“what have you been drinking”€¦ · -medication (even over-the-counter remedies) may increase...
TRANSCRIPT
“What Have You Been Drinking”? Presentation Handout
2014 NENA Pan-American Conference
Carole Rush, RN, M.Ed., CEN, FAEN
Clinical Nurse Educator, Okotoks Urgent Care
Alcohol and Injury (ACICR Report 2013)
Leading causes of injury and alcohol-related deaths in Alberta in 2009
• Motor vehicle crashes
• Falls
• Hypothermia
• Drowning
• Asphyxia
Top 5 causes of major trauma and alcohol-related injuries in 2010:
• MVCs
• Falls
• Assault
• ATV / Snowmobile
• Pedestrians
What is a ‘standard drink’? (From Alberta Alcohol and Drug Abuse Commission, AADAC)
1 Regular Beer (4-5% alcohol = 341 ml
1 glass Table Wine (12% alcohol) =142 ml
1 small glass Sherry/Port (20% alcohol) = 85 ml
1 shot of spirits (40% alcohol) = 43 ml
Alcohol Absorption, Metabolism and Elimination Quick Review
Absorption:
Unlike food, alcohol does not have to be digested before it can be absorbed into the bloodstream
• Alcohol molecules are already small, and pass easily and quickly into the bloodstream
• A minute quantity of alcohol vapour is inhaled and absorbed into blood stream via nasal membranes and lungs
• More absorption through mucous membranes of tongue and cheeks
• Quite a lot of alcohol is absorbed through stomach wall
• Most of alcohol is absorbed in the duodenum and small intestine (20 feet of tubing with large surface area!)
• Easily crosses blood-brain barrier
Metabolism
97% is metabolized by your body—mainly liver
Several enzymes involves: Alcohol dehydrogenase is main enzyme workhorse—found mostly in liver and stomach
Elimination
Mostly through kidneys/urine—some through feces, breath and sweat
Ethanol Metabolism Rates per hour (on average) Legal BAC in Canada = .08 = 80mg/dl = 17.4 mmol/L
• Non drinkers’ = 2.6 mmol/L
(12 mg/dl)
• ‘Social drinkers’: 3.2 mmol/L
(15 mg/dl)
• ‘Heavy Users’ = 6.5 mmol/L
(30 mg/dl)
Factors that will determine how alcohol will affect an individual
• Alcohol Content
-The alcohol content of each drink will determine your BAC, not the number of drinks you consume
• Emotional State of Mind
-Your mood can make a difference in how you react to alcohol—but it will not alter your BAC level
• Body Weight and Type -Generally, the less you weight, the more you will be affected by alcohol -Still, even among people of the same weight, a well-muscled individual will be less affected than someone with a higher percentage of body fat
Drinking Time -The more time you take to consume one drink, and the more time you allow to pass between drinks, the less the effect the drinks will have because your body will have gained extra time to metabolize the alcohol
• Fatigue -If you are tired, the effect of alcohol will be stronger than if you are well rested
• Food -The less food you have in your stomach, the more you will be affected by the alcohol you have consumed as it will be absorbed faster into the bloodstream
• Gender
Females tend to have a greater amount of body fat (less water) versus muscle—alcohol moves into water tissues
easier—so alcohol stays more in blood than moving into tissues
-Females have less of the enzyme alcohol dehydrogenase (which breaks down alcohol) than males
• Medication
-Medication (even over-the-counter remedies) may increase the effect of alcohol
Aspirin: For some reason we are not quite sure of aspirin appears to block the action of alcohol dehydrogenase.
What this means is that if you take aspirin before drinking you will became much more intoxicated on a much
smaller dose of alcohol than usual. It is generally recommended that you do not take aspirin for around six hours
before drinking alcohol. If you have taken aspirin before drinking be cautious and try to limit your alcohol intake
as much as possible.
Cayenne pepper: Cayenne pepper dilates the blood vessels and apparently leads higher BACs and more
exposure of the brain to alcohol. In short if you drink alcohol while ingesting a lot of cayenne pepper you will
become much drunker than usual. Avoid red pepper vodka!
Tylenol (acetaminophen, paracetamol): Even by itself Tylenol can cause liver failure. Combining Tylenol with
alcohol is a horrible one two punch to the liver.
Ambien: mixing alcohol with ambien is just about a sure recipe for a blackout or a brownout. People who mix
the two also often report sleepwalking or even sleep eating.
