1 / 123

Ethanol Abuse and Toxic Alcohol Ingestion

Ethanol Abuse and Toxic Alcohol Ingestion. Chris Hall, PGY-5 McMaster University U of C Academic Day August 2, 2007. Objectives. Approach to the “intoxicated” patient Pharmacology of alcohols Common clinical scenarios in EtOH Diagnostic and management challenges of toxic alcohols

latham
Télécharger la présentation

Ethanol Abuse and Toxic Alcohol Ingestion

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Ethanol Abuse andToxic Alcohol Ingestion Chris Hall, PGY-5 McMaster University U of C Academic Day August 2, 2007

  2. Objectives • Approach to the “intoxicated” patient • Pharmacology of alcohols • Common clinical scenarios in EtOH • Diagnostic and management challenges of toxic alcohols ***Case-based and evidence-centred

  3. Case #1 • 56 yo male • “Known alcoholic” • Unresponsive on park bench • No witnesses; no apparent trauma • “Smells of alcohol” as per EMS

  4. Case #1 • Afebrile, HR 102, BP 140/85, RR 22, O2 sat 91% • CBS: 5.5 • Neuro: GCS 11; moves 4 limbs • Sonorous resps; Gag present • Chest: scattered crackles • Abdo, extremities: WNL

  5. Case #1 • Any additional information you’d like? • What is your working Dx? • How will you proceed from this point?

  6. The “Intoxicated” Patient • V I T A M I N C D E • A E I O U T I P S • “Intracranial” vs. “Extracranial”

  7. Intracranial Seizures Vascular Infectious Neoplastic Traumatic Extracranial O2 / CO2 Infectious Toxins / WD Metab. / Endo. Environmental The “Intoxicated” Patient

  8. The “Intoxicated” Patient • Reasonable DDx for Case #1: • Ethanol / other co-ingestions • Head trauma • CNS / other infection • Hypoglycemia / AKA • Wernicke encephalopathy • Alcohol withdrawal (+/- seizures)

  9. Immediate Action • Airway / Breathing • Hemodynamic stability • Reversible causes • The “Coma Cocktail” (?!)

  10. Further Management • History and P/E • Investigations • Which ones?

  11. Case #1 • TAKE HOME MESSAGE: • DO NOT assume EtOH to be the cause of the “intoxicated” patient’s presentation • Keep the differential broad; systematic approach to eliminate other DDx

  12. Ethanol: Pharmacology

  13. Alcoholic Trivial Pursuit • What is “100-proof alcohol”? • 50% EtOH by weight

  14. Alcoholic Trivial Pursuit • What is considered “one alcoholic drink”? • 15g of EtOH • 1 oz 50% (liquor) • 4 oz 12% (wine) • 10 oz 5% (beer)

  15. Alcoholic Trivial Pursuit • How much EtOH would a 70kg male need to drink to reach an EtOH level of 30 mmol/L? • 3 • 5 • 7 • 9 • 11

  16. Alcoholic Trivial Pursuit • TRUE OR FALSE: • Men are less susceptible to acute alcohol intoxication • Caffeine masks EtOH intoxication • Prickly pear is an antidote for veisalgia • Hydration accelerates metabolism of EtOH • Intoxication is lessened by co-ingesting food

  17. Pharmacology • EtOH rapidly absorbed • Stomach and small bowel • Multifactorial effects on rate • Food • GI disease • Meds (gastric emptying) • Idiopathic

  18. Pharmacology • EtOH metabolized by ADH and ALDH • Stomach and liver; 5-10% unchanged via urine • Gender / ethnic differences in metabolism • Rate: 3-4mM/h (non-drinker) up to 7.5mM/h (chronic drinker)

  19. Ethanol: Metabolism

  20. Clinical Presentation • CNS Effects: • GABA Agonism + NMDA Antagonism • Inebriation, poor impulse control, ataxia • “Set-up” for withdrawal • CVS Effects: • Vasodilation, reduced CO • Dysrhythmias

  21. Clinical Presentation • GI Effects: • N/V/D  volume loss • Pancreatitis, gastritis, hepatitis • GI Bleeding • Metabolic Effects: • HypoNa, Hypoglycemia •  osmol gap; no anion gap • Ketonemia after binges

  22. Clinical Presentation • Hematologic Effects: • Anemia ( MCV) • Thrombocytopenia • Lymphopenia

  23. Case #2 • 46 yo male • CC: “Unwell” • HR: 115, BP 165/100, RR 25, sat 100% • Tremulous • Sweaty • Alert, not confused • Exam otherwise WNL

  24. Case #2 • Discuss: • Your working / differential diagnoses • Your initial management and approach to this patient

  25. Alcohol Withdrawal • GABA receptor downregulation + NMDA receptor upregulation • Anxiety, sweating, tremor, autonomic overdrive, altered LOC, seizures • Generally in chronic abusers

