ACUTE ALCOHOL INTOXICATION

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ACUTE ALCOHOL INTOXICATION

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drinking is a pause from thinking
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Different alcohol poisonings.

• Acute ethanol intoxication
• Acute methanol poisoning.
• Acute ethylene glycol poisoning.
• Acute isopropyl alcohol poisoning

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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

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• One unit 8 gm of alcohol
• One oz 30ml
• Proof 2ethanol by volume
• One drink 44ml of whiskey(80proof),3-5oz wine
  or 12 oz beer.
• BAC blood alcohol conc.
• 0.1BAC 100 mg alcohol in 100ml blood.

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pharmacology

• C2H5OH
• Colorless, odourless liquid
• M.Wt - 46
• Vd - 0.54 L/Kg
• 1gm ethyl alcohol 7.1 kcal energy

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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.

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Distribution elimination

• Distributed to almost every tissue.
• peroxidase-catalase system
• Ethanol
  acetadehydeNADH
• NAD
• microsomal oxidase system
• 
  acetate
• CO2H2O
  acetyl coA

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• 1st 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.

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pathophysiology

• GABA. Glutamate.
• ?NAD/NAD ratio.
• ?ketogenesis.
• ?gluconeogenesis
• ?glycogenolysis
• Fluid electrolyte imbalance.

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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

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• 0.27-0.4 stupour
• 0.35-0.5 coma
• 0.45 DEATH

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Asscociated acute problems.

• Alcoholic ketoacidosis.
• Alcoholic hypoglycemia.
• Fluid electrolyte imbalance.
• Wernickes encephalopathy.

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• Acute effects on heart.
• Acute GI efects.
• Acute alcoholic myopathy.
• Trauma
• Associated other substance poisoining.

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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

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• Alcohol poor food intake
  dehydration
• ? ?
  ?
• Acetaldehyde glycogenolysis
  ?counter
• 
  regulatory
• ?
  hormones
• Acetate ?
  ?
• ?
• ?NADH/NAD
  ?glucagon
• ratio
  ?insulin
• ?
• ?gluconeogenesis

ketogenesis
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• Altered mental status
• Kussumal breathing
• Ketotic breath
• Lab finding
• high anion gap acidosis
• ?beta hydroxybutyrateacetoacetate
• ?insulin level
• Exclude other causes of ?AG acidosis

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Alcoholic hypoglycemia

• Chronic street alcoholic found unresponsive
• Symptoms
• neuroglycopenic ?confusion,fatigue,seizure,
  
• loss of
  consciousness?death
• autonomic responses ? palpitation ,tremor
  ,
• 
  sweating
• Signs
• pallor ,diaphoresis
• tachycardia,raised systolic B.P
• transient focal neurological signs

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Water and electrolytes disorders

• 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 alcoholics?seizure altered sensorium
• Central pontine mylenolysis

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Other electrolytes abnormalities

• Hypomagnesemia
• Hypophosphatemia
• Hpokalemia
• Hypocalcemia

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Wernicke-korsakoffs syndrome

• 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

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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.

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Acute alcoholic myopathy

• Acute muscle necrosis mainly in binge drinkers
• Alcoholism is the most common cause of
  rhabdomyelisis
• Raised CKMM,myoglobinuria,
• Acute tubular necrosis??urea ,creatinine
• Conservative management

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Acute gastrointestinal effect

• Acute gastritis esophagitis.
• Epigastric distress and gastrointesinal bleeding.
• Mallory-weiss tear.
• Acute hepatitis pancreatitis.

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Differential diagnosis in acutely intoxicated
patient.

• Toxic
• Metabolic
• Infectious diseases
• Neurologic
• Miscellaneous
• Trauma

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Management

• Airway
• Breathing
• Circulation
• Intubate if poor gag reflex
• Fingerstick glucose , iv dextrose
• Thiamin 100 mg im/ iv stat.
• magnesium

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• 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.

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• Blood alcohol conc (BAC)
• Enhanced elimination
• evacuation after 1 hr little
  benefit
• activated charcoal.
• fructose
• haemodialysis
• metadoxine (300-900mg iv)

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Methanol poisoning

• CH3OH(wood alcohol)
• Solvent ,antifreeze, paint remover.
• Epidemics of methanol toxicity.
• Poisoning mainly by ingestion

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• Methanol NAD
  formaldehyde
• 
  NADH
• ( alcohol dehydrogenase)
• 
  formate
• 
  (folate)
• 
  CO2 H2O

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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.