Narcotic painkillers: Another recipe for blackout and disturbed behavior. Avoid mixing alcohol with Percocet,
percodan, vicodin, oxycontin, codeine, morphine or any other narcotic pain killers.
Top Five New Ways of Getting Intoxicated (Google for more info and/or watch videos on You Tube)
1. Vodka Tampons
2. Butt Chuggin
3. Boozy Bears
4. Eye Ball shots
5. Off-label use of Hand Sanitizer
Acute Intoxication
Shot Straws
In order to combat the age old problem of grimacing after taking a tequila shot and scrambling for a chaser, the
inventors of Shot Straws apparently have a solution.
You take the shot out of an over-sized straw with a valve at the bottom in order to drink your shot and chaser one right
after the other
See more at: http://www.tailgatingideas.com/#sthash.H4bzREj3.dpuf
Caffeine and Energy Drinks
• Health Canada says the average healthy adult should not exceed 400 mg caffeine in 24 hours
• Sizes of average drinks is increasing
• Teenager may also be more sensitive to the effects of caffeine because they are less experienced with it
• Consumer Reports found that energy drink manufacturers often fail to list all their ingredients and the amounts
of caffeine are not always what the label says(often up to 20% higher)—not regulated
Caffeine also in some Chewing Gum!
Marketing pitch: It can be a great way to get a pick-me-up without having the inconvenience of guzzling down an
energy drink or a coffee...
Online Guide to How much caffeine in some gum:
www.caffeineinformer.com/efs-guide-to-caffeine-gum
Caffeinated food available in Canada
www.thestar.com/business/2013/05/07/caffeinated_food_available_in_canada.html
Product
Claims
Flavors
Packaging
Mojo Alternative Alcoholic Beverage + Guarana
- “At 7% + guarana, Mojo is not your mother’s cooler”
- “Guarana… contains 2.5 more caffeine than the coffee bean itself!”
- Tropic fruit - Fruit punch - Strawberry & kiwi - Dragon fruit - Green apple
- “Mojo comes in 330ml plastic bottles that are easy to hold with no breakage when you’re out tearing it up on the dance floor.”
- “It can be bought individually or in 4-packs… it’s up to you”
Rockstar + Vodka
- “The bold taste you expect from Original Rockstar only we’ve turned up the volume by adding 6.9% premium vodka”
- Original - Mango Orange
- n/a
Rev Energy
- n/a
- Original Rev - Rev Factor (cranberry & pomegranate) - Rev LoW (raspberry & citrus)
- “New larger size – same great taste: Now enjoy original Rev in a single serve 473ml bottle”
- “Rev comes in plastic bottles that are easy to hold with zero breakage when you’re out tearing it
Emergency Assessment and Interventions for Acute Intoxication/Caffeine Ingestion/ Combos
History
“What have you been drinking?”
“How much have you had to drink?”
Get more details of alcohol and caffeine ingestion and combinations of substances...
But, be aware of other methods of alcohol absorption that we have discussed….so that the patient might still say
‘no’ to the drinking question…but still be intoxicated...
Also ask about ingestion of caffeine enhanced food like chewing gum, chocolate
Recent history of Trauma? Involved in altercation? (may not recall...)
Medications? Blood thinners?
Past/current alcohol use? Provides their expected rate of ethanol metabolism
Other medical history—e.g. cardiac
ABCD’s still crucial: Supportive care as necessary with resources you have
Consult your local Poison Centre/Poison Control
• Airway: Protect from aspiration
– LOC may deteriorate
– Oropharyngeal or nasopharyngeal airway as needed and tolerated
– Consider intubation for patients unable to protect airway
• Breathing
– Assess rate and rhythm
– Bradypnea common with high levels ETOH
– Depth of ventilation may be inadequate/ supplemental oxygen
– Caffeine is a bronchodilator
Circulation
– Intoxication/ Caffeine can cause volume depletion
• Warm IV fluids
• Vasopressors if hypotension refractory to fluids
– Dopamine
– NorEpinephrine
– Phenylephrine (may not stock in your department)
– Continuous cardiac monitoring
– 12-lead ECG-watch for signs of ischemia and dysrhythmias
– “Holiday Heart” syndrome
• “Dysrhythmias, usually atrial fibrillation, which develop while an individual is on vacation or
away from work, and linked to heavier consumption of alcohol”
• Pts may or may not have a history of chronic alcohol use
• -The type of alcohol is insignificant
• -One study found that as many as 66% of all new onset atrial fibrillation in persons under age 65
was related to alcohol intoxication
• -Caffeine does not seem to increase the risk of Atrial Fib
Dysrhythmia Treatment Guidelines
• The treatment of dysrhythmias depends on the nature of the dysrhythmia and the patient’s clinical presentation
• Good idea to consult PADIS
• Dehydration, hypoxemia, metabolic acidosis and electrolyte disturbances may contribute to morbidity
• Hypokalemia—K+ supplementation
• Rhabdomyolysis—treat with IV fluids to prevent renal failure
• Pts with SVT and adequate BP and no evidence of ischemia can be treatment with supportive care
• Pts with persistent SVT, hypotension or evidence of ischemia require intervention to control their heart rate or
to restore sinus rhythm
• Initial treatment of caffeine-induced SVT should include benzodiazepines in order to reduce CNS
stimulation and release of catecholamines
• A short-acting cardioselective beta-blocker (e.g. Esmolol if you stock) or a calcium channel blocker (e.g.