  26. Spectrum of Illness • Simple Withdrawal • Alcoholic Hallucinosis • Withdrawal Seizures • Delirium Tremens

  27. Alcohol Withdrawal: Rx • Holbrook et al (CMAJ 1999) • Metaanalysis of WD Rx • BZD vs placebo or other Rx • BZD better than placebo • More successful outcomes • Less likely to drop out of Rx • Unable to properly pool results otherwise

  28. Choice of BZD? • Ritson et al, (Drug Alc Dependence 1986) • RCT; N=40 • Standing lorazepam vs diazepam • Less anxiety; smoother course with valium

  29. Choice of BZD? • Diazepam is the traditional choice • Lorazepam is preferred in patients with severe liver disease

  30. Benzodiazepines • Dosing • Diazepam: 5 mg iv / 10 mg po q 10 min • Lorazepam: 1-2 mg iv / 2 mg po q 15 min • NB: longer time of onset; beware dose stacking • Titrate to effect • (But how?)

  31. CIWA • 10-item scale • Min score = 0, Max score = 67 • Score < 8 considered mild withdrawal (Rx threshold) • Takes 5 min to complete

  32. Symptom-Guided Rx • 2002 Arch Int Med & 1994 JAMA: • 2 RCTs • CIWA-guided Rx reduces BZD use, length of Rx vs. standing BZD protocol • Guide therapy with symptoms; avoid standing dosing schedules • Do not fear huge doses

  33. Adjunctive Rx • Carbamazepine • 2 RCTs (Am J Psych 1989; J Gen Int Med 2002) • Similar to BZD in Rx of withdrawal symptoms • Valproate • 1 RCT (Alc Clin Exp Res 2001) • Less BZD needed when Rx with VA

  34. Simple Withdrawal: Rx • Adjuncts, cont’: • Beta Blockers • Clonidine • Haldol • Magnesium

  35. Withdrawal: Disposition • RCT (NEJM, 1989) • CIWA < 15; no comorbidities • Outpatient Rx as safe as Inpatient Rx, cost less, lasted less time • Inpatients more likely to complete Rx • Outpatients got daily follow-up and BZD dosing

  36. Withdrawal: Disposition • Discharge home if: • Mild withdrawal at time of d/c (CIWA < 8 - 15 after 4-6 h observation) • Easily controlled w/ BZD • Not intoxicated • Responsible supervision preferred • No prior hx of seizures or DT

  37. Case #2 ,Part 2 • BZD sedation is ordered for the patient • 60 min later, patient is more tremulous, agitated • While trying to get out of bed, has generalized T/C sz

  38. Case #2, Part 2 • What are your initial steps? • How will you treat this patient?

  39. Withdrawal Seizures • Usually GTC, self-terminating • 15-25% have > 1 seizure • < 8% go into status • May herald onset of DT

  40. Seizure Management • ABCs • Rule out reversible causes • Lorazepam likely longer anticonvulsant effect than diazepam

  41. Seizure Management BZD (e.g. Ativan 2-4 mg iv)  Phenobarbital 15-20 mg/kg  Propofol / Midazolam / Pentobarb  Inhalational Anaesthesia, paralysis, EEG monitoring

  42. What about Dilantin? • EBM (Ann Emerg Med 1991 & 1994): • 2 RCTs; 55 & 147 patients • No difference in relapse of seizures vs placebo • Mechanism of action unlikely to affect seizures in EtOH withdrawal • Likely to have little impact on Rx

  43. Withdrawal Seizures • Some Questions to ponder: • Who can be released from the ED? • When is a CT Head warranted? • When should patients start an anticonvulsant?

  44. CT Head • New / changed seizures • Focal seizure • Focal examination / meningismus • Failure to recover usual mental status • Mental status out of proportion to EtOH • Recent head trauma • +/- fever (prior to LP?)

  45. Disposition • Normal workup and exam • Single seizure • Withdrawal well-controlled • Not intoxicated • Adequate supervision / follow-up

  46. Starting an Anticonvulsant • Controversial • Seizure may be due to withdrawal or may represent underlying epileptic d/o • Generally, leave it to neurology!

  47. Case #3 • 60 yo male • “Alcoholic” by own report • 2-week “binge” until yesterday • Since then, N/V, AP, “dizziness & blurred vision”

  48. Case #3 • HR 114, BP 105/60, RR 28, sat 100% • CBS: 3.0 • Chest: clear • Neuro: slightly drowsy; no focality; no tremor • Abdo: tender epigastrium • Urine dip: negative for ketones, blood, WBC

  49. Case #3 • Working diagnosis / differential? • Approach to management?

More Related