acute alcohol intoxication. [email protected]@gmail.com
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“ “ drinking is a pause from thinking”drinking is a pause from thinking”
Different alcohol poisonings.Different alcohol poisonings.
Acute ethanol intoxicationAcute ethanol intoxication
Acute methanol poisoning.Acute methanol poisoning.
Acute ethylene glycol poisoning.Acute ethylene glycol poisoning.
Acute isopropyl alcohol poisoningAcute isopropyl alcohol poisoning
Acute ethanol intoxicationAcute ethanol intoxication SourcesSources
I. alcoholic drinksI. alcoholic drinks
-beer (3.5-9%)-beer (3.5-9%)
-stout (4.2%)-stout (4.2%)
-wines (12.5-13.5%)-wines (12.5-13.5%)
-spirits (37-40%)-spirits (37-40%)
-cider (5.5-8%)-cider (5.5-8%)
-sparkling or flavored alcoholic drinks-sparkling or flavored alcoholic drinks
II. non alcoholic beveragesII. non alcoholic beverages
One unit = 8 gm of alcoholOne unit = 8 gm of alcohol
One oz = 30mlOne oz = 30ml
Proof =2Proof =2*%ethanol by volume*%ethanol by volume
One drink = 44ml of whiskey(80%proof),3-5oz wine One drink = 44ml of whiskey(80%proof),3-5oz wine or 12 oz beer.or 12 oz beer.
BAC –blood alcohol conc.BAC –blood alcohol conc.
0.1%BAC =100 mg alcohol in 100ml blood.0.1%BAC =100 mg alcohol in 100ml blood.
pharmacologypharmacology CC22HH55OHOH
Colorless, odourless liquidColorless, odourless liquid
M.Wt - 46M.Wt - 46
Vd - 0.54 L/KgVd - 0.54 L/Kg
1gm ethyl alcohol – 7.1 kcal energy1gm ethyl alcohol – 7.1 kcal energy
AbsorptionAbsorption
GIT ,20% in stomach,rest in small intestineGIT ,20% in stomach,rest in small intestine
80%-90% absorption within 30-60mins.80%-90% absorption within 30-60mins.
Absorption also depends on other factorsAbsorption also depends on other factors
Females attain higher blood alcohol level.Females attain higher blood alcohol level.
Inhalation –pulmonary vascular bed.Inhalation –pulmonary vascular bed.
Distribution& eliminationDistribution& elimination
Distributed to almost every tissue.Distributed to almost every tissue.
peroxidase-catalase systemperoxidase-catalase system
Ethanol acetadehyde+NADHEthanol acetadehyde+NADH
+NAD+NAD
microsomal oxidase systemmicrosomal oxidase system
acetateacetate
CO2+H2O acetyl coACO2+H2O acetyl coA
11stst order to zero order kinetics at 5 mg/ 100mlBA order to zero order kinetics at 5 mg/ 100mlBACC..
100-125 mg/ kg /hr100-125 mg/ kg /hr
BAC decreases by 15-25 mg /100ml/ hr.BAC decreases by 15-25 mg /100ml/ hr.
2-10% unchanged in urine.2-10% unchanged in urine.
Appreciable but insignificant amount in respiration.Appreciable but insignificant amount in respiration.
pathophysiologypathophysiology GABA. Glutamate.GABA. Glutamate.
↑↑NAD/NAD ratio.NAD/NAD ratio.
↑↑ketogenesis.ketogenesis.
↓↓gluconeogenesisgluconeogenesis
↑↑glycogenolysisglycogenolysis
Fluid & electrolyte imbalance.Fluid & electrolyte imbalance.
Stages of intoxicationStages of intoxication
BABACC STAGES STAGES 0.01-0.05 sobriety 0.01-0.05 sobriety
0.03-0.12 euphoria0.03-0.12 euphoria
0.09-0.25 excitement0.09-0.25 excitement
0.18-0.30 confusion0.18-0.30 confusion
0.27-0.4 stupour0.27-0.4 stupour
0.35-0.5 coma0.35-0.5 coma
0.45+ DEATH0.45+ DEATH
Asscociated acute problems.Asscociated acute problems.