Diltiazem/Cardizem) for control of HR, but may contribute to hypotension
• Because of the catechholamine excess, the use of beta-blockers raises the theoretical concern
that unopposed alpha stimulation could precipitate a hypertensive crisis, but such a case has not
been reported with caffeine toxicity
• Adenosine is unlikely to be effective because caffeine antagonizes adenosine receptors and it’s short
half-life once in the peripheral circulation + does not cross blood-brain barrier
• Cardioversion for hemodynamically unstable pts, or those who do not respond to medications
• Consider cardioversion for alcohol-induced Atrial Fibrillation since these patients are less likely to have
structural heart issues that would cause this rhythm to reoccur
• V-Tach: Stable treat with amiodarone or lidocaine (ACLS Guidelines)
• Unstable perform cardioversion
Note: Caffeine toxicity is very similar to theophylline toxicity
(GI upset, cardiac dysrhythmias, hypotension and seizures) Source: PADIS, Calgary, Alberta, January 2014
• Disability / Dextrose
– Monitor blood glucose
– May require glucose, Narcan, Thiamine (‘coma cocktail’ as needed)
– Behaviour may range from severe agitation and violence to lethargy and coma
• Restraints may be needed
– Seizures
• Benzodiazepines: Lorazepam good choice
Notes on Thiamine:
-Historical literature states that if glucose was given first to a patient with marginal thiamine reserves
(e.g. alcoholic), it would send that patient into Wernicke-Korsakoff syndrome. In an alcoholic pt,
hypoglycemia of any cause is far more likely cause of depressed LOC than is Wernicke-Korsakoff
syndrome.
-doing a quick glucometer can avoid uneeded glucose administration to pts considered at risk for
inadequate thiamine stores
-Wernicke-Korsakoff syndrome develops over hours to days
-So, in patients with known or strongly suspected hypoglycemia, administer the glucose and deliver
thiamine as soon afterward as possible
Oral vs IV Thiamine:
– -orally administered thiamine may be poorly absorbed in the alcoholic
– -IM route is painful
– -IV is preferred route by bolus or as part of fluid hydration and multivitamin preparation
Source: Emergency Medicine Secrets (3rd edition, 2003). In Chapter 83: Alcohol-Related Disorders, authored by
John A Marx, pages 366-370.
