What are investigations for alcohol intoxication?
Assess:
Quantity and frequency, tolerance
CIWA Questionnaire: in-patient vs outpatient
CBC + differential
Lytes! CaMP - Ca++, Mg, Phosphate - mg really important in alc.
ECG +- CT Head +- EEG
TSH!
B12, folate, glucose levels (random, fasting HbA1C)
Worry about substance-induced metabolic acidemia
Renal function (Cr, BUN, eGFR), liver function (ALT, GGT, AST)
Urine + serum tox screen for other substances
Physical exam – look for stigmata of chronic liver disease such as ascites, spider nevi, palmar erythema, etc
ALWAYS: CBC, urine dipstick , pregnancy if appropriate, TSH, lytes, BUN, Cr, liver enzymes, B12 (key!), ECG +- CT head +- EEG
Blood alcohol, INR, CXR, urinalysis
Physical exam
Think CBC + + heart + hormones+ kidney + lytes+ liver + metabolic +other CHHKMLLO
Treatment for alcohol intoxication?
“Follow CIWA protocol for withdrawal”
- diazepam 10-20 mg IV/PO or lorazepam 2-4 mg IV/PO Q1H until calm
can use CIWA protocol and give benzos till CIWA <10
- thiamine 100 mg IM/IV, than 50-100 mg/day
- Mg sulfate 4 g IV over 1-2 hrs if hypomagnesic
admit if DT or multiple seizures
Supplement thiamine, B12, folate, multivitamins before giving glucose
Worry about Wernicke-Korsakoff
Wernicke’s encephalopathy - carb processing is requiring thiamine, which is depleted in alcoholics -> think the same effects as intoxication, on withdrawal: ataxia, dizziness (body) + nystagmus, paralyzed gaze (eyes)
Korsakoff’s syndrome – memory loss secondary to thiamine deficiency anterograde, recent memories, irreversible in 75% of cases.
Can give them benzos – like diazepam (Valium) CIWA recommends starting with diazepam (valium) 20 mg PO Q1-2 hrs, no max (some alcoholics may need it in hundreds)
Interest only, CIWA guidelines for alcohol withdrawal:
If CIWA =>10
Diazepam 20 mg PO q 1-2 hrs, some patients may need several hundred mg, observe for 1-2 hrs after last dose, no take home
If seizures or hx of seizures diazepam 20 mg q1h for >+ 3 doses
If cannot tolerate diazepam PO, give diazepam 2-5 mg IV/min – max 10-20 mg q1h, or lorazepam SL
If hallucinating:
Haloperidol 2-5 mg IM/PO q 1-4 hrs max 5/day
Admit if still in withdrawal after 80 mg diazepam, delirium tremens, arrhythmias or multiple seizures, medically ill
What does alcohol do to neurotransmitters?
- alcohol is a “downer”
- it activates GABA and inhibits glutamate receptors in CNS
- it also activates serotonin
How is alcohol metabolized and where does antabuse or disulfiram fit in?
alcohol - > acetaldehyde (alcohol dehydrogenase enzyme)
acetaldehyde -> acetic acid (acetaldehyde dehydrogenase enzyme)
Disulfiram (antabuse) -> blocks acetaldehyde dehydrogenase from converting acetaldehyde into acetic acid -> build up -> increased blood flow to head, flushing, headache, N/V, palpitations, SOB, etc
Do not use in pregnancy, psychosis (think that in either condition do not want increased blood flow to the head), severe CV (again, no increased blod flow)
Monitor liver enzymes! Issues with adherence, give to motivated patients only
Approach to any patient presenting with altered LOC?
- DONT
- Dextrose (glucose) - measure blood sugar before administering if possible: adults 0.5-1.0 g/kg (1-2 ml/kg) IV of D50W, kids half
- Oxygen
- Naloxone (muscarinic receptor competitive antagonist) - antidote for opiods - dagnostic and therapeutic, great for undifferentiated comatose. Load at 2 mg initial bolus IV/IM/SL/SC, if no response after 2-3 mins, increase by 2 mg every few mins to max 10 mg, if known chronic user or see track marks, give 0.01 mg/kg, maintain at 2/3 of the dose that produced patient arousal
- Thiamine (Vit B1) give 100 mg IV/IM with IV/PO glucose to all patients to prevent/tx Wernicke’s encephalopathy, thiamine a necessary cofactor in glucose metaboism, give thiamine before glucose, but do not delay glucose if thiamine not available
- Thiamine defficiency: alcoholics, anorexics, hyperemesis of pregnancy, malnutrition
Long term complications of alcohol use (W K)?
- Wernicke’s encephalopathy: caused by thiamine (B1) deficiency from poor nutrition
- can be reversed with thiamine therapy
- Thiamine (Vit B1) give 100 mg IV/IM with IV/PO glucose to all patients to prevent/tx Wernicke’s encephalopathy, thiamine a necessary cofactor in glucose metaboism, give thiamine before glucose, but do not delay glucose if thiamine not available
Thiamine defficiency: alcoholics, anorexics, hyperemesis of pregnancy, malnutrition
- presenting with (think alcohol intoxication + eyes): ataxia, confusion, + ocular (nystagmus, gaze palsies)
If untreated, Wernicke’s encephalophay -> Korsakoff syndrome
- impaired recent memory, anterograde amnesia, compensatory confabultion (unconsiously making up information that cannot remember)
- reversible in only about 20%
CAGE questionnaire?
