Multicenter assessment of the revisit risk for a further drug-related problem in the emergency department in cocaine users (MARRIED-cocaine study).

INTRODUCTION AND OBJECTIVES: Emergency departments (EDs) in Spanish hospitals daily attend a large number of patients for adverse reactions or clinical complications resulting from cocaine use. After discharge, some of these patients revisit the ED for the same reason within a year. The objective of the present study was to quantify the rate of such revisits and identify the factors associated with them. METHOD: We performed a retrospective, multicenter study with cohort follow-up and without a control group, conducted in the EDs of six Spanish hospitals during 12 months (January-December 2009). We included all ED patients attended for cocaine-related symptoms who reported recent cocaine use and those with cocaine-positive urine analysis by immunoassay without declared consumption. Twelve independent variables assessed for each hospital ED were collected: sex, age, place of consumption, month, day, and time of consumption, mode of arrival at the ED, discharge diagnosis, psychiatric assessment on the ED episode, concomitant drugs, destination on discharge, and history of previous ED visits related with drug use and alcohol use. The dependent variable was a subsequent visit to the ED associated with drug use, identified using the computerized hospital admissions system. RESULTS: The study included 807 patients, of whom 6.7% revisited the ED within 30 days, 11.9% within 3 months and 18.9% within 1 year. The variables significantly associated with ED revisits were: presence of clinical manifestations directly related to cocaine (p < 0.05), ED attendance on a working day (p < 0.05), history of ED visits related with the consumption of alcohol (p < 0.001) or drugs (p < 0.001), and the need for urgent consultation with a psychiatrist (p < 0.001), although only the last four were independent predictors in multivariate analysis. We derived a score based on these variables to predict risk of revisits (MARRIED-score, ranging from 0 to 400 points), which had a reasonably good predictive value for revisit (area under ROC of 0.75; 95% CI 0.71-0.79).

Factores que influyen en la realización de una valoración psiquiátrica en pacientes que consultan por intoxicación por cocaína / Factors predicting the decision to perform a psychiatric evaluation in patients with cocaine intoxication

Objetivo: Los consumidores de cocaína presentan frecuentemente alteraciones psiquiátricas. El objetivo de este trabajo es determinar qué factores influyen en la decisión de solicitar una valoración psiquiátrica urgente ante una intoxicación por cocaína. Método: Registro de dos años de las intoxicaciones por cocaína asistidas en urgencias. Se dividieron en dos grupos en función de si se realizó una valoración psiquiátrica. Se recogió edad, sexo, constantes vitales, escala de Glasgow, asociación de alcohol u otras sustancias de abuso, número de drogas consumidas, tiempo transcurrido desde el consumo, turno de asistencia, antecedentes psiquiátricos y de intoxicaciones previas, sintomatología y destino. El análisis estadístico incluyó una regresión logística para determinar factores independientes asociados a la realización de valoración psiquiátrica. Resultados: Se recogieron 327 casos. Se realizó una valoración psiquiátrica en 69(21,1%). Los pacientes valorados por psiquiatría eran de mayor edad (p = 0,007), habían asociado benzodiacepinas más frecuentemente (p = 0,002), tenían mayor porcentaje de antecedentes psiquiátricos (p < 0,001) y agitación psicomotriz (p = 0,001) y tenían sintomatología neurológica con menor frecuencia (p = 0,001). La regresión logística mostró que la asociación de benzodiacepinas (OR = 2,58; IC 95%: 1,18-5,64;p = 0,018), los antecedentes psiquiátricos (OR = 7,40; IC 95%: 3,51-15,64; p < 0,001)y la ausencia de sintomatología neurológica (OR = 2,74; IC 95%: 1,36-5,50; p = 0,005) eran factores independientes para realizar una valoración psiquiátrica. Conclusiones: La valoración psiquiátrica urgente se realiza en pocas ocasiones. El consumo conjunto de benzodiacepinas, los antecedentes psiquiátricos y la ausencia de sintomatología neurológica se asocian a la solicitud de valoración psiquiátrica (AU)

