ACUTE ALCOHOL

INTOXICATION
.

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drinking is a pause from thinking

Different alcohol poisonings.
Acute ethanol intoxication

Acute methanol poisoning.

Acute ethylene glycol poisoning.

Acute isopropyl alcohol poisoning

Acute ethanol intoxication
Sources
I. alcoholic drinks
-beer (3.5-9%)
-stout (4.2%)
-wines (12.5-13.5%)
-spirits (37-40%)
-cider (5.5-8%)
-sparkling or flavored alcoholic drinks
II. non alcoholic beverages


One unit = 8 gm of alcohol

One oz = 30ml

Proof =2*%ethanol by volume

One drink = 44ml of whiskey(80%proof),3-5oz wine
or 12 oz beer.

BAC blood alcohol conc.

0.1%BAC =100 mg alcohol in 100ml blood.

pharmacology
C2H5OH

Colorless, odourless liquid

M.Wt - 46

Vd - 0.54 L/Kg

1gm ethyl alcohol 7.1 kcal energy
Absorption
GIT ,20% in stomach,rest in small intestine

80%-90% absorption within 30-60mins.

Absorption also depends on other factors

Females attain higher blood alcohol level.

Inhalation pulmonary vascular bed.

Distribution& elimination
Distributed to almost every tissue.
peroxidase-catalase system

Ethanol acetadehyde+NADH
+NAD
microsomal oxidase system
acetate

CO2+H2O acetyl coA
1
st
order to zero order kinetics at 5 mg/ 100mlBAC.

100-125 mg/ kg /hr

BAC decreases by 15-25 mg /100ml/ hr.

2-10% unchanged in urine.

Appreciable but insignificant amount in respiration.


pathophysiology
GABA. Glutamate.

NAD/NAD ratio.

ketogenesis.

gluconeogenesis

glycogenolysis

Fluid & electrolyte imbalance.

Stages of intoxication
BAC STAGES
0.01-0.05 sobriety

0.03-0.12 euphoria

0.09-0.25 excitement

0.18-0.30 confusion

0.27-0.4 stupour

0.35-0.5 coma

0.45+ DEATH
Asscociated acute problems.
Alcoholic ketoacidosis.

Alcoholic hypoglycemia.

Fluid & electrolyte imbalance.

Wernickes encephalopathy.
Acute effects on heart.

Acute GI efects.

Acute alcoholic myopathy.

Trauma

Associated other substance poisoining.

Alcoholic ketoacidosis:
Dillon et al

High anion gap acidosis

Normal or low glucose level

Chronic alcoholics

Binge drinking wks before symptoms

Dehydration, starvation due to vomiting ,gastritis





Alcohol poor food intake dehydration

Acetaldehyde glycogenolysis counter
regulatory
hormones
Acetate

NADH/NAD glucagon
ratio insulin

gluconeogenesis




ketogenesis
Altered mental status

Kussumal breathing

Ketotic breath

Lab finding
high anion gap acidosis
beta hydroxybutyrate:acetoacetate
insulin level

Exclude other causes of A;G acidosis

Alcoholic hypoglycemia
Chronic street alcoholic found unresponsive


Symptoms
neuroglycopenic confusion,fatigue,seizure,
loss of consciousnessdeath
autonomic responses palpitation ,tremor ,
sweating

Signs
pallor ,diaphoresis
tachycardia,raised systolic B.P
transient focal neurological signs





all alcoholics are dehydrated is false.
Immediate in urine volume followed by ADH.
Hydration also depends on
-diet,nonalcoholic fluids,type of drinks
-vomiting, diarrhea,infection
Water intoxication & hyponatremia in severe chronic
alcoholicsseizure& altered sensorium
Central pontine mylenolysis
Water and electrolytes disorders
Hypomagnesemia

Hypophosphatemia

Hpokalemia

Hypocalcemia


Other electrolytes abnormalities
As high as 12.5% in alcoholics.
Major reversible cause of death.
If untreated 10-20% mortality rate.
Thiamine deficiency is the root cause.
Magnesium deficiency in thiamin resistant cases.
Clinical features
global confusion
ocular abnormalities
ataxia

Wernicke-korsakoffs syndrome
Acute effect on heart
Direct negative inotropic effect & vasodilation.
PR & QT prolongation
Both supraventricular & venntricular
arrythmia.
holiday heart syndrome
Various degree of heart block.
+ve correlation between and sudden cardiac
death.

