ONE BOURBON, ONE

SCOTCH, ONE BEER:

ALCOHOL INTOXICATIONNICOLE S. TANGCO, MD

PRE-RESIDENT

DEPARTMENT OF PSYCHIATRY

DOES THIS SOUND FAMILIAR?YOU DON’T NORMALLY DRINK A LOT, BUT IT’S THE

BIRTHDAY OF YOUR BEST FRIEND SO YOU DECIDE IT’S OK TO LET LOOSE. AFTER TAKING MORE THAN YOUR USUAL AMOUNT OF BEER, YOU START TALKING A LOT MORE IN A SOMEWHAT SLURRED VOICE AND YOU FIND IT HARDER TO WALK STRAIGHT. YOU ALSO START FLIRTING WITH THAT GUY OR GIRL YOU’VE NEVER HAD THE NERVE TO TALK TO BEFORE. FINALLY, YOU PASS OUT ON YOUR FRIEND’S COUCH, AND WHEN YOU WAKE UP, YOU CAN BARELY REMEMBER WHAT HAPPENED THE NIGHT BEFORE.

YOU ARE NOT ALONE!• MORE THAN HALF OF ALL AMERICANS

AGED 12 AND OLDER REPORT BEING CURRENT DRINKERS OF ALCOHOL (ABOUT 135.5 MILLION DRINKERS)

• ABOUT ¼ (59.7 MILLION) REPORTED BINGE DRINKING 30 DAYS PRIOR TO THE STUDY SURVEY

• 17 MILLION REPORTED HEAVY DRINKING

• FOR MOST, DRINKING ALCOHOL IS CONTROLLED AND RELATIVELY SAFE

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, RESULTS FROM THE 2012 NATIONAL SURVEY ON DRUG USE AND HEALTH: SUMMARY OF NATIONAL FINDINGS, NSDUH SERIES H-46, HHS PUBLICATION NO. (SMA) 13-4795. ROCKVILLE, MD: SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, 2013.

ALCOHOL INTOXICATION: DEFINITION

OCCURS WHEN DRINKING EXCESS ALCOHOL LEADS TO INAPPROPRIATE BEHAVIOR AND IMPAIRED JUDGMENT. IT MAY CAUSE SLURRED SPEECH, LOSS OF COORDINATION, UNSTEADY WALKING OR RUNNING, DIFFICULTY PAYING

ATTENTION OR REMEMBERING, CONFUSION OR COMA

ETHANOL: PHARMACOLOGY• CH3CH2OH

• WATER-SOLUBLE ALCOHOL

• RAPIDLY CROSSES CELL MEMBRANES

• ABSORPTION OF ETHANOL OCCURS VIA THE GASTROINTESTINAL SYSTEM,

• STOMACH (70 PERCENT)

• DUODENUM (25 PERCENT),

• REMAINING INTESTINE (~5 PERCENT)

• WHEN THE STOMACH IS EMPTY, PEAK BLOOD ETHANOL LEVELS ARE REACHED BETWEEN 30 AND 90 MINUTES AFTER INGESTION.

VONGHIA L, LEGGIO L, FERRULLI A, ET AL. ACUTE ALCOHOL INTOXICATION. EUR J INTERN MED 2008; 19:561. 5. MARCO CA, KELEN GD. ACUTE INTOXICATION. EMERG MED CLIN NORTH AM 1990; 8:731

ETHANOL: PHARMACOLOGY

• CONVERTED TO ACETALDEHYDE BY ALCOHOL DEHYDROGENASE

• CH3CH2OH + NAD CH3CHO + NADH

• ACETALDEHYDE CONVERTED TO ACETIC ACID THEN TO CO2 AND H2O IN THE KREBS CYCLE

• RATE OF METABOLISM IS ZERO ORDER – NOT DOSE DEPENDENT AT BAC >O.2G/L

ETHANOL: PHARMACOLOGY

• METABOLISM OF ETHANOL: LIVER (MAJORITY)

• ENZYME: ALCOHOL DEHYDROGENASE

• OTHER SITES OF METABOLISM

• GASTRIC MUCOSA (DECREASED IN WOMEN)

