www.jped.com.br
REVIEW
ARTICLE
Identification
and
initial
management
of
intoxication
by
alcohol
and
other
drugs
in
the
pediatric
emergency
room
夽
Thiago
Gatti
Pianca
a,
Anne
Orgle
Sordi
b,
Thiago
Casarin
Hartmann
b,c,
Lisia
von
Diemen
d,∗aHospitaldeClínicasdePortoAlegre,Servic¸odePsiquiatriadaInfânciaeAdolescência,PortoAlegre,RS,Brazil bHospitaldeClínicasdePortoAlegre,Servic¸odePsiquiatriadeAdic¸ão,PortoAlegre,RS,Brazil
cCentrodeSaúdeInstitutodeAposentadoriasePensõesdosIndustriários,Servic¸odeEmergênciaPsiquiátrica,PortoAlegre,RS,
Brazil
dUniversidadeFederaldoRioGrandedoSul,DepartamentodePsiquiatriaeMedicinaLegal,PortoAlegre,RS,Brazil
Received2May2017;accepted12June2017 Availableonline5September2017
KEYWORDS
Bingedrinking; Substanceabuse; Substance-related disorders;
Pediatricemergency medicine
Abstract
Objective: Toreviewthescreening,diagnosis,evaluation, andtreatmentofintoxicationby alcoholandotherdrugsinchildrenandadolescentsintheemergencyscenario.
Datasource: Thiswasanarrativeliteraturereview.
Datasummary: Thedetectionofthisproblemintheemergencyroomcanbeachallenge, espe-ciallywhenitsassessmentisnotstandardized.Theintentionalandepisodicuseoflargeamounts ofpsychoactivesubstancesbyadolescentsisausualoccurrence,andunintentional intoxica-tionismorecommoninchildrenyoungerthan12years.Theclinicalpictureinadolescentsand childrendiffersfromthatinadultsandsomeparticularitiesareimportantintheemergency scenario.Aftermanagementoftheacutecondition,interventionstargetingtheadolescentat riskmaybeeffective.
Conclusion: Thediagnosisandtreatmentofintoxicationbyalcoholandotherdrugsin adoles-centsandchildrenintheemergencyscenariorequiresasystematicevaluationoftheuseof thesedrugs.Therearefewspecifictreatmentsforintoxication,andthemanagement compre-hendssupportmeasuresandmanagementofrelatedclinicalcomplications.
©2017SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
夽
Pleasecitethisarticleas:PiancaTG,SordiAO,HartmannTC,vonDiemenL.Identificationandinitialmanagementofintoxicationby alcoholandotherdrugsinthepediatricemergencyroom.JPediatr(RioJ).2017;93:46---52.
∗Correspondingauthor.
E-mail:lisiavd@gmail.com(L.vonDiemen). http://dx.doi.org/10.1016/j.jped.2017.06.015
PALAVRAS-CHAVE
Consumoexcessivode álcool;
Abusodesubstâncias; Distúrbios
relacionadosa substâncias; Medicinade emergência pediátrica
Identificac¸ãoemanejoinicialdeintoxicac¸õesporálcooleoutrasdrogasnasala deemergênciapediátrica
Resumo
Objetivo: Revisarorastreamento,diagnóstico,abordagemetratamentodasintoxicac¸õespor álcooleoutrasdrogasdecrianc¸aseadolescentesnocontextodeemergência.
Fontesdosdados: Foirealizadaumarevisãonarrativadaliteratura.
Síntesedosachados: Adetecc¸ãodesseproblemanasaladeemergênciapodeserumdesafio, especialmentequandosuaavaliac¸ãonãoépadronizada.Ousointencionaleemgrandes quan-tidadesepisódicasdesubstânciaspsicoativaséopadrãoemadolescenteseaintoxicac¸ãonão intencionalémaiscomumemcrianc¸asmenoresde12anos.Oquadroclínicoemadolescentes eemcrianc¸as diferedosadultosealgumasparticularidadessãoimportantesnocontextode emergência. Apóso manejodoquadroagudo, intervenc¸ões visando o adolescente de risco podemserefetivas.
