It’s one of those time honored treatments that most hospital-based providers are familiar with. The banana bag, reserved for intoxicated patients presenting to the ED or admitted to the hospital. They’ve been around so long, we just take them for granted. But like most things that have become dogmatic, they are due to be questioned from time to time.
A banana bag is a proprietary mix of “good” stuff, including electrolytes and vitamins, especially thiamine and magnesium. The exact content varies from hospital to hospital. Thiamine and other B vitamins give the resulting solution the characteristic color, hence the term “banana.”
Does it actually do good things like ward off Wernicke’s encephalopathy and megaloblastic anemia? A paper from Jacobi Medical Center in the Bronx prospectively evaluated a series of intoxicated people entering their ED. They drew vitamin B12, folate, and thiamine levels to see if they were deficient enough to even need vitamin supplementation.
- These folks (only 77 patients) were very drunk! Average BAC was 280mg/dL.
- Vitamin B12 and folate levels were not critically low in any patient
- Thiamine was low in 15% of patients, but none had clinical evidence of a deficiency
- Later review of prior visits revealed that some patients with low levels had received a previous banana bag within 1 month. Did it do any good?
Bottom line: Most of our intoxicated patients are not vitamin deficient, and don’t need supplementation. The real kicker is that we almost never really try to find out if the patient might be a chronic abuser and potentially at risk. We just hang the bag. Remember, everything we do in medicine has a potential downside. And if the patient really doesn’t need a banana bag in the first place, there is no benefit to balance that risk. The next time you ask for that little yellow bag, think again!
Reference: Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med 26(7):729-795, 2008.
What exactly is the CIWA protocol? For one, it’s the most popular search term on this blog! Here’s a recap.
It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.
The Clinical Institute Withdrawal Assessment measures 10 items that are association withdrawal:
- Nausea / vomiting
- Paroxysmal sweats
- Tactile disturbances (itching, bugs crawling on skin, etc)
- Visual disturbances
- Auditory disturbances
All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.
The total score is used to determine whether benzodiazepines should given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.
The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.
For a copy of the CIWA scoring criteria, click here.
Happy Hour – FAIL (Drinking and Driving PSA)
Here’s a great public service announcement to share with the social media generation. Shows the consequences in an indirect, but very effective way.
The Centers for Disease Control (CDC) released a report on binge drinking in the US last week that is quite alarming. It provides a host of facts that should alarm any trauma professional. And I’m fairly certain that these statistics apply to just about any other country as well.
The study indicated that 1 in 6 adults in the USA is a binge drinker! My understanding of the term binge is that 5 or more alcoholic beverages are consumed at one sitting. Obviously, this behavior puts one at risk for trauma, including interpersonal violence, car crashes, and injuries due to falls. About 80,000 people per year die due to this, and it costs our economy over $200B per year.
Here are some of the factoids that were uncovered:
- The highest number of binge drinkers was in the 18-34 year age group
- The 65+ year age group drank the most during a binge (!!)
- Most alcohol-impaired drivers were binge drinking (!!!)
- The average highest number of drinks consumed during a binge was 8. In an average drinker, the resulting blood alcohol concentration would be about 0.24 mg/dl, or 3 times the legal limit.
- The northern tier states tended to have the most binge drinkers (18-25%)
What can trauma professionals do? In the US, all Level I and II trauma centers verified by the Amican College of Surgeons are required to screen all patients for problems with alcohol. This requirement should be adopted at all centers, regardless of country or level. Additionally, specific prevention programs should be developed, and existing community programs should be supported.
Reference: CDC Vital Signs -Jan 2012
All trauma professionals are keenly aware of how often alcohol is involved in automobile crashes. Something you may not know is that one third of drug tests for other substances are positive in drivers involved in car crashes!
There has been a 5 percent increase in the number of positive drug screens in drivers over the past 4 years. The drugs range from hallucinogens to prescription pain medications.
Seventeen states have enacted legislation making it illegal to drive while on various types of legal and illegal drugs. However, these laws are difficult to enforce because:
- They are more difficult to detect, both by law enforcement at the scene and in the hospital
- We don’t know a lot about the impact of these drugs on driving performance
- A positive drug screen does not tell us when the substance was taken and if it is at a significant level
Drug screens are typically obtained in the ED in seriously injured drivers. It’s a good idea to order one in any patient with a significant head injury. This allows the clinician to guess (and it’s just a guess) that the medications may be impairing the mental status exam. Any patients who have a positive screen should have a documented chemical dependency evaluation and be provided with referral information to get further help.
Reference: National Highway Traffic Safety Administration