Thanksgiving is not often considered to be a high-risk holiday. Unlike the 4th of July, with the threat of fireworks injuries, or St. Patrick's Day, with rampant alcohol use, Thanksgiving is straight out of a Norman Rockwell painting. Family, friends, turkey, apple pie. What could go wrong?
Plenty, according to the American College of Emergency Physicians (ACEP), which warns consumers about potential threats ranging from bacterial contamination of food to injuries sustained by weekend warriors participating in a pick-up game of family football. Medscape spoke with Robert Glatter, MD, an attending physician in the Department of Emergency Medicine at Lenox Hill Hospital in New York, about common causes of injury and illness that clinicians should be aware of at this time of the year.
Medscape: Football, with its high risk for head injuries, has been in the news often recently. And many family Thanksgiving gatherings come complete with a family football game. Is this a frequent reason for emergency department (ED) visits? Are there specific injuries that are more common in this type of casual play?
Dr. Glatter: We see a lot of families together, and they're having football games and soccer games -- and in that light, we're seeing a lot of injuries: scrapes, bruises, and sometimes concussions. People are not wearing helmets typically in these kinds of games, and they are at risk for head injuries. Especially now with the heightened awareness of concussions in the media, it is important for people to be aware that even a pick-up game of family football can place someone at risk for a head injury. Clinicians must recognize that that possibility exists -- even in a relatively low-impact, friendly family game -- and evaluate these patients accordingly. Wearing helmets and protective padding in these kinds of family games is not such a bad idea, particularly given the disparity in player size that is likely in a game involving all family members, from little kids to adults.
Medscape: Auto accidents are clearly a big concern. The Centers for Disease Control and Prevention reported in 2001 that motor vehicle crashes over the holiday accounted for 500 deaths and over 43,000 ED visits. Does your experience reflect this concern?
Dr. Glatter: Absolutely. We see a lot of people who are distracted during the holidays. In truth, they're distracted all year long, especially with new smartphones and tablets and multimedia in vehicles. People need to be aware and focus on the road and try to maintain that focus because of the risk for auto accidents, especially with the sheer volume of drivers on the road at holiday time. The issue of distraction is very pervasive in our society.
Medscape: The ACEP warns consumers about the risks of overeating, with subsequent chest pain that may be confused with cardiac chest pain. Clinicians are very familiar with the heartburn/heart attack confusion and the necessary diagnostic evaluation, and frequently educate patients about ways to distinguish between these 2 scenarios.
However, we don't do as good of a job informing patients that overeating is a risk factor for a myocardial infarction (MI). Can you speak about the assessment of patients on Thanksgiving who may be at higher risk for both reflux and an MI? Does anything change in your approach to these patients?
Dr. Glatter: The main issue we typically see at this time of year is holiday heart syndrome, which is caused by the combination of alcohol and overeating -- often, binge drinking and binge eating -- in people with otherwise normal hearts. This leads to supraventricular arrhythmias, typically atrial fibrillation. Sometimes caffeine adds to the mix, and you can have illicit substances too, but typically it is the alcohol and food that put a patient at risk.
People with cardiac disease, including known atrial fibrillation, can experience this syndrome, too. If these patients are consuming large amounts of alcohol as well as overeating, they may experience this arrhythmia. Generally, though, we often see it in people without any preexisting history of heart disease or arrhythmias.
This syndrome usually responds to hydration, typically via intravenous fluids. Medications for rate control are sometimes necessary; however, if the heart rate does not exceed 110-120 beats/min and the patient is really clinically stable, fluids are all they need and this rhythm disturbance clears spontaneously. If rate control medications are used, patients may never require further medications in the future.
It seems that alcohol has a direct cardiotoxic effect on the heart but may also lead to hyponatremia. Alcohol also triggers a surge of epinephrine and norepinephrine which tends to, we believe, promote the development of the arrhythmia in those at risk. An arrhythmia sometimes can lead to a supply-and-demand imbalance in terms of coronary blood flow, putting those at risk for MI at a higher level of risk.
Medscape: In addition, I would presume that overeating can increase the numbers of patients with simple reflux causing chest pain related to overeating.