Conclusão: Odiagnósticoetratamentodasintoxicac¸õesporálcooleoutrasdrogasem adoles-centesecrianc¸asememergênciarequerumaavaliac¸ãosistemáticadousodessasdrogas.Há poucostratamentosespecíficosparaintoxicac¸ãoeomanejoédesuporteedascomplicac¸ões clínicasrelacionadas.
©2017SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4. 0/).
Introduction
The use of psychoactive substances (PAS) among adoles-cents is a worldwide problem. In Brazil, heavy episodic drinkingisstillhigheramongboys(24%),buthasincreased amonggirls(from11%to20%).1Druguse,exceptfor alco-holand tobacco,wasreported by 24%of elementary and high school students; energy drinks combined with alco-hol(15%),marijuana(6%),inhalants(9%),anxiolyticdrugs (5%),andcocaine(2.5%)werethemostprevalent.2In pedi-atricemergencies,ahigherproportionofadolescentsusing PASisexpected;patientspresentduetointoxication symp-toms,complicationsofpreexistingdiseases,andtraumatic injuries.
The challenge in the care of these patients starts at problem detection. When there is no established pro-tocol for the assessment of PAS use in the emergency unit, the frequency and severity of use are usually underestimated.3Thedelayinthediagnosisornon-diagnosis of a disorder caused by PAS use in the emergency room may increase hospitalization time, costs, and the risk of rehospitalization.4
The treatment of PAS-related intoxication among ado-lescents initially involves the diagnosis and symptomatic treatment and/or approach of theother consequencesof theiruse.Aftertheacuteconditionismanaged,the emer-gencyunitisan importantplaceofreferral fortreatment andforpreventiveapproachesincasesofdisordersrelated to PAS use. The aim of this article was to describe the assessment, diagnosis, symptoms, and initial approachof PAS intoxication, aswell as briefinterventions for at-risk adolescents.
Diagnosis
Substanceusesurveillance
Agood screening toolto beused in the emergencyroom should be brief, easy to implement, and have adequate sensitivity and specificity to complement patient clinical evaluation and to provide subsidies for the therapeutic intervention. The literature is quite controversial in the indication of screening instruments to detect the use or diagnosisofproblemsinvolvingPAS,andthereisnospecific guideline for the assessment of young individuals.5 Cur-rently,therearesomevalidatedquestionnaires,aswellas somebiochemicalanalysisteststhatevaluatethepresence ofPASinbiologicalmatrix.
Several tools have already been tested for this popu-lation,butthecare, relax, alone,family,friends,trouble (CRAFT) and the alcohol use disorder identification test (AUDIT) are the tools with the best performance.6 The advantageofCRAFTisthatitalsoassessesconsumptionof multipledrugs withamoderatesensitivity andspecificity. Foralcoholissues,theAUDITshowedthehighestsensitivity andspecificity(95% and77%, respectively), andit canbe appliedinapproximately2min.The mostappropriate cut-offtodetermine problemsrelatedtoalcohol consumption is3.7Itisalsoworthnotingthatthequestion‘‘Howoften didyoudrinkinthepreviousmonth?’’whentheanswerwas equaltoorgreaterthanthreeepisodes,showedasensitivity of90%andspecificityof84%todetectthisproblem.7
alternativesintheemergencyunit,duetothefastresults andtheir ability to identify the recent PAS intake.8 Test-ingtheairexpired throughtheethylalcohol meter islow cost,noninvasive,andhasagoodcorrelationwithalcohol consumption,beingveryusefulfortheassessmentofrecent alcoholintoxication.