Acute alcoholic myopathy
Acute muscle necrosis mainly in binge
drinkers
Alcoholism is the most common cause of
rhabdomyelisis
Raised CKMM,myoglobinuria,
Acute tubular necrosisurea ,creatinine
Conservative management


Acute gastrointestinal effect

Acute gastritis & esophagitis.

Epigastric distress and gastrointesinal
bleeding.

Mallory-weiss tear.

Acute hepatitis & pancreatitis.


Toxic

Metabolic

Infectious diseases

Neurologic

Miscellaneous

Trauma

Differential diagnosis in acutely intoxicated
patient.
Management
Airway
Breathing
Circulation
Intubate if poor gag reflex
Fingerstick glucose , iv dextrose
Thiamin 100 mg im/ iv stat.
magnesium


2 mg naloxone
Exclude other causes of intoxication
ABG
Osmolar gap.
2Na+ + BUN/2.8 + Glu/18 + Eth/4.6
Serum electrolytes
Anion gap.
Correct other electrolyte abnormalities
Dilantin
CT scan.






Blood alcohol conc (BAC)

Enhanced elimination
evacuation after 1 hr little benefit
activated charcoal.
fructose
haemodialysis
metadoxine (300-900mg iv)
Methanol poisoning
CH3OH(wood alcohol)

Solvent ,antifreeze, paint remover.

Epidemics of methanol toxicity.

Poisoning mainly by ingestion


Methanol + NAD+ formaldehyde +
NADH
( alcohol dehydrogenase)


formate

(folate)

CO2 + H2O
Clinical effects
Inebriated but lack of euphoria.
1-72 hrs of latent period.
Fatal dose 60-240 ml.
Vertigo ,nausea,vomiting, diarrhea,abdominal
pain,dyspnea,agitation.
Blurred vision,photophobia, visual acuity
Bradycardia, blindness, seizures,coma.
Physical examination
constricted visual field,fixed &dilated pupils,
retinal edema &hyperemia of disk

resp apnea ,opisthotonus,& seizure in pts dying of
Methanol intoxication

Lab finding
high anion gap acidosis (correlates with
mortality)
high osmolar gap

serum methanol> 20 mg/dl symptoms
> 50 mg/ dl serious
> 100 mg/ dl ocular signs
Specific treatment
aggressive tt of acidosis
ethanol
achieve BAC of 100- 150mg /100ml
loading 0.8gm/ kg of 5 10% ethanol
followed by 130mg/kg/hr.
oral loading if no iv preparation
if dialysis,250-350 mg/kg/hr.
ethanol indications
methanol >20 mg/100ml,symptomatic
acidosis, need for HD.
ingestion >o.4ml/kg

Folic acid 30 mg iv every 4 hrly
Leucovorin 1-2mg/kg iv
4-methyl pyrazole(fomepizole ) 15-20 mg/kg iv
Haemodialysis not haemoperfusion
Haemodialysis indications:
methanol>20-50mg/100ml
acidosis not responsive to bicarbonate
formate levels > 20 mg/100ml
visual impairment
renal impairement
Dialysis till methanol level0mg/100ml and acidosis
clears.
Ethylene glycol poisoning
Colourless, odourless ,nonvolatile,water soluble.

Paints,polishes, cosmetics,antifreeze.

Viscous & sweet poormans substitute for alcohol.

Minimal lethal dose 1-1.5ml/kg.

Peak level 1-4 hr.

Eth glycol + NAD+ glycoldehyde +NADH
alc dehydrogenase

glycolate

lactate
oxalate glyoxylate
hypocalcemia
renal failure
myocardial deprssion

Clinical effects
Described by pons & custer

Stage 1 inebriated without odour of alcohol.
(1-12hrs) other CNS symptoms.

Stage 2-- CVS changes
(12-24 hrs)

Stage3-- ARF
(24-72 hrs)


Lab finding:
oxalate crystals in urine.
hypocalcemia
A: G acidosis
tt mainly on history & clinical symptoms.
Specific treatment:
ethanol
pyridoxine
thiamine
magnesium
4-methyl pyrazole
HD


Isopropyl alcohol poisoning
2-propanol,isopropanol.