Alcoholic ketoacidosis.Alcoholic ketoacidosis.
Alcoholic hypoglycemia.Alcoholic hypoglycemia.
Fluid & electrolyte imbalance.Fluid & electrolyte imbalance.
Wernicke’s encephalopathy.Wernicke’s encephalopathy.
Acute effects on heart.Acute effects on heart.
Acute GI efects.Acute GI efects.
Acute alcoholic myopathy.Acute alcoholic myopathy.
TraumaTrauma
Associated other substance poisoining.Associated other substance poisoining.
Alcoholic ketoacidosis:Alcoholic ketoacidosis: Dillon et alDillon et al
High anion gap acidosis High anion gap acidosis
Normal or low glucose levelNormal or low glucose level
Chronic alcoholicsChronic alcoholics
Binge drinking wks before symptomsBinge drinking wks before symptoms
Dehydration, starvation due to vomiting ,gastritisDehydration, starvation due to vomiting ,gastritis
Alcohol Alcohol poor food intake poor food intake dehydrationdehydration
↓ ↓ ↓ ↓ ↓ ↓
Acetaldehyde glycogenolysis ↑counter Acetaldehyde glycogenolysis ↑counter
regulatoryregulatory
↓ ↓ hormoneshormones
Acetate ↓ ↓Acetate ↓ ↓
↓ ↓
↑↑NADH/NAD ↑glucagonNADH/NAD ↑glucagon
ratio ↓insulinratio ↓insulin
↓ ↓ ↓↓gluconeogenesisgluconeogenesis
ketogenesis
Altered mental statusAltered mental status Kussumal breathingKussumal breathing Ketotic breathKetotic breath
Lab findingLab finding high anion gap acidosishigh anion gap acidosis ↑ ↑beta hydroxybutyrate:acetoacetatebeta hydroxybutyrate:acetoacetate ↓ ↓insulin levelinsulin level
Exclude other causes of ↑A;G acidosisExclude other causes of ↑A;G acidosis
Alcoholic hypoglycemiaAlcoholic hypoglycemia Chronic “street alcoholic” found unresponsiveChronic “street alcoholic” found unresponsive
SymptomsSymptoms neuroglycopenic →confusion,fatigue,seizure,neuroglycopenic →confusion,fatigue,seizure, loss of consciousness→deathloss of consciousness→death autonomic responses → palpitation ,tremor , autonomic responses → palpitation ,tremor , sweatingsweating
SignsSigns pallor ,diaphoresispallor ,diaphoresis tachycardia,raised systolic B.Ptachycardia,raised systolic B.P transient focal neurological signstransient focal neurological signs
““all alcoholics are dehydrated” is false.all alcoholics are dehydrated” is false. Immediate Immediate ↑↑ in urine volume followed by ↑ADH. in urine volume followed by ↑ADH. Hydration also depends onHydration also depends on
-diet,nonalcoholic fluids,type of drinks-diet,nonalcoholic fluids,type of drinks
-vomiting, diarrhea,infection-vomiting, diarrhea,infection Water intoxication & hyponatremia in severe chronic Water intoxication & hyponatremia in severe chronic
alcoholics→seizure& altered sensorium alcoholics→seizure& altered sensorium Central pontine mylenolysisCentral pontine mylenolysis
Water and electrolytes disordersWater and electrolytes disorders
HypomagnesemiaHypomagnesemia
HypophosphatemiaHypophosphatemia
HpokalemiaHpokalemia
HypocalcemiaHypocalcemia
Other electrolytes abnormalitiesOther electrolytes abnormalities
As high as 12.5% in alcoholics.As high as 12.5% in alcoholics. Major reversible cause of death.Major reversible cause of death. If untreated 10-20% mortality rate.If untreated 10-20% mortality rate. Thiamine deficiency is the root cause.Thiamine deficiency is the root cause. Magnesium deficiency in thiamin resistant cases.Magnesium deficiency in thiamin resistant cases. Clinical featuresClinical features
global confusionglobal confusion
ocular abnormalitiesocular abnormalities
ataxiaataxia
Wernicke-korsakoff’s syndromeWernicke-korsakoff’s syndrome
Acute effect on heartAcute effect on heart
Direct negative inotropic effect & vasodilation.Direct negative inotropic effect & vasodilation. PR & QT prolongation PR & QT prolongation Both supraventricular & venntricular arrythmia.Both supraventricular & venntricular arrythmia. ““holiday heart syndrome”holiday heart syndrome” Various degree of heart block.Various degree of heart block. +ve correlation between and sudden cardiac +ve correlation between and sudden cardiac
death.death.