Urinetestsareperformedusingatesttapethatcan mea-sure the presence of metabolites of the most varied PAS classes thathave been recently consumed.The detection timeisvariableforeachsubstance:marijuanafromoneto 30days(dependingonwhethertheuseisacuteorchronic), cocainefrom one tothreedays, amphetaminesfrom two tofourdays,benzodiazepinesandbarbituratesuptoseven days.9
Urinescreeningtestsmayshowfalse-negativeresultsdue tohigh cut-offpoints,buta false-positivetestis unlikely, especiallyinanemergencyenvironment,wherethepretest probabilityisalreadyhigh ifthe test isperformed due to clinicalsuspicion.8
Drug testing in adolescents always includes important ethicaland confidentiality issues withparents. Generally, theadolescent shouldalways consenttothetest. In seri-oussituations,suchasaccidentvictims,suicideattempts, seizures,orotherrisksituationsinwhichthepatient’s con-sent cannot be obtained, it is justified to perform them without his/her consent.8 Regarding confidentiality, the adolescent should authorize the parents’ access to the result,whichshouldonlybeinformedtotheparentsagainst thepatient’swishesifanacuterisksituationisidentified.8
Evaluationandmanagementofsubstanceuse
When an adolescent that uses PAS is identified, a more detailedassessment of this use becomesnecessary. In an emergencycontext,informationontheconcomitantuseof otherPAS,amounts,andtimesincethelastintakeare essen-tialforthemanagement.Basedonthesedata,itshouldbe estimatedwhethertheintoxicationsymptomswillincrease ordecreaseinthenextfewhours.Ifpossible,itisimportant toobtain informationontheage ofonsetandprogression for theuse ofeach PAS, frequency andvariability ofuse, aswell asthe directand indirect consequencesof use in relationtothedomains:family,educational,social, psycho-logical,andmedical.Theuseofadultdiagnosticcriteriais stronglydebatedinthiscontext,sincetheabstinenceand tolerancecriteriadonotadequatelyapplytoadolescents.10 Thus,thefocusistoidentifytheadolescentatriskforthe developmentofPASabuse.
Alcoholintoxication
Alcohol intoxication is common among adolescents, and approximately 15% of users ages 15 and older engage in heavyepisodicdrinking.The mainmechanismofthe phar-macodynamics of alcohol is the facilitation of inhibitory transmissionofthecentralnervoussystem(CNS).The symp-toms of acute alcohol intoxication are dose-dependent, related to the serum level that is reached, but there is greatindividualvariabilityin thedose needed toproduce them.11Themostcommonsymptomsare:moodorbehavior change,slurredspeech,lackofcoordination,unstablegait,
nystagmus,attentionormemorydeficitand,inmoresevere cases, stupor or coma. It is important toemphasize that theeffects ontheconsciousnesslevelfollow acontinuum accordingtothebloodalcoholconcentration,rangingfrom mildsedationtocoma.11Additionally,alcoholcancause sev-eralpotentiallylethalmetaboliceffects.Hypoglycemiaisa rare effectin adults,but childrenand adolescentsareat greaterriskofdevelopingit.12 Othermetaboliceffectsare acidosis, hypokalemia, hypomagnesemia, hypoalbumine-mia,hypocalcemia,andhypophosphatemia.Cardiovascular effects may also occur: tachycardia, peripheral vasodila-tion, andvolume depletion, which may contributeto the inductionofhypothermiaandhypotension.11
In young individuals, alcohol intoxication tends to be moreseverethaninadults,astheyusuallydonotshow tol-erancetothe effectsdeveloped byrepeatedexposures.13 Adolescents present a higher probability of intentional intoxication,especiallyinapatternknownasheavyepisodic drinking (binge drinking), which consists in the intake of large amounts in a short period of time. There are cul-tural factors thateven stimulatethis and other practices suchthe‘‘warming up,’’asitis knowninBrazil,which is theconsumptionofalcoholwhengettingreadytogooutto parties.