Background and objective: Cocaine users often present in an altered mental state. This study aimed to determine factors that influence the decision to request emergency psychiatric evaluation in cases of cocaine intoxication. Methods: Cases of cocaine intoxication attended in the emergency department were registered over 2 years. Patients were classified in 2 groups according to whether a psychiatric evaluation was performed or not. We recorded age, sex, vital signs, Glasgow score, combined abuse of alcohol or other substances, number of drugs used, time elapsed since drug use, emergency department work shift, mental health history, prior intoxications, symptoms,. Logistic regression analysis was performed to identify factors that were independently associated with performance of a psychiatric evaluation. Results: A total of 327 cases were registered. A psychiatric evaluation was performed in 69 (21.10%). The group of patients receiving such an evaluation were older (P=.007), had a higher rate of benzodiazepine use (P=.002), had higher rates of history of mental illness (P<.001) and psychomotor agitation (P=.001), and a lower rate of neurologic symptoms(P=.001). Logistic regression showed that factors that were independently related to performance of a psychiatric evaluation were benzodiazepine use (OR, 2.58; 95% confidence interval [CI], 1.18-5.64; P=.018), history of mental illness (OR, 7.40; 95% CI, 3.51-15.64; P<.001), and absence of neurologic signs (OR, 2.74; 95% CI, 1.36-5.50; P=.005).Conclusions: Psychiatric evaluation is not often performed in emergency situations. Associated use of benzodiazepines, a history of mental illness, and an absence of neurologic symptoms are associated with a decision to request psychiatric evaluation (AU)

Características de los fallecimientos producidos en un servicio de urgencias hospitalario / Characteristics associated with emergency department deaths

Objetivos: Describir las características demográficas y asistenciales de los pacientes que fallecieron en nuestro servicio de urgencias hospitalario y analizar en qué puntos se podría mejorar la atención asistencial a este grupo de pacientes. Método: Estudio descriptivo de los pacientes que fallecieron en el servicio de urgencias entre el 1 de enero y el 31 de diciembre del 2006, excluyendo los pacientes fallecidos en las áreas de pediatría y ginecología. Se recogieron datos demográficos y clínicos, así como el tiempo de permanencia y la ubicación del paciente en el momento del óbito. Resultados: La tasa de mortalidad fue 0,2%. El perfil habitual fue el de un paciente de edad avanzada cuyo fallecimiento era esperado. La causa más frecuente de muerte fue la neoplasia en fase terminal y la mediana de permanencia en urgencias, de 6 horas. Únicamente se realizaron maniobras de reanimación cardiopulmonar en una cuarta parte de los pacientes. La prevalencia de pacientes con deterioro cognitivo fue del 32%.En la mayoría de ocasiones se consideró adecuada la ubicación del paciente en el momento de producirse su fallecimiento. Conclusiones: Dado el porcentaje no despreciable de pacientes afectos de una enfermedad terminal que fallecen en los servicios de urgencias se debería mejorar los circuitos de derivación hacia unidades más específicas. También es conveniente la elaboración de protocolos específicos para este grupo de pacientes (AU)

Objectives: To report clinical and demographic characteristics of patients who died in our hospital emergency department and to assess several aspects of medical care that could be improved. Methods: Descriptive study of patients who died in the Emergency Department between January 1st and December31st, 2006, excluding those patients who expired in the areas of pediatrics and gynecology. Demographic and clinical data, length of stay and location/placement of the patient at the time of death were recorded. Results: Mortality rate was 0.2%. The most common type of patient was an elderly person whose death was expected. The most frequent cause of death was end-stage malignant disease and the median length of stay was 6 hours. Only 25% of patients undergone cardiopulmonary resuscitation maneuvers. Prevalence of cognitive impairment was32%. Patient location at the time of death was considered correct in most cases. Conclusions: Given the significant ratio of patients with a terminal illness who die in the Emergency Departments, to enhance the transfer to more specific areas is mandatory. To design specific protocols for this group of patients is also desirable (AU)

[Poisoning by liquid ecstasy (GHB) in hospital emergency departments of Barcelona: a 2-years study]. / Intoxicaciones por éxtasis líquido atendidas en servicios de urgencias hospitalarios de la ciudad de Barcelona durante 2 años.