Acute alcoholic myopathyAcute alcoholic myopathy
Acute muscle necrosis mainly in binge Acute muscle necrosis mainly in binge drinkersdrinkers
Alcoholism is the most common cause of Alcoholism is the most common cause of rhabdomyelisisrhabdomyelisis
Raised CKMM,myoglobinuria,Raised CKMM,myoglobinuria, Acute tubular necrosisAcute tubular necrosis→↑urea ,creatinine→↑urea ,creatinine Conservative managementConservative management
Acute gastrointestinal effectAcute gastrointestinal effect
Acute gastritis & esophagitis.Acute gastritis & esophagitis.
Epigastric distress and gastrointesinal Epigastric distress and gastrointesinal bleeding.bleeding.
Mallory-weiss tear.Mallory-weiss tear.
Acute hepatitis & pancreatitis.Acute hepatitis & pancreatitis.
ToxicToxic
MetabolicMetabolic
Infectious diseasesInfectious diseases
NeurologicNeurologic
MiscellaneousMiscellaneous
TraumaTrauma
Differential diagnosis in acutely intoxicated Differential diagnosis in acutely intoxicated patient.patient.
ManagementManagement
AirwayAirway BreathingBreathing CirculationCirculation Intubate if poor gag reflexIntubate if poor gag reflex Fingerstick glucose , iv dextroseFingerstick glucose , iv dextrose Thiamin 100 mg im/ iv stat.Thiamin 100 mg im/ iv stat. magnesiummagnesium
2 mg naloxone2 mg naloxone Exclude other causes of intoxication Exclude other causes of intoxication ABGABG Osmolar gap.Osmolar gap. 2Na+ + BUN/2.8 + Glu/18 + Eth/4.62Na+ + BUN/2.8 + Glu/18 + Eth/4.6 Serum electrolytesSerum electrolytes Anion gap.Anion gap. Correct other electrolyte abnormalitiesCorrect other electrolyte abnormalities DilantinDilantin CT scan.CT scan.
Blood alcohol conc (BAC)Blood alcohol conc (BAC)
Enhanced eliminationEnhanced elimination
evacuation after 1 hr little benefitevacuation after 1 hr little benefit
activated charcoal.activated charcoal.
fructosefructose
haemodialysishaemodialysis
metadoxine (300-900mg iv)metadoxine (300-900mg iv)
Methanol poisoningMethanol poisoning
CH3OH(wood alcohol)CH3OH(wood alcohol)
Solvent ,antifreeze, paint remover.Solvent ,antifreeze, paint remover.
Epidemics of methanol toxicity.Epidemics of methanol toxicity.
Poisoning mainly by ingestion Poisoning mainly by ingestion
Methanol + NAD+ formaldehyde + Methanol + NAD+ formaldehyde +
NADHNADH
( alcohol dehydrogenase)( alcohol dehydrogenase)
formateformate
(folate)(folate)
CO2 + H2OCO2 + H2O
Clinical effectsClinical effects
Inebriated but lack of euphoria.Inebriated but lack of euphoria. 1-72 hrs of latent period.1-72 hrs of latent period. Fatal dose 60-240 ml.Fatal dose 60-240 ml. Vertigo ,nausea,vomiting, diarrhea,abdominal Vertigo ,nausea,vomiting, diarrhea,abdominal
pain,dyspnea,agitation.pain,dyspnea,agitation. Blurred vision,photophobia,Blurred vision,photophobia,↓ visual acuity↓ visual acuity Bradycardia, blindness, seizures,coma.Bradycardia, blindness, seizures,coma.