Thepatternofrepeatedbingedrinkingisrelatedtobrain disordersthatmaydevelopintoalcoholisminadulthood.14
Managementofalcoholintoxication
Beforestarting treatment,it is importanttoestimatethe bloodalcoholcontent(BAC).Ifthemeterisavailable,itisa goodoption,becausetheexpiredairhasagoodcorrelation withthealcohollevels.IfBACisincreasing,theadolescent shouldbecloselymonitoredforCNSdepression.Whenthis objectivemeasureisnotavailable,itcanbeestimatedby the amountconsumed andhowlong thelastconsumption wasmade.Foraroughestimatein olderadolescents,the metabolizationofone dose(14gofethanol)perhour can becalculated.
The management of acute intoxication for all individ-ualsshouldbefocusedontheclinicalcomplicationspresent, suchascorrectionofhypoglycemia,hypomagnesaemia,or managementofrestlessness.Forsevere restlessness, typi-calantipsychotics,suchashaloperidol,shouldbepreferred becauseof a lowerchance of alcohol interaction. Gastric contentaspirationshouldbepreventedwiththe administra-tionofantiemetics,aswellasmaintainingairwaypatency, dependingonthedegreeofpatientsedation.Venousaccess isobtained,ifnecessary,toensurefluidadministration.
Inchildren andadolescents,the treatment followsthe same guidelines, with special attention to hypoglycemia and hypothermia.12 Some studies have shown a beneficial effect of metadoxine in accelerating alcohol metabolism anddecreasing thetimeofintoxicationwithasingledose of900mgIVinadults.15Therearenostudiesonmetadoxine useforthispurposeinthepediatricpopulation.
Marijuanaintoxication
the following effects16: euphoria, pleasurable feelings, decreased anxiety,depression, and attention. Some users whoaremoreanxious,psychologicallyvulnerable,or inex-periencedwiththedrugmaypresentwithincreasedanxiety, dysphoria,and panic attacks. Vasodilationand rednessof the conjunctivae (one of the most characteristic signs of marijuanause)arecommon,andposturalhypotensionand syncopemayalsooccur.Insomecases,thereisanincrease in bloodpressure, dry mouth,increased appetite, nystag-mus,and slurredspeech.16 Changesin sensoryperception mayoccur:colorsbecomeclearerandmusicmorevivid. Per-ceptionofspace,reactiontime,attention,concentration, memory, and risk assessment are alsoaltered. The latter remainalteredformuchlongerthanthesubjective intoxi-cationsensation andtheseeffectsmaypersistfor 12---24h afteruse.
Marijuana increasesheartratetoasmuchas160beats perminuteforafewminutesafteruse,16adose-dependent effect that is probably not relevant in young individuals, unlesstheyhavea previouscardiovascular problem. How-ever,casesofmarijuana-associatedarrhythmiashavebeen reported.Itsuse increasesthe relativerisk ofmyocardial infarctionby4.8-foldintheone-hourperiodafteritsuse.17 AmongpatientsadmittedtogeneralhospitalsinFrancedue tomarijuana use, 29% of patients had some cardiovascu-larcomplications,ofwhom3.5%hadmyocardialinfarction, and 2% had a stroke, with noapparent cause other than marijuanause.18Additionally,31%ofthepatientshad respi-ratorycomplaints(dyspneaor hemoptysis), ofwhom 3.5% hadspontaneouspneumothorax.
The occurrence of psychoticoutbreaks associatedwith the use of marijuana when utilized in large amounts or in preparations with higher concentrations is not infrequent.16,19 Up to 9.5% of users may experience psy-choticepisodesthatlastlongerthantheintoxication.19
Managementofmarijuanaintoxication
The management of cannabinoid intoxication is predom-inantly support therapy. Most cases of mild intoxication resolvethemselveswithinafewhours,andmaybebetter comfortedby accommodating patients in dimly-litrooms, fewerstimuliand,inveryagitatedcases,benzodiazepines suchasdiazepamat adose of5mgbyoral route.Incases withcardiacor respiratorycomplications,theseshouldbe managed accordingtothe underlying etiology.The useof activatedcharcoal is not recommendedfor casesof mar-ijuanaingestion.20 Caseswithpsychosisshouldbe treated withantipsychotics,preferablyatypical drugs, due tothe lowerincidenceofadverseeffects.