Dr. Glatter: Reflux symptoms can indeed be attributable to just simple reflux. But in patients who are at higher risk for cardiac disease, we have to first rule out anything like an acute coronary syndrome before treating, and discharging, someone with a diagnosis of reflux. We will treat these folks concurrently for both conditions. But we have to be careful with the subset of patients who are at higher risk for coronary artery disease, especially those with diabetes, preexisting arrhythmias, known coronary disease, or hypertension. You have to do a risk factor assessment and always be alert to the issues and the risks that predispose an individual to an MI in that setting.
Medscape: Not all family gatherings around the dinner table are happy, and much has been written about the high stress levels that can accompany a fractious family event. What is your experience? Do you see more ED visits as a result of anxiety, or even panic, accompanying family conflict?
Dr. Glatter: We see lots of panic attacks and anxiety, which can manifest with chest pain that mimics a coronary syndrome. It is important, though, to fully evaluate someone before labeling them as having a panic attack. You have to risk-stratify people, because alcohol, overindulgence, and high emotional energy are all risk factors for coronary syndromes. You have to be careful. Yes, we do see an increase in the number of patients with symptoms attributable to anxiety, but you have to avoid the risk of applying that diagnosis inaccurately. Clinicians have to sift through and delineate those who are at higher risk.
We see lots of patients with depression, and anxiety -- obviously, more than any other time of the year. Close family quarters create clashes and arguments, which can sometimes lead to fistfights and facial trauma that ends up in the hospital. Some families get aggressive, especially with the alcohol. It's another concern.
Interviewer: What about older adults? Are there specific concerns in this population?
Dr. Glatter: Yes. We do see older adults being brought in for evaluation by family members who may not have seen them in a while, maybe 6 or more months. Their older relative may have had some degree of decline, simply as a result of age, that was not witnessed by family. Being together at the holidays, the family may then perceive the decline as an acute event, when in fact it has been more of a chronic process.
The family has not seen the individual recently enough to be able to recognize what may be a new baseline. Their older relative may look more frail and not as chipper as in the past. So, the family members get together collectively and decide that there is a need for an evaluation to be certain that this is not something acute in nature. That can be difficult and may require a very careful evaluation in order to avoid indiscriminate testing.
Medscape: Are there any other concerns specific to this holiday that clinicians should be aware of?
Dr. Glatter: We are seeing an increased use of stimulant drinks, often in combination with alcoholic beverages, and that can be a very dangerous combination. People want to be able to stay awake and enjoy the holidays, so they combine a stimulant containing high amounts of caffeine with alcohol. We particularly see this use in teens, who often refer to the combined drink as a "raging bull" or "speedball." It helps those who consume large amounts of caffeine stay awake and combat the sedative effects of the alcohol; it also places them at high risk for arrhythmias, elevated blood pressure, anxiety, and agitation.
There is also an increased use of synthetic cannabinoids, such as spice, K2, and bath salts. People are apt to try them during holiday times, when they're around friends and family. It is important to be aware of this and to warn people that these drugs are not safe to use recreationally and that they can have very dangerous side effects, including elevated blood pressure -- also putting users at risk for arrhythmias, stroke, and intracranial bleeding.
We have also begun to see an increase in use of electronic cigarettes, especially in teens. E-cigs deliver liquid nicotine in a vaporized form. Some teens are coming in to the ED agitated and quite anxious, with elevated heart rates due to inhalation of large amounts of nicotine. Teens may use the liquid nicotine devices at a party and then come in with elevated heart rates.
Electronic cigarettes may come in a variety of flavors: vanilla, chocolate, mint. The companies entice young people by making the e-cigarettes in unique and satisfying flavors.
The heightened energy around the holidays and the frenetic pace of people's lives -- emotionally and physically -- tend to produce a perfect storm. During the rest of the year we obviously see people for similar types of conditions -- chest pain, shortness of breath, alcohol intoxication -- but the stakes are higher at this time of year, with other family members close at hand, potentially contributing to increased levels of anxiety.
Medscape Family Medicine © 2013 WebMD, LLC
Cite this: How Safe Is Thanksgiving? - Medscape - Nov 21, 2013.