BACKGROUND AND OBJECTIVE: Liquid ecstasy (GHB) is a new cause of drug overdose in our country. To describe the epidemiological profile and clinical manifestations, we analyzed cases of poisoning by GHB attended by the Emergency Departments (ED) of 2 hospitals of the city of Barcelona. PATIENTS AND METHOD: During two years (2003-2004) all cases of poisoning or overdose due to GHB attended in the ED of the Hospital del Mar and the Hospital Clinic of Barcelona were collected. The diagnosis was clinical and/or by means of toxicological analysis. Epidemiological, clinical, laboratory and therapeutic variables as well as the evolution were collected. RESULTS: A total of 339 patients (mean age 23.5 years, 62% male) were identified. Most patients (89%) were admitted during the early morning and during weekends (89%). Symptoms began in a public place in 97%. Reduced consciousness was the most important clinical manifestation, since 72% of patients had a Glasgow Coma Score of 12 or less. Seventy per cent stated having consumed GHB with other drugs, mainly ethyl alcohol (53%) and cocaine (16%). Some form of treatment was required in 32% of cases and 20 cases were administered an antidote: naloxone (12 cases), flumazenil (8 cases) and physostigmine (6 cases). Five patients needed orotracheal intubation and ventilatory support. One patient needed advanced vital support. There were no deaths. CONCLUSIONS: GHB intoxication leading to reduced consciousness is a frequent motive for admission to the ED, mostly in young people and in the early morning during the weekend. GHB intoxication should be discarded in all cases of coma of unknown origin.

Intoxicaciones por éxtasis líquido atendidas en servicios de urgencias hospitalarios de la ciudad de Barcelona durante 2 años / Poisoning by liquid ecstasy (GHB) in hospital emergency departments of Barcelona: a 2-years study

Fundamento y objetivo: El éxtasis líquido o ácido g-hidroxibutírico (GHB) es una nueva causa de sobredosis de droga de abuso en nuestro medio. El objetivo es describir el perfil epidemiológico y las características clínicas de los intoxicados por GHB atendidos en los servicios de urgencias de 2 hospitales de Barcelona. Pacientes y método: Durante 2 años (2003-2004) se han estudiado los casos de intoxicación o sobredosis por GHB atendidos en el Hospital del Mar y en el Hospital Clínic de Barcelona. El diagnóstico fue clínico y/o por análisis toxicológico. Se analizaron variables epidemiológicas, clínicas, analíticas, terapéuticas y evolutivas. Resultados: Se identificó a 339 pacientes. La edad media fue 23,5 años y el 62% eran varones. Se atendió a la mayoría de pacientes de madrugada (89%) y durante un fin de semana (89%), y el inicio de los síntomas se produjo en un lugar público (97%). La sintomatología se caracterizó por la disminución del grado de conciencia, ya que el 72% de los casos presentaba 12 puntos o menos en la escala de coma de Glasgow. El 70% de los pacientes reconoció el consumo combinado de GHB con otras drogas, entre las cuales las más habituales fueron el alcohol etílico (53%) y la cocaína (16%). El 32% de los casos requirió algún tipo de tratamiento y a 20 de ellos se les administraron antídotos: naloxona (12 casos), flumazenilo (8 casos) o fisostigmina (6 casos). Cinco pacientes precisaron intubación orotraqueal y soporte ventilatorio, y hubo de practicarse soporte vital avanzado en un caso. No se registraron fallecimientos. Conclusiones: En los servicios de urgencias, la intoxicación por GHB es una causa frecuente de consulta por disminución del grado de conciencia, sobre todo en pacientes jóvenes, en fin de semana y de madrugada. La intoxicación por GHB debe descartarse en todo coma de origen desconocido

Background and objective: Liquid ecstasy (GHB) is a new cause of drug overdose in our country. To describe the epidemiological profile and clinical manifestations, we analyzed cases of poisoning by GHB attended by the Emergency Departments (ED) of 2 hospitals of the city of Barcelona. Patients and method: During two years (2003-2004) all cases of poisoning or overdose due to GHB attended in the ED of the Hospital del Mar and the Hospital Clinic of Barcelona were collected. The diagnosis was clinical and/or by means of toxicological analysis. Epidemiological, clinical, laboratory and therapeutic variables as well as the evolution were collected. Results: A total of 339 patients (mean age 23.5 years, 62% male) were identified. Most patients (89%) were admitted during the early morning and during weekends (89%). Symptoms began in a public place in 97%. Reduced consciousness was the most important clinical manifestation, since 72% of patients had a Glasgow Coma Score of 12 or less. Seventy per cent stated having consumed GHB with other drugs, mainly ethyl alcohol (53%) and cocaine (16%). Some form of treatment was required in 32% of cases and 20 cases were administered an antidote: naloxone (12 cases), flumazenil (8 cases) and physostigmine (6 cases). Five patients needed orotracheal intubation and ventilatory support. One patient needed advanced vital support. There were no deaths. Conclusions: GHB intoxication leading to reduced consciousness is a frequent motive for admission to the ED, mostly in young people and in the early morning during the weekend. GHB intoxication should be discarded in all cases of coma of unknown origin