• WOMEN HAVE INCREASED VULNERABILITY TO THE ACUTE COMPLICATIONS OF ALCOHOL INTOXICATION

• DECREASED “FIRST-PASS” METABOLISM AND SMALLER VOLUME OF DISTRIBUTION

FREZZA M, DI PADOVA C, POZZATO G, ET AL. HIGH BLOOD ALCOHOL LEVELS IN WOMEN. THE ROLE OF DECREASED GASTRIC ALCOHOL DEHYDROGENASE ACTIVITY AND FIRST-PASS METABOLISM. N ENGL J MED 1990; 322:95.

ETHANOL: PHARMACOLOGY

• CLEARANCE OF ETHANOL:

• UNHABITUATED DRINKER: 15-20MG/DL (3 – 4.5MMOL/L) PER HOUR

• CHRONIC ETHANOL ABUSE: 25-35 MG/DL (5.5 – 8 MMOL/L) PER HOUR

ETHANOL: PHARMACOLOGY

• THE EFFECTS OF ALCOHOL INTOXICATION OCCUR WHEN ALCOHOL CROSSES THE BLOOD-BRAIN BARRIER, WHICH IS RELATIVELY EASY BECAUSE:

• THE MOLECULE IS SMALL

• IT IS ALSO LIPOPHILIC, AND SOMEWHAT POLAR

HTTP://WWW.RISE.DUKE.EDU/APEP/PAGES/PAGE.HTML?020403

OTHER SOURCES OF ETHANOL

• MOUTHWASH

• PERFUME

• COLOGNE

• COOKING EXTRACTS

• OTC MEDICATIONS

DSM CRITERIA FOR ALCOHOL INTOXICATION

• A. RECENT INGESTION OF ALCOHOL.

• B. CLINICALLY SIGNIFICANT MALADAPTIVE BEHAVIORAL OR PSYCHOLOGICAL CHANGES (E.G., INAPPROPRIATE SEXUAL OR AGGRESSIVE BEHAVIOR, MOOD LABILITY, IMPAIRED JUDGMENT, IMPAIRED SOCIAL OR OCCUPATIONAL FUNCTIONING) THAT DEVELOPED DURING, OR SHORTLY AFTER, ALCOHOL INGESTION.

• C. ONE (OR MORE) OF THE FOLLOWING SIGNS, DEVELOPING DURING, OR SHORTLY AFTER, ALCOHOL USE:

• (1) SLURRED SPEECH

• (2) INCOORDINATION

• (3) UNSTEADY GAIT

• (4) NYSTAGMUS

• (5) IMPAIRMENT IN ATTENTION OR MEMORY

• (6) STUPOR OR COMA

• D. THE SYMPTOMS ARE NOT DUE TO A GENERAL MEDICAL CONDITION AND ARE NOT BETTER ACCOUNTED FOR BY ANOTHER MENTAL DISORDER.

CLINICAL PRESENTATION

• IT IS RARELY THE CAUSE FOR THE ACUTE PRESENTATION

• BINGE DRINKING ≥ 5 ALCOHOLIC DRINKS GENERALLY RESULTS IN ALCOHOL INTOXICATION

• WOMEN: ≥ 4 DRINKS

WHAT IS ONE DRINK?

• A STANDARD "DRINK" IN THE UNITED STATES CONTAINS ABOUT 0.6 FLUID OUNCES OR 14 GRAMS OF "PURE" ALCOHOL, AND IS THE EQUIVALENT OF:

• 12 OUNCES OF REGULAR BEER

• 8-9 OUNCES OF MALT LIQUOR

• 5 OUNCES OF WINE

• 1.5 OUNCES OF 80 PROOF DISTILLED SPIRITS

CLINICAL PRESENTATION• SIGNS AND SYMPTOMS OF ALCOHOL INTOXICATION INCLUDE:

• SLURRED SPEECH

• NYSTAGMUS

• DISINHIBITED BEHAVIOR

• INCOORDINATION

• UNSTEADY GAIT

• MEMORY IMPAIRMENT

• STUPOR OR COMA

• PERIPHERAL VASODILATION HYPOTENSION AND TACHYCARDIA (MAY ALSO BE SECONDARY TO VOLUME LOSS)

BLOOD ALCOHOL CONCENTRATION AND RELATED EFFECTS

Blood Alcohol Concentration Effects

Between 0.01 and 0.10 percent (<100 mg/dL or 22 mmol/L)

Euphoria and mild deficits in coordination, attention, and cognition

Between 0.10 and 0.20 percent greater deficits in coordination and psychomotor skills, decreased attention, ataxia, impaired judgment, slurred speech, and mood variability

Between 0.20 to 0.30 percent lack of coordination, incoherent thoughts, confusion, and nausea and vomiting

Exceeds 0.30 percent Stupor and loss of consciousness can occur. Some patients experience coma and respiratory depression, and death is possible.

BLOOD ALCOHOL CONCENTRATION AND RELATED EFFECTS

Blood alcohol concentration Clinical effects

20-50 mg/dL (4.4-11 mmol/L) Diminished fine motor coordination

50-100 mg/dL (11-22 mmol/L Impaired judgement; impaired coordination

100-150 mg/dL (22-33 mmol/L) Difficulty with gait and balance

150-250 mg/dL (33-55 mmol/L) Lethargy; difficulty sitting upright without assistance

300 mg/dL (66 mmol/L) Coma in the non-habituated drinker

400 mg/dL (88 mmol/L) Respiratory depression

ADAPTED FROM: MARX JA. ROSEN'S EMERGENCY MEDICINE: CONCEPTS AND CLINICAL PRACTICE, 5TH ED, MOSBY, INC., ST. LOUIS 2002. P. 2513. COPYRIGHT © 2002 ELSEVIER

OTHER CLINICAL FEATURES

• MAY INDUCE MULTIPLE DERANGEMENTS:

• HYPOGLYCEMIA

• LACTIC ACIDOSIS

• HYPOKALEMIA

• HYPOMAGNESEMIA

• HYPOCALCEMIA

• HYPOPHOSPHATEMIA

DIFFERENTIAL DIAGNOSIS• ALCOHOL INTOXICATION AS A CAUSE OF ALTERED MENTAL STATUS IS A

DIAGNOSIS OF EXCLUSION

• RULE OUT OTHER CAUSES FIRST:

• HEAD TRAUMA

• HYPOXIA

• HYPOGLYCEMIA

• HYPOTHERMIA

• HEPATIC ENCEPHALOPATHY

DIFFERENTIAL DIAGNOSIS

• CONSIDER INTAKE OF OTHER ALCOHOLS:

• PATIENTS WITH SEVERE METABOLIC ACIDOSIS AND AN INCREASED ANION GAP: INTOXICATION WITH OTHER ALCOHOLS (METHANOL OR ETHYLENE GLYCOL)

• PATIENT WITH UNEXPECTEDLY INCREASED LEVELS OF SERUM KETONES OR ACETONE WITHOUT METABOLIC ACIDOSIS IN THE SETTING OF CLINICAL ALCOHOL INTOXICATION: ISOPROPYL ALCOHOL INGESTION

DIFFERENTIAL DIAGNOSIS

• CONSIDER THE INTAKE OF OTHER SUBSTANCES:

• SYMPATHOMIMETIC DRUGS

• OPIOIDS

• BENZODIAZEPINES

• BARBITURATES

• DESIGNER DRUGS

LABORATORY WORK-UP

• SERUM ALCOHOL CONCENTRATION

• SUPERIOR TO BREATH ANALYSIS IN TERMS OF ACCURACY

• LEGAL LIMIT IN THE UNITED STATES: 80MG/DL

• NO SET LIMIT IN THE PHILIPPINES (RA 10586)