Other emergency interventions
• Anti-emetics as needed
• May do serial ETOH levels, other drug levels (depending on what your lab can do)
• Rule out other medical issues/injuries
• May need to be monitored for many hours and / or transferred for admission
• Discharge considerations: Challenging
• Ensure no missed diagnoses
• Definition of intoxication
• Clinically sober
• Patient competence
• Road Test
• Discharge to appropriate environment/ Safety
• Discuss use of Form 1 under Mental Health Act
Notes from a toxicology perspective:
Gastric lavage not indicated
Activated charcoal does not bind to ethanol
Activated charcoal does bind to caffeine
References
Journal Articles/ News Reports and Articles
Budzikowski, A. (January 4, 2012). Holiday Heart Syndrome. Accessed from: http://emedicine.medscape.com/article/155050-overview Caldeira, D., Martins,C., Brandao Alves, L., Pereira, H., Ferreira, J., Costa. J. (2013). Caffeine does not increase the risk of atrial fibrillation: A systemic review and meta-analysis of observational studies. Accessed from http://www.medscape.com/viewarticle/810608_print Ellisand, E., Burke, Garance. (January 16, 2013). Energy drinks under more scrutiny in Canada as US ER visits double. Vancouver Sun and Associated Press. Accessed from http://www.vancouversun.com/story_print.html?id=7829825& Fries, K. (July 8, 2013). Energy Drinks in the ED. Accessed from: http://www.medscape.com/viewarticle/804258_print Fryhofer, S. (2011). Drunk and Wide Awake: Energy Drink Cocktails. Accessed from http://www.medscape.com/viewarticle/743831?src=mp&spon=24 HealthDay News. (July 15, 2011). Drinking alcohol may prolong, not relieve, stress. Accessed from http://consumer.healthday.com/printer.asp?AID=654747 Hurley,J., Liebman, B. (May 2013) Coffee Quake: Explosion in the Java Aisle. Nutrition Action Healthletter. Keenan, T. (November 1, 2012). Energy Drink Wake-Up Call. Published in The Calgary Herald. Lovett, E., McNiff, E. (September 21, 2012) 5 Shocking Ways Your Kids Try to Get Drunk. Accessed from: http://abcnews.go.com/Health/shocking-ways-kids-drunk/print?id=17281602 Medical News Today (April 19, 2011). Mixing Red Bull and Alcohol to stay awake at parties can be a dangerous combination. Accessed from http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=222720 Ringenberg, T., Kalabalik, J., Robinson, C. (2013). Binge drinking and alcohol poisoning in the adolescent population. US Pharmacist; 38(5) HS3-HS6. Yew, D. (September 3, 2013). Caffeine Toxicity Treatment & Management. Accessed from: http://emedicine.medscape.com/article/821863-treatment
Personal Communication
January 2014 with Mark Yarema, MD, FRCPC, Medical Director, PADIS, Alberta Health Services
Reports/ Documents
Alberta Centre for Injury Control and Research (2013). Injuries and Alcohol in Alberta. University of Alberta School of Public Health.
Accessed from www.acicr.ca
American Heart Association (March 21, 2013). Energy drinks may increase blood pressure, disturb heart rhythm: American Heart
Association Meeting Report. Accessed from http://newsroom.heart.org/news/energy-drinks-may-increase-blood-pressure-disturb-
heart.
Atlantic Collaborative on Injury Prevention. (March 2011). Caffeinated Alcoholic Beverages and Injury.
Accessed from http://hpclearinghouse.net/files/folders/alcohol__injury/entry14279.aspx
The Dawn Report: Emergency Department Visits involving Energy Drinks
http://www.samhsa.gov/data/2k11/web_dawn_089/web_dawn_089_html.pdf
Books
Emergency Medicine Secrets (3rd edition, 2003). In Chapter 83: Alcohol-Related Disorders, authored by John A Marx, pages 366-370.
Additional References on Health Effects of Alcohol, Caffeine and Alcohol Screening
(content not covered in presentation, but may be of interest to participants)
Frieden, T., Yox, S. (January 7, 2014) Too Much Alcohol: Making Screening and Counseling Routine; An Interview with CDC Director
Tom Frieden, MD. Accessed from http://www.medscape.com/viewarticle/818635_print
Chang, R. (2011). Binge drinking can damage young brains: study.
Accessed from: http://medscape.com/viewarticle/745589?src=mp&spon=24
Healthday News (July 15, 2011). Binge drinking may impair teen brain development.
Accessed from http://consumer.healthday.com/printer.asp?ID=654746
National Institute on Alcohol Abuse and Alcoholism (2012). Beyond Hangovers: Understanding Alcohol`s Impact on Your Health. NIH
Publication Number 10-7604.
Robeson, P. (2012). Canada`s Low-Risk Alcohol Drinking Guidelines: A Tool for Injury Prevention in Alberta.
Accessed from: http://acicr.ca/our-services/newsletters/volume-15-sept-2012-to-aug-2013
Thompson, D. (December 2, 2013). Energy drinks affect heart, MRI Scans Show.
Accessed from: http://consumer.healthday.com/vitamins-and-nutrition-informatiion-27/caffeine-health-news
U.S. Department of Health and Human Services/National Institutes of Health. (2007). What Colleges Need to Know Now: An Update
on College Drinking Research. NIH Publication Number 07-5010.
Vega, C. (October 3, 2013). Fill”er Up! Health Effects of Coffee: Best Evidence Review of Health Effects of Coffee.
Accessed from: http://www.medscape.com/viewarticle/811891_print