Physical examinationPhysical examination
constricted visual field,fixed &dilated pupils,constricted visual field,fixed &dilated pupils,
retinal edema &hyperemia of diskretinal edema &hyperemia of disk
resp apnea ,opisthotonus,& seizure in pts dying of resp apnea ,opisthotonus,& seizure in pts dying of
Methanol intoxicationMethanol intoxication
Lab findingLab finding
high anion gap acidosis (correlates with high anion gap acidosis (correlates with
mortality)mortality)
high osmolar gaphigh osmolar gap
serum methanol> 20 mg/dl symptomsserum methanol> 20 mg/dl symptoms
> 50 mg/ dl serious> 50 mg/ dl serious
> 100 mg/ dl ocular signs> 100 mg/ dl ocular signs
Specific treatmentSpecific treatment aggressive tt of acidosisaggressive tt of acidosis ethanolethanol achieve BAC of 100- 150mg /100mlachieve BAC of 100- 150mg /100ml loading 0.8gm/ kg of 5 – 10% ethanolloading 0.8gm/ kg of 5 – 10% ethanol followed by 130mg/kg/hr.followed by 130mg/kg/hr. oral loading if no iv preparationoral loading if no iv preparation if dialysis,250-350 mg/kg/hr.if dialysis,250-350 mg/kg/hr. ethanol indicationsethanol indications methanol >20 mg/100ml,symptomaticmethanol >20 mg/100ml,symptomatic acidosis, need for HD.acidosis, need for HD. ingestion >o.4ml/kgingestion >o.4ml/kg
Folic acid 30 mg iv every 4 hrlyFolic acid 30 mg iv every 4 hrly Leucovorin 1-2mg/kg ivLeucovorin 1-2mg/kg iv 4-methyl pyrazole(fomepizole4-methyl pyrazole(fomepizole ) 15-20 mg/kg iv ) 15-20 mg/kg iv Haemodialysis not haemoperfusionHaemodialysis not haemoperfusion Haemodialysis indications:Haemodialysis indications:
methanol>20-50mg/100mlmethanol>20-50mg/100ml
acidosis not responsive to bicarbonateacidosis not responsive to bicarbonate
formate levels > 20 mg/100mlformate levels > 20 mg/100ml
visual impairmentvisual impairment
renal impairementrenal impairement Dialysis till methanol levelDialysis till methanol level≈0mg/100ml and acidosis ≈0mg/100ml and acidosis
clears.clears.
Ethylene glycol poisoningEthylene glycol poisoning
Colourless, odourless ,nonvolatile,water soluble.Colourless, odourless ,nonvolatile,water soluble.
Paints,polishes, cosmetics,antifreeze.Paints,polishes, cosmetics,antifreeze.
Viscous & sweet –poorman’s substitute for alcohol.Viscous & sweet –poorman’s substitute for alcohol.
Minimal lethal dose 1-1.5ml/kg.Minimal lethal dose 1-1.5ml/kg.
Peak level 1-4 hr.Peak level 1-4 hr.
Eth glycol + NAD+ glycoldehyde +NADHEth glycol + NAD+ glycoldehyde +NADH
alc dehydrogenasealc dehydrogenase
glycolateglycolate
lactatelactate
oxalate glyoxylate oxalate glyoxylate
hypocalcemiahypocalcemia
renal failurerenal failure
myocardial deprssionmyocardial deprssion
Clinical effectsClinical effects Described by pons & custerDescribed by pons & custer
Stage 1– inebriated without odour of alcohol.Stage 1– inebriated without odour of alcohol. (1-12hrs) other CNS symptoms.(1-12hrs) other CNS symptoms.
Stage 2-- CVS changesStage 2-- CVS changes (12-24 hrs)(12-24 hrs)
Stage3-- ARFStage3-- ARF (24-72 hrs)(24-72 hrs)
Lab finding:Lab finding: oxalate crystals in urine.oxalate crystals in urine. hypocalcemiahypocalcemia ↑↑A: G acidosisA: G acidosis tt mainly on history & clinical symptoms.tt mainly on history & clinical symptoms. Specific treatment:Specific treatment: ethanolethanol pyridoxinepyridoxine thiaminethiamine magnesiummagnesium 4-methyl pyrazole4-methyl pyrazole HDHD
Isopropyl alcohol poisoningIsopropyl alcohol poisoning
2-propanol,isopropanol.2-propanol,isopropanol.