Ecstasyintoxication
3,4-Methylenedioxymethamphetamine (MDMA), popularly known as ecstasy, is a substance commonly consumed by individuals attending raves. There is a considerable upward trend in prevalence, and its use is associated withpotentially fatal complications. The acute effectsof MDMA intoxication are a mix of the effects of hallucino-gensandstimulants.Itsmostcommonphysiologicaleffects are hyperthermia, hypertension, tachycardia, sweating,
hyponatremia(duetoinappropriatesecretionofantidiuretic hormone),muscletension,bruxism,andinsomnia.
The psychological symptoms are euphoriaand changes insensoryperception(increasedtactilestimulation, hallu-cinations,andincreasedperceptionofcolorsandsounds); panicattacksandtoxicpsychosescanalsooccur.Thepeakof actionoccursaround2hafterconsumption,withahalf-life ofaround8h.Itisimportanttonotethatthe pharmacoki-neticsofMDMAarenon-linear,i.e.,smallincreasesinthe oraldosecangreatlyincreaseserumconcentration.
Ecstasyintoxicationmanagement
Acute intoxication management is mainly supportive, directedtothesymptomsshownbythepatients.Themost concerning symptom is hyperthermia, potentiated by the context in which the drug is used, in a warm environ-mentandwithintensephysicalactivity.21Restlessnessand seizures should be controlled with benzodiazepines, car-diovascular effects with beta-blockers, and temperature with external cooling measures. Attention must be paid towater-electrolyte imbalance due to the intense water consumption,whichiscommonamongtheseusers. Antipsy-chotics should be avoided, due to the decrease in the convulsivethreshold.22
Cocaineintoxication
Theadministrationrouteofcocainewillinfluenceitsonset ofaction,intensity,anddurationofeffects.Cracksmoking and injectable routes will have more intense, short-lived effects, but with a post-effect of craving and dysphoria. Asfor theinhaled route, theeffectsareless intense,but havealongerduration.Emergencycareisgenerallysought duetopsychologicalorcardiaceffects.Thecommoneffects areexcitement, euphoria,and high self-esteem,but high doses lead to anxiety, restlessness, irritability, paranoid symptoms,andintensecraving.Regardingcardiaceffects, cocaine results in a dose-dependent effect of increased heartrate, blood pressure,andvasoconstriction.There is an increase in cardiac demand,and ischemia,ventricular andsupraventricular arrhythmiamay occur(either due to thedirecteffectorischemia).
The drug use causes an increase in temperature, decreasedperspirationandperipheralcirculation,andmay resultin severe hyperthermia.23 Complicationsthat occur intheCNSareseizures,cerebralischemiaorhemorrhage, headache,andfocal neurologicalsymptoms.Seizuresmay occuraftertheuseoflargeamounts,evenwithoutprevious epilepticfocus. Fromthe pulmonary point of view, pneu-mothorax,pneumomediastinum,orpneumopericardiumcan occurasaconsequenceofValsalvapracticetopreventdrug exhalation.Vasoconstrictionandincreasedcoagulationcan leadtoischemiaandinfarctionofseveralorgansinaddition totheheartandbrain,suchasthelungs,kidneys,spleen, andintestines.
Managementofcocaineintoxication
Thediagnosis isclinical andmaybeaidedbyurinalysis or examstoassesscomplications,suchaselectrocardiogram, cardiac enzymes, and cranial tomography, amongothers. Initialmanagementissupportiveandthetreatmentof rest-lessness,hypertension, and hyperthermia, or the present complications should be prioritized. The use of benzodi-azepines, such as diazepam, is the treatment of choice for restlessness and to relieve cardiovascular symptoms. Patientswithhyperthermia shouldbe cooledquickly, ide-ally within 30min. Routine treatment should be adopted in case of complications, but some care must be taken. Beta-blockers should notbe used,as theymay aggravate vasoconstrictionandhypertension.