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• Physical examination
• constricted visual field,fixed dilated
  pupils,
• retinal edema hyperemia of disk
• resp apnea ,opisthotonus, seizure in pts
  dying of
• 
  Methanol intoxication

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• Lab finding
• high anion gap acidosis (correlates with
• 
  mortality)
• high osmolar gap
• serum methanolgt 20 mg/dl symptoms
• gt 50 mg/ dl
  serious
• gt 100 mg/ dl
  ocular signs

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• 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 gt20 mg/100ml,symptomatic
• acidosis, need for HD.
• ingestion gto.4ml/kg

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• 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
• methanolgt20-50mg/100ml
• acidosis not responsive to bicarbonate
• formate levels gt 20 mg/100ml
• visual impairment
• renal impairement
• Dialysis till methanol level0mg/100ml and
  acidosis clears.

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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.

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• Eth glycol NAD glycoldehyde
  NADH
• alc dehydrogenase
• 
  
  
  
• 
  glycolate
• lactate
• oxalate
  glyoxylate
• hypocalcemia
• renal failure
• myocardial deprssion

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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)

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• 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

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Isopropyl alcohol poisoning

• 2-propanol,isopropanol.
• Clear, volatile ,bitter taste,aromatic odour
• Solvent, disinfectant.
• 2nd to ethanol as most commonly ingested alcohol.

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• 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.

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• isopropyl alcohol
  acetone
• alc dehydrogenase
• 
  acetate
• 
  formate
• Very few ketoacids
• CNS depressant.
• NAD/NADH ratio ?ed.

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• Clinical effects
• within 30-60 mins.
• lacking euphoria
• nausea,vomiting,haemorrhgic gastritis.
• ocular signs
• sweet ,pungent odor of acetone
• coma, hypoventilation resp
  arrest

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• Diagnosis
• inebriated with ve or low ethanol.
• elevated osmolar gap
• ketosis without acidosis
• gt50mg/dl toxic,200-400mg/dl lethal.
• Treatment
• GI evacuation.
• dialysis if 3-4 ml /kg of 70
  solution
• blood level gt400mg/dl
• unrespnsive
  hypotension
• renal failure,coma.

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Anesthetic management in acute alcohol
intoxicated pts.

• acute problems
• altered sensorium poor assesment.
• .
• fluid electrolytes derangements.
• acid base disorders
• full stomach aspiration.

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• 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

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• 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.

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• Unpredictable awakening from anaesthesia
• Withdrawal syndrome in postop period.
• Long term hospitization.

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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.

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• 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.

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• 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.

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• Recognition of alcohol misuse in surgical pts.
• - history physical examination.
• -CAGE questionnaire.
• -laboratory markers
• CDT, GGT, MCV.

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• Revised clinical institute withdrawal
  assesment(CIWA)for alcohol scale.
• nausea vomiting
• tremor
• anxiety
• agitation
• tactile disturbances
• auditory disturbances
• visual disturbances
• headache/fullness in head.
• orientation/clouding of consciousness .

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• Treatment of alcohol misuse in ward pts..
• prophylaxis.
• 1st line tt diezepam, lorazepam,
  chlordizepoxide
• alternative chlormethimazole, ethanol.
• therapy
• establish diagnosis CIWA score
• CIWA score gt20 ICU start
  treatment.
• 10-20 start
  treatment
• lt10 watch

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• Start with benzodiazepines.
• symptom-triggered regimen.
• fixed schedule regimen
• Additional medications as needed
• beta blockers, clonidine, haloperidol.
• Monitor pt every 4hr by CIWA score.

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• Intravenous tt for AWS in surgical ICU pts.
• prophylaxis
• start with benzodiazepines
• add additional medications.
• monitor every hr by CIWA score.
• maintain score lt10 for 24 hrs.
• therapy
• start with benzodiazepines
• add additional medications.
• titrate medications to decrease score
  lt10.
• monitor every hr by CIWA score.
• until lt10 for 24 hrs.

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• WISHING U
• HAPPY VALENTINE DAY
• 
  
• LOVE MAY B LESS INJURIOUS THAN
• 
  ALCOCHOL

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thank You
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