Clear, volatile ,bitter taste,aromatic odourClear, volatile ,bitter taste,aromatic odour
Solvent, & disinfectant.Solvent, & disinfectant.
22ndnd to ethanol as most commonly ingested alcohol. to ethanol as most commonly ingested alcohol.
Twice potent than ethanol as CNS depressant.Twice potent than ethanol as CNS depressant.
Toxic dose--- 1ml/kg of 70 % solution.Toxic dose--- 1ml/kg of 70 % solution.
Lethal dose---2-4ml/kg.Lethal dose---2-4ml/kg.
80% absorbed from GIT in 30 mins.80% absorbed from GIT in 30 mins.
Dermal absorption & inhalation.Dermal absorption & inhalation.
isopropyl alcohol acetoneisopropyl alcohol acetone
alc dehydrogenase alc dehydrogenase acetate+acetate+ formateformate Very few ketoacidsVery few ketoacids
CNS depressant.CNS depressant.
NAD/NADH ratio NAD/NADH ratio ↑ed.↑ed.
Clinical effectsClinical effects within 30-60 mins.within 30-60 mins. lacking euphorialacking euphoria
nausea,vomiting,haemorrhgic gastritis.nausea,vomiting,haemorrhgic gastritis.
ocular signs ocular signs
sweet ,pungent odor of acetonesweet ,pungent odor of acetone
coma, hypoventilation resp arrestcoma, hypoventilation resp arrest
DiagnosisDiagnosis inebriated with –ve or low ethanol.inebriated with –ve or low ethanol. elevated osmolar gapelevated osmolar gap ketosis without acidosisketosis without acidosis >50mg/dl toxic,200-400mg/dl lethal.>50mg/dl toxic,200-400mg/dl lethal.
Treatment:Treatment: GI evacuation.GI evacuation. dialysis if 3-4 ml /kg of 70% solutiondialysis if 3-4 ml /kg of 70% solution blood level >400mg/dlblood level >400mg/dl unrespnsive hypotensionunrespnsive hypotension renal failure,coma.renal failure,coma.
Anesthetic management in acute alcohol Anesthetic management in acute alcohol intoxicated pts.intoxicated pts.
acute problemsacute problems
altered sensorium & poor assesment.altered sensorium & poor assesment... fluid & electrolytes derangements.fluid & electrolytes derangements.
acid –base disordersacid –base disorders
full stomach & aspiration.full stomach & aspiration.
hypothermia.hypothermia.
consent.consent. ↓↓MAC of anesthetic gases & analgesia.MAC of anesthetic gases & analgesia. multiple trauma with airway involvement.multiple trauma with airway involvement.
Problems due to chronic alchoholismProblems due to chronic alchoholism hypoproteinemia hypoproteinemia liver dysfunction.liver dysfunction. cardiomyopathy.cardiomyopathy. haematological abnormalities.haematological abnormalities. increase infectionsincrease infections
other substance abuser.other substance abuser. HIV ,hepatitis.HIV ,hepatitis. Altered drug metabolismAltered drug metabolism
CYP2E1 .CYP2E1 .
long term consumption induces MEOS.long term consumption induces MEOS.
↑↑metabolism of certain drugs.metabolism of certain drugs.
conversion of many foreign substances into highly conversion of many foreign substances into highly
toxic metabolites.toxic metabolites.
perianesthetic plasma fluoride kinetics.perianesthetic plasma fluoride kinetics.
short term consumption has opposite effects.short term consumption has opposite effects.
Unpredictable awakening from anaesthesiaUnpredictable awakening from anaesthesia
Withdrawal syndrome in postop period.Withdrawal syndrome in postop period.
Long term hospitization.Long term hospitization.
Alcohol withdrawal syndrome in surgical Alcohol withdrawal syndrome in surgical patients.patients.
chronic alcohol misuse is more common in surgical chronic alcohol misuse is more common in surgical patients(upto 43% in ENT pts) than in patients(upto 43% in ENT pts) than in psychiatric(30%) or neurological (19%) pts.psychiatric(30%) or neurological (19%) pts.