Accidental
intoxication
in
children
Recently, accidental consumption of PAS by children has become more common.When the ingestion has not been observed byan adult, it takesa high degree of suspicion tomakethediagnosis.Thepresentationofpsychiatricand neurologicalsymptoms in children without an identifiable pathologyshouldindicatethepossibilityofaccidental intox-icationbysomePAS.Childrentendtopresentwithethanol intoxicationwhen thereis accidental consumption of any productthatcontainsitintheircomposition,suchas mouth-washes, cosmetics, cleaning products, or beverages left by their parents at home. Making such substances inac-cessibletochildren significantlyreduces thelikelihood of accidents.25
Inparticular,therearereportsofincreasedfrequencyof marijuanapoisoningin childrenin theUnitedStates, con-centratedin statesin whichit hasbeen decriminalized.26 Marijuanalegalizationhasmadeitpossibletomarket sev-eralediblepresentationsofthisdrug,includingsomeforms ofcandyandsweets,whichmayinadvertentlybeconsumed bychildren.27
The main symptoms seen in the emergency room in children under 3 years who consumed marijuana include sinus tachycardia (58.6%), mydriasis (48.3%), decreased level of consciousness (34%, Glasgow Scale <12), somno-lence(24%,GlasgowScale12---14),hypoventilation(20.6%), restlessness(10.3%),andseizures(23.53%).27 Inolder chil-dren,neurologicalsymptoms,especiallysedation,arealso more common, but they may also present with ataxia, restlessness,irritability,orgastrointestinalsymptoms. Car-diorespiratorysymptomsarerarer.26
Accidentalexposuretomarijuanausuallydoesnotleadto seriousconsequences,butcanresultinsignificantmorbidity duetotheneedfortreatmentandemergencycare,suchas examsandprocedures.28Unintentionalexposurestococaine arerareinchildren(6%),butresultinamoreseriousclinical picturethan exposure toother substances.29 A retrospec-tivestudywithchildrenundertheageof3yearsadmitted totheemergencyunitwithconfirmedexposuretococaine29 showedthat themost commonsymptoms aretachycardia (50%) and seizures (33%), followed by restlessness (25%), decreased level of consciousness (22%), gastrointestinal symptoms(17%),fever (14%),hypertension(14%), respira-tory depression (11%), cyanosis (8%), mydriasis (8%), and ataxia(8%).Approximately40%mayrequireintensivecare,
Table 1 Brief intervention indication according to the
AUDITscore.
Risklevel Intervention AUDITscore
ZoneI Educational 0---7
ZoneII Counseling 8---15
ZoneIII Briefcounseling andcontinuous monitoring
16---19
ZoneIV Referraltoa specialist
20---40
AUDIT,alcoholusedisorderidentificationtest.
and27%havemoresevereevents,suchasmultipleseizures, need for intubation, renal failure, and rhabdomyolysis.23 Respiratory symptoms (especially when exposed to crack cocaine)andfevermayoccur.30
Managementispredominantly supportive:patientswith cardiacmanifestationsshouldbemonitoredforECGand car-diac enzymesfor 8---12h in theabsence of complications, whichshouldbetreatedaccordingtocurrentprotocols.The use of activated charcoal for detoxification at a dose of 0.5---1mg/kg body weight may be required.31 In children, accidentalintoxicationbyMDMAisanimportantdifferential diagnosisofseizureswithhyperthermia,andparentsusually denysubstanceuse.32
Brief
intervention
AdmissiontoanemergencyroomafterPASintoxication,as wellasbeingtreatedforacomplicationofsuchanevent,is awindowofopportunitytouseaninterventiondirectedat theadolescentandparents/guardians,aimingtomakethem ponderontheuseofthesesubstances.Thebrief interven-tion(BI)isbasedonmotivationalinterview(MI)techniques and thus comprises an empathetic, non-judgmental, and non-confrontationalapproachaimedatcounselingandthe developmentofmotivationforachangeinbehavior.33
Oneofthe most preeminentmanuals onBIfor alcohol userssuggestsevaluatingtheriskzoneforalcoholusebefore applying the intervention, according to the AUDIT score. Basedonthat, themostrecommendedconduct shouldbe applied,according toTable1.The educationalconduct is toprovideinformationabouttherisksassociatedwith alco-holuseand,wheneverpossible,toprovideabrochure.The counselingmeans providingfeedbackontheAUDITresult, educatingtheindividualsabouttherisks,andadvisingthem onhowtochangethisbehavior.
