Acquired Brain Injury (ABI), and in particular traumatic brain injury, is frequently associated with alcohol and/or substance misuse. It is necessary to take a detailed history as it is important to avoid inappropriate labelling of patients as ‘alcoholics’, solely on the basis of being admitted after having consumed alcohol.
In the event that alcohol and/or substance misuse is confirmed (or cannot be excluded, but is considered highly likely) consider managing withdrawal symptoms which may compound problems related to brain injury (in particular increased agitation). The potential for withdrawal syndromes following brain injury is high.
Management of Withdrawal Syndromes
Initiate local hospital protocols for management of withdrawal syndromes and/or consult toxicology/metabolic medicine/psychiatry team for advice. Management of withdrawal syndromes should include:
- Fluid replacement.
- Be aware of hyponatraemia risk, and avoid over-rapid correction.
- Note potential for other causes of hyponatraemia.
- Be aware of seizure potential. Consider prophylactic treatment if other risks also indicate it.
- In situations of associated suspected drug overdose, be aware of possibility of serotonin syndrome which can mimic Paroxysmal Sympathetic Hyperactivity/Dysautonomia
- Benzodiazepines for agitation.
- Vitamin supplementation.
Consider the possibility of pre-existing neurological complications of alcohol and/or substance misuse as possible causes of confusion or incoordination, especially in the following:
- Korsakoff’s/Wernicke’s encephalopathy.
- Peripheral neuropathy.
- Hepatic encephalopathy.
- HIV related complications.
Consider phlebotomy for nutritional screening to include:
- Haemoglobin plus or minus iron, folate, vitamin B12.
- Albumin.
- Trace elements e.g. magnesium, iron, zinc, selenium, calcium.
- Refer for dietetic/nutritional advice if indicated.
- Consider testing (and consent issues) for HIV/hepatitis if indicated.
Prior to discharging the patient from hospital, it is important to:
- Consider referral to alcohol and/or substance misuse support services.
- Provide advice regarding risks of returning to alcohol and/or substance misuse because this may lead to seizure activity and exacerbate ABI related impairments, particularly cognitive, communicative and coordination skills. It may lead to an increased risk of the person sustaining further injuries, including brain injury. In addition, long term alcohol and/or substance misuse may lead to further risks to the person’s physical and mental health and wellbeing.