Almost half of all trauma beds are occupied by Almost half of all trauma beds are occupied by patients who were injured while under the influence patients who were injured while under the influence of alcohol.of alcohol.
Normal postoperative course into life threatening Normal postoperative course into life threatening situation.situation.
Hangover :Hangover :tremors,nausea,vomiting.tremors,nausea,vomiting.
weakness, irritability, insomniaweakness, irritability, insomnia..
Delirium tremens: Delirium tremens: 2-4 days of complete abstinence2-4 days of complete abstinence
disorientationdisorientation
poor attention span.poor attention span.
visual &auditary hallucination.visual &auditary hallucination.
marked autonomic disturbances.marked autonomic disturbances.
respiratory & cardiovascular collapse.respiratory & cardiovascular collapse.
death.death.
Rum fitsRum fits
12-48 hrs after aheavy bout of drinking.12-48 hrs after aheavy bout of drinking.
multiple seizures 2-6 at a time.multiple seizures 2-6 at a time.
sometimes status epilepticus.sometimes status epilepticus. Alcoholic hallucinosis Alcoholic hallucinosis
auditory hallucinations.auditory hallucinations.
clear consciousness.clear consciousness.
Recognition of alcohol misuse in surgical pts.Recognition of alcohol misuse in surgical pts.
- - history &physical examination.history &physical examination.
-CAGE questionnaire. -CAGE questionnaire.
-laboratory markers -laboratory markers
CDT, GGT, MCV.CDT, GGT, MCV.
Revised clinical institute withdrawal Revised clinical institute withdrawal assesment(CIWA)for alcohol scale.assesment(CIWA)for alcohol scale.
1.1. nausea &vomitingnausea &vomiting
2.2. tremortremor
3.3. anxietyanxiety
4.4. agitationagitation
5.5. tactile disturbancestactile disturbances
6.6. auditory disturbancesauditory disturbances
7.7. visual disturbancesvisual disturbances
8.8. headache/fullness in head.headache/fullness in head.
9.9. orientation/clouding of consciousness .orientation/clouding of consciousness .
Treatment of alcohol misuse in ward pts.Treatment of alcohol misuse in ward pts. .. prophylaxis.prophylaxis. 11stst line tt : diezepam, lorazepam, chlordizepoxide line tt : diezepam, lorazepam, chlordizepoxide alternative: chlormethimazole, ethanol.alternative: chlormethimazole, ethanol. therapy:therapy: establish diagnosis & CIWA scoreestablish diagnosis & CIWA score CIWA score >20 ICU & start treatment.CIWA score >20 ICU & start treatment. 10-20 start treatment10-20 start treatment <10 watch<10 watch
Start with benzodiazepines.Start with benzodiazepines.
symptom-triggered regimen.symptom-triggered regimen.
fixed –schedule regimenfixed –schedule regimen
Additional medications as needed Additional medications as needed
beta blockers, clonidine, haloperidol.beta blockers, clonidine, haloperidol.
Monitor pt every 4hr by CIWA score.Monitor pt every 4hr by CIWA score.
Intravenous tt for AWS in surgical ICU pts.Intravenous tt for AWS in surgical ICU pts. prophylaxisprophylaxis start with benzodiazepines start with benzodiazepines add additional medications.add additional medications. monitor every hr by CIWA score.monitor every hr by CIWA score. maintain score <10 for 24 hrs.maintain score <10 for 24 hrs.
therapytherapy start with benzodiazepines start with benzodiazepines add additional medications.add additional medications. titrate medications to decrease score <10.titrate medications to decrease score <10. monitor every hr by CIWA score.monitor every hr by CIWA score. until <10 for 24 hrs.until <10 for 24 hrs.
WISHING UWISHING U
HAPPY VALENTINE DAYHAPPY VALENTINE DAY
LOVE LOVE MAY B LESS INJURIOUS MAY B LESS INJURIOUS THAN THAN
ALCOCHOLALCOCHOL
