une des premières modalités du développement de l’addictologie à l’Hôpital. Si les références organisationnelles sont nombreuses pour développer une équipe de liaison et de soin en addictologie (ELSA), les repères cliniques sont rares pour aider les agents dans une relation de soin atypique, par les conditions de brièveté et d’unicité de la rencontre et la nécessité d’établir un lien pour rapidement le défaire en relayant vers d’autres professionnels. Nous proposons d’aborder en dix points l’essentiel des éléments structurant l’activité clinique en alcoologie de liaison, considérant tour à tour les conditions pour pouvoir : parler d’alcool à quelqu’un qui ne demande rien, oser parler d’alcool et d’autres substances, travailler avec l’urgence, composer avec les pressions ou contraintes aux soins, travailler avec la répétition et l’échec, repérer puis prendre en compte les conduites addictives, éviter le piège de la causalité, intervenir dans un temps limité, renoncer à mesurer les effets de ses interventions, et enfin travailler avec tous les soignants.
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Because 40% of motor vehicle fatalities in the United States are alcohol-related, interventions delivered by trauma clinicians targeted to reduce drinking are of particular importance to public health. The objective of this study was to test the effectiveness of hospital-based brief intervention strategies to reduce alcohol consumption and other health-related outcomes in the year after an alcohol-related vehicular injury. Brief interventions are clinically based strategies including assessment and direct feedback about drinking alcohol, goal setting, behavioral modification techniques, and the use of a self-help manual. The study was a randomized controlled trial of two types of brief intervention with a 12-month follow-up. Participants with alcohol-related vehicular injury who were admitted to Level I trauma centers were eligible for enrollment. Enrolled participants were randomized to a control, simple advice, or brief counseling condition. Primary outcome variables were alcohol consumption (standard drinks/month, binges/month), adverse driving events (driving citations, traffic crashes), and changes in health status (hospital and emergency department admissions). The study enrolled 187 participants at baseline and retained 100 across 12 months. Participants had a significant decrease in alcohol consumption and traffic citations at 12 months as compared with baseline. Mean standard drinks/month declined from 56.80 (SD 63.89) at baseline to 32.10 (SD 53.20) at 12 months. Mean binges/month declined from 5.79 (SD 6.98) at baseline to 3.21 (SD 6.17) at 12 months. There were no differences in alcohol consumption, adverse driving events, or health status by condition. Whether the reductions in alcohol consumption and traffic citations were a result of the crash, hospitalization for injury, screening for alcohol use, or combination of these factors is difficult to determine. Further work is needed to understand the mechanisms involved in reductions of health-related outcomes and the role of brief intervention in this population.
Article
Alcohol and illicit drug abuse are major health care problems frequently leading to emergency department admission. The aims of this survey were (1) to determine for the Ghent University Hospital how frequently substance abuse contributed to emergency department admissions, (2) to describe the most important clinical features of these patients and (3) to determine how frequently these patients were referred to appropriate psychiatric services. All 1,941 patients attending the emergency department during the month of September 2003 were registered by the attending emergency department personnel. After exclusion of 8 cases, 1,933 patients were included: 198 (10%) with substance abuse leading to the emergency department admission (= INTOX group) and 1,735 (90%) in the NON-INTOX group. Males and the 21-50 years age group were overrepresented in the INTOX group. Patients with substance abuse were also overrepresented during the night, but not during the weekend. Among the patients from the INTOX group the most frequent reason for the emergency department visit was a psychiatric problem (102/198; 51%). Traumatic lesions related to a fight (n= 19), to a traffic accident (n= 17) and to leisure time activities (n=30) were also frequent. In most patients, only alcohol was abused (144/198; 73%), most frequently chronically (102/144; 71%). In 13% (26/198), there was only illicit drug use, and in 14% (28/198) alcohol abuse was combined with illicit drug use. Among the 54 patients with illicit drug use (with or without alcohol abuse) the most frequently reported drugs were cannabis (54%), cocaine (41%), amphetamines (39%) and opiates (39%). With regard to referral to appropriate psychosocial services it was striking that 53% (19/36) of trauma patients with chronic substance abuse were not offered that type of help. We conclude that abuse of alcohol--and to a much lesser degree illicit drugs--is a frequent cause of emergency department admissions. Our data may help to convince and/or reinforce health care policy makers, emergency department medical directors and the public that alcohol consumption (much more than illicit drugs) is responsible for avoidable morbidity and mortality, and that well-co-ordinated strategies against unhealthy alcohol use are urgently needed. In this respect, the importance of detection and referral of emergency department patients with unhealthy alcohol use should be stressed.
Article
Alcohol misuse are severe financial burden for health care system in Poland. AUDIT and CAGE are two questionnaires used for diagnosis of alcohol abuse. We analyzed the incidence of alcohol problem among emergency unit's patients and correlation of this phenomenon with the reason of admittance to the hospital. 30% patients of Clinical Hospital Emergency Unit of Gdańsk misuse alcohol. Injuries and acute intoxications were considerably more frequent reason of attendances to emergency unit in population of patients with drinking problem. AUDIT questionnaire is more effective and sensitive diagnostic instrument comparing to CAGE and may be useful for identification for both, addicted and misusing alcohol patients.