BI, in addition to providing risk education and feed-back,alsosupportstheideaofengagingyoungindividualsin behaviorchangesbysettinggoalsforthesechanges.Inthis situation,itisimportanttoalsocounselthefamilyto moni-tortheseobjectivesandtoprovideinformationonwhereto seekhelp,ifnecessary.IndividualswithAUDITscoresabove 20arethosewhoalreadyhaveapatternofalcohol depend-ence and shouldtherefore bereferred toa specialist for treatmentofthedisorder.33
intoxication(AAI)werecarriedoutintheUnitedStatesand Europe,andonlyonestudywasconductedinBrazil.34 The largeststudy that isstillbeingdeveloped is beingcarried out in Germany. HaLT (stop --- close tothe limit) is a BI-basedpreventionprojectfor youngindividualswithAAIin theemergencyroomthathasalreadybeenimplementedin morethan170locations.35
Moststudiessoughttoevaluate,asprimaryoutcome,the reductioninalcoholconsumptionafteraBI.However,many studiesdidnotfindasignificantdifferenceinrelationtothe controlgroups.Thisresultisexplained,forthemostpart,by thefactthatthecontrolgroupitselfalsodecreasedalcohol consumption after the emergencyadmission. Overall, the studiesuseda BIbasedonMI techniques, lasting approxi-mately45min,andsomestudiesalsousedapproacheswith parents.33,36
Although the findings were inconclusive in relation to thetotalamountofalcoholicbeveragesingestedafterthe BI in emergencies,it wasobserved thatyoung individuals who were submitted to a BI had a significant reduction in secondaryoutcomes,such asnumberofingested doses and number of drinks per week, days onwhich alcoholic beverages were ingested, and number of heavy drinking episodes in a follow-up of up to 12 months.37,38 Another interestingfindingwasadecreaseincaraccidentsrelated to alcohol consumption in those who were submitted to aBI.38
The only study developed in Brazilshowed a predomi-nantly male population (90.3%) and a high prevalence of alcohol dependence (37.9% in the BI group; 35.2% in the controlgroup), demonstratingthat, in thiscountry, inter-ventions aimed at the treatment may be asimportant as interventionsfocused solelyon prevention. In that study, therewasnosignificantdifferencebetweenthegroups,but therewasanoveralldecreaseinalcoholconsumptioninthe three-monthfollow-up.34
TheBIiswellestablishedforadultsthatseekemergency careafterintoxicationepisodes,howeverthisintervention hasnotshownsuperiorityovercontrolconditionsin adoles-cents.Thismightberelatedtotheimportanceofintegrated approachesincludingthefamilyinthesecases.
Conclusion
CasesofPASintoxication,whetheraccidentalorintentional, arecommonandshouldhaveahighlevelofsuspicion.Itis importantforthecliniciantobeawareofintoxicationsigns, astheclinicalpicturecanbeeasilymistakenasother prob-lems. Emergency treatment is predominantly supportive, butit shouldberememberedthatmost caseswillrequire care for the underlying causes of intoxication. Moreover, gettingtoemergencycareduetoPASintoxicationisa win-dow of opportunity for the implementation of prevention measures.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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