- C - “wanted to cut down your drinking”
- A - “annoyed by criticism of your drinking”
- G - “guilty about drinking”
- E - “taken a drink in the morning to prevent shakes “eye opener” “ (think to wake up)
What constitutes heavy drinking in males and females?
- females: no more than 3 drinks a day and 7 drinks per week
- males: no more than 4 drinsk per day and 14 drinks per week
*
What blood tests would alcohol influence? what anemia may precipitate?
- AST: ATL ratio > 2:1
- elevated GGT
- can have increased MCV and thus macrocytosis
Sx of alcohol intoxication:
Alcohol intoxication
- Slurred speech = dysarthria
- Ataxia
- Reduced cognition
- Dizziness
- Nausea/vomiting
- Disinhibition
- CNS depression
- ocular: nystagmus + diplopia
- hypotension
DDx on EtOH intoxication?
- head trauma, hemorrhage
- depressants/street drugs
- hypoglycemia (glocometer)
- hepatic encephalopahty: confusion, change in LOC, coma
- Wernicke’s encephalopathy
- stroke
EtOH withdrawal timelines?
6-8 hrs - mild withdrawal: tremour, anxiety, insomnia, agitation, autonomic hyperactivity, nausea, vomiting
1-2 days alcoholic hallucinations - visual most common, auditory and tactile possible, VS N often
8h-2 days - seizures - brief generalized tonic-clonic (alc.depressant, so CNS hyperstimulated), CT head if focal seizure
3-5 days -Delirium Tremens 5% of untreated withdrawals, 15-25% mortality: severely confused (delirium), tremors (tremens), agitation, insominia, hallucinations
VS: (elevated from CNS hyperstimulation): tachycardia, hyperpyrexia, diaphoresis, …
CIWA alcohol withdrawal symptoms (FYI)
- N/V
- tremour
- anxiety
- agitation
- visual distrubances (most common)
- tactile distrubances
- auditory disturbances
- headache
- disorientation
- paroxysmal sweats
- 10 sx each scored out of 7, except orientation, out of 4
Signs of cocaine intoxication?
- cocaine - blocks dopamine reuptake -> stimulant
- CNS: euphoria, hypertension, tachycardia, dilated pupils, loss of appetitie, psychomotor agitation, sweats
- prolonged use can cause to paranoia and psychosis (hyperstimulation)
- tactile and visual hallucinations on cocaine and PCP - think people are into sex in those two - tactile
Why worry about cocaine OD? how to treat?
overdose: hypertension, tachycardia, tonic-clonic seizures, dyspnea, ventricular arrhythhmias
also, cocaine is a vasoconstrictor - > can lead to MI
can treat with benzos for agitation and anxiety, and propanolol or labetalol to reduce MI risk (hypertension and arrhythmias)
Cocaine withdrawal s/s?
not life threatening, “crash” in 1-48 hrs
CNS depression = opposite to intoxication: increased appetite, sleepiness, fatigue, malaise, depression, constircted pupils, vivid dreams,, Sx can last for weeks in chornic use
What are amphetamines? what do they stimulate?
block reuptake and facilitate release of dopamine and norepinephrine
dextroamphetamine (Dexedrine), methylphenidate (Ritalin), methamphetamine (Desoxyn)
used to treat narcolepsy, ADHD
can me made at home - > can cause serotonin syndrome with SSRIs if not made well (most club drugs made to release dopamine, NE and serotonin)
ex. MDMA - Ecstasy, MDEA
stimulant and hallucinogenic
PCP use: effects, intoxication, treatment, withdrawal
PCP - hallucinogenic, stimulates NMDA glutamate receptors and activates dopaminergic neurons
stimulant or depressant, depending on the dose
Sx: nystagmus, especially rotatory ( also vertical and horizontal possible), agitation, hallucinations, depersonalizations, dysarthria (slurred speech), synesthesia (cross over in modalities), memory issues, assaultiveness (violence most likely of all drugs)
CNS: hypertension, tachycardia, muscle rigidity, high pain tolerance
Tx: monitor vitals, T and lytes, minimize sensory stimulation, can use benzos and antipsychotics (lorazepam and haloperidol )
can have flashbacks (recurrence of intoxication due to release of the drug from body lipid stores)
SIMILAR IN LSD, muchrooms and other hallucinogens
alcohol intoxication, ddx and dx using DSM 5?
DDx: alcohol use disorder
Dx: delirium
unspecified anxiety d/o
major neurocognitive disorder (previously dementia)
BioPsychoSocial approach to alcohol use disorder
Bio:
must discontinue benzos and antipsychotics - not a long term solution
reduce alcohol use as much as possible - 12 step program a possibility
Psycho: PSYCHOEDUCATION
motivational interviewing
family therapy
diet and exercise regiment important = think influences mental health
stress management techniques
Social:
AAA or other 12 step program
social work - finances, employment
follow-up through substance abuse program in the community
reconciliation with family
sleep hygeine + stress management
activities without alcohol, alcohol removed from home