Clear, volatile ,bitter taste,aromatic odour

Solvent, & disinfectant.

2
nd
to ethanol as most commonly ingested alcohol.

Twice potent than ethanol as CNS depressant.

Toxic dose--- 1ml/kg of 70 % solution.

Lethal dose---2-4ml/kg.

80% absorbed from GIT in 30 mins.

Dermal absorption & inhalation.


isopropyl alcohol acetone
alc dehydrogenase

acetate+
formate
Very few ketoacids

CNS depressant.

NAD/NADH ratio ed.
Clinical effects
within 30-60 mins.

lacking euphoria

nausea,vomiting,haemorrhgic gastritis.

ocular signs

sweet ,pungent odor of acetone

coma, hypoventilation resp arrest
Diagnosis
inebriated with ve or low ethanol.
elevated osmolar gap
ketosis without acidosis
>50mg/dl toxic,200-400mg/dl lethal.

Treatment:
GI evacuation.
dialysis if 3-4 ml /kg of 70% solution
blood level >400mg/dl
unrespnsive hypotension
renal failure,coma.
Anesthetic management in acute alcohol
intoxicated pts.
acute problems

altered sensorium & poor assesment.
.
fluid & electrolytes derangements.

acid base disorders

full stomach & aspiration.

hypothermia.
consent.
MAC of anesthetic gases & analgesia.
multiple trauma with airway involvement.


Problems due to chronic alchoholism
hypoproteinemia
liver dysfunction.
cardiomyopathy.
haematological abnormalities.
increase infections

other substance abuser.
HIV ,hepatitis.
Altered drug metabolism
CYP2E1 .
long term consumption induces MEOS.
metabolism of certain drugs.
conversion of many foreign substances into highly
toxic metabolites.
perianesthetic plasma fluoride kinetics.
short term consumption has opposite effects.

Unpredictable awakening from anaesthesia

Withdrawal syndrome in postop period.

Long term hospitization.
Alcohol withdrawal syndrome in surgical
patients.
chronic alcohol misuse is more common in surgical
patients(upto 43% in ENT pts) than in
psychiatric(30%) or neurological (19%) pts.

Almost half of all trauma beds are occupied by
patients who were injured while under the influence
of alcohol.

Normal postoperative course into life threatening
situation.


Hangover :tremors,nausea,vomiting.
weakness, irritability, insomnia.

Delirium tremens: 2-4 days of complete abstinence
disorientation
poor attention span.
visual &auditary hallucination.
marked autonomic disturbances.
respiratory & cardiovascular collapse.
death.


Rum fits
12-48 hrs after aheavy bout of drinking.
multiple seizures 2-6 at a time.
sometimes status epilepticus.
Alcoholic hallucinosis
auditory hallucinations.
clear consciousness.
Recognition of alcohol misuse in surgical pts.

- history &physical examination.

-CAGE questionnaire.

-laboratory markers
CDT, GGT, MCV.
Revised clinical institute withdrawal
assesment(CIWA)for alcohol scale.
1. nausea &vomiting
2. tremor
3. anxiety
4. agitation
5. tactile disturbances
6. auditory disturbances
7. visual disturbances
8. headache/fullness in head.
9. orientation/clouding of consciousness .
Treatment of alcohol misuse in ward pts..
prophylaxis.
1
st
line tt : diezepam, lorazepam, chlordizepoxide
alternative: chlormethimazole, ethanol.

therapy:
establish diagnosis & CIWA score
CIWA score >20 ICU & start treatment.
10-20 start treatment
<10 watch

Start with benzodiazepines.

symptom-triggered regimen.

fixed schedule regimen

Additional medications as needed
beta blockers, clonidine, haloperidol.

Monitor pt every 4hr by CIWA score.
Intravenous tt for AWS in surgical ICU pts.
prophylaxis
start with benzodiazepines
add additional medications.
monitor every hr by CIWA score.
maintain score <10 for 24 hrs.

therapy
start with benzodiazepines
add additional medications.
titrate medications to decrease score <10.
monitor every hr by CIWA score.
until <10 for 24 hrs.



WISHING U

HAPPY VALENTINE DAY


LOVE MAY B LESS INJURIOUS THAN
ALCOCHOL
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