• MELLANBY EFFECT: EFFECTS ARE MORE PROMINENT WHEN LEVELS ARE RISING

LABORATORY WORK-UP

• BLOOD CHEMISTRY STUDIES

• CBG/RBS

• ELECTROLYTES

• ABGS

• TRAUMA WORK-UP IF WITH HISTORY OF TRAUMA

MANAGEMENT• SUPPORTIVE MANAGEMENT FOR ACUTE UNCOMPLICATED ALCOHOL

INTOXICATION

• MUST GIVE THIAMINE (VITAMIN B1) TO PREVENT OR TREAT WERNICKE’S ENCEPHALOPATHY, ALONG WITH DEXTROSE

• 100MG PARENTERAL THIAMINE

• IF AGITATED, VIOLENT, OR UNCOOPERATIVE, MAY GIVE CHEMICAL SEDATION

• BENZODIAZEPINES AND TYPICAL ANTIPSYCHOTICS

• BUT WATCH OUT FOR EXACERBATION OF RESPIRATORY DEPRESSION

MANAGEMENT• ONCE THE ACUTE INTOXICATION HAS BEEN ADDRESSED, CHECK FOR

POSSIBLE SUBSTANCE ABUSE

• MILD ETHANOL INTOXICATION

• OBSERVATION AND SERIAL EXAMINATION UNTIL CLINICAL SOBRIETY

• NO NEED FOR IV FLUIDS IF WITHOUT SIGNS OF HYPOVOLEMIA

• MODERATE ETHANOL INTOXICATION

• WITH SIGNS OF VOLUME DEPLETION, HYPOTENSION, OR MALNUTRITION: IV FLUIDS

• INVESTIGATE ANY ALTERATION IN TE LEVEL OF CONSCIOUSNESS

CHASE PB, BIROS MH. A RETROSPECTIVE REVIEW OF THE USE AND SAFETY OF DROPERIDOL IN A LARGE, HIGH-RISK, INNER-CITY EMERGENCY DEPARTMENT PATIENT POPULATION. ACAD EMERG MED 2002; 9:1402.

NOBAY F, SIMON BC, LEVITT MA, DRESDEN GM. A PROSPECTIVE, DOUBLE-BLIND, RANDOMIZED TRIAL OF MIDAZOLAM VERSUS HALOPERIDOL VERSUS LORAZEPAM IN THE CHEMICAL RESTRAINT OF VIOLENT AND SEVERELY AGITATED PATIENTS. ACAD EMERG MED 2004; 11:744.

MANAGEMENT

• SEVERE ETHANOL INTOXICATION (ETHANOL POISONING)

• AGGRESSIVE SUPPORTIVE CARE

• AT HIGHER BAC, WATCH OUT FOR RESPIRATORY STATUS

• IF UNABLE TO MAINTAIN SPONTANEOUS RESPIRATION, INTUBATE AND PROVIDE MECHANICAL VENTILATION

• IV FLUIDS

• ISOTONIC CRSYTALLOIDS

MANAGEMENT

• DO NOT GIVE ACTIVATED CHARCOAL OR DO GASTRIC LAVAGE

• RAPID RATE OF ABSORPTION

ETHANOL INTOXICATION IN CHILDREN

• YOUNG CHIODREN

• MAY OCCUR IN UNATTENDED CHILDREN, OR MAY BE GIVEN BY CARETAKER TO SILENCE NOISY CHILDREN

• PROFOUND HYPOGLYCEMIA, COMA, AND HYPOTHERMIA DEATH

• TOXIC DOSE = 0.4ML/KG OF 100% ETHANOL

• PEAK SERUM ETHANOL 50 MG/DL

SELBST SM, DEMAIO JG, BOENNING D. MOUTHWASH POISONING. REPORT OF A FATAL CASE. CLIN PEDIATR (PHILA) 1985; 24:162.

ETHANOL INTOXICATION IN CHILDREN

• PRETEENS AND TEENAGERS

• ACCOUNT FOR 11% OF ALL ALCOHOLIC BEVERAGES CONSUMED

• ASSOCIATED WITH FATAL MOTOR CRASHES, VIOLENCE, SEXUAL ASSUALT, SUICIDAL THOUGHTS, UNPLANNED PREGNANCY

• DOSES TO ACHIEVE INTOXICATION IS SIMILAR TO ADULTS