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ACUTE ALCOHOL INTOXICATION. . www.anaesthesia.co.in anaesthesia.co.in@gmail.com. “ drinking is a pause from thinking”. Different alcohol poisonings. Acute ethanol intoxication Acute methanol poisoning. Acute ethylene glycol poisoning. Acute isopropyl alcohol poisoning.

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acute alcohol intoxication

ACUTE ALCOHOL INTOXICATION

.

www.anaesthesia.co.inanaesthesia.co.in@gmail.com

different alcohol poisonings
Different alcohol poisonings.
  • Acute ethanol intoxication
  • Acute methanol poisoning.
  • Acute ethylene glycol poisoning.
  • Acute isopropyl alcohol poisoning
acute ethanol intoxication
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

slide6
One unit = 8 gm of alcohol
  • One oz = 30ml
  • Proof =2*%ethanol by volume
  • One drink = 44ml of whiskey(80%proof),3-5oz wine or 12 oz beer.
  • BAC –blood alcohol conc.
  • 0.1%BAC =100 mg alcohol in 100ml blood.
pharmacology
pharmacology
  • C2H5OH
  • Colorless, odourless liquid
  • M.Wt - 46
  • Vd - 0.54 L/Kg
  • 1gm ethyl alcohol – 7.1 kcal energy
absorption
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.
distribution elimination
Distribution& elimination
  • Distributed to almost every tissue.

peroxidase-catalase system

Ethanol acetadehyde+NADH

+NAD

microsomal oxidase system

acetate

CO2+H2O acetyl coA

slide10
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.
pathophysiology
pathophysiology
  • GABA. Glutamate.
  • ↑NAD/NAD ratio.
  • ↑ketogenesis.
  • ↓gluconeogenesis
  • ↑glycogenolysis
  • Fluid & electrolyte imbalance.
stages of intoxication
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

slide13
0.27-0.4 stupour

0.35-0.5 coma

0.45+ DEATH

asscociated acute problems
Asscociated acute problems.
  • Alcoholic ketoacidosis.
  • Alcoholic hypoglycemia.
  • Fluid & electrolyte imbalance.
  • Wernicke’s encephalopathy.
slide15
Acute effects on heart.
  • Acute GI efects.
  • Acute alcoholic myopathy.
  • Trauma
  • Associated other substance poisoining.
alcoholic ketoacidosis
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
slide17
Alcohol poor food intake dehydration

↓ ↓ ↓

Acetaldehyde glycogenolysis ↑counter

regulatory

↓ hormones

Acetate ↓ ↓

↑NADH/NAD ↑glucagon

ratio ↓insulin

  • ↓gluconeogenesis

ketogenesis

slide18
Altered mental status
  • Kussumal breathing
  • Ketotic breath
  • Lab finding

high anion gap acidosis

↑beta hydroxybutyrate:acetoacetate

↓insulin level

  • Exclude other causes of ↑A;G acidosis
alcoholic hypoglycemia
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

water and electrolytes disorders
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
other electrolytes abnormalities
Other electrolytes abnormalities
  • Hypomagnesemia
  • Hypophosphatemia
  • Hpokalemia
  • Hypocalcemia
wernicke korsakoff s syndrome
Wernicke-korsakoff’s 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

acute effect on heart
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.
acute alcoholic myopathy
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
acute gastrointestinal effect
Acute gastrointestinal effect
  • Acute gastritis & esophagitis.
  • Epigastric distress and gastrointesinal bleeding.
  • Mallory-weiss tear.
  • Acute hepatitis & pancreatitis.
differential diagnosis in acutely intoxicated patient
Differential diagnosis in acutely intoxicated patient.
  • Toxic
  • Metabolic
  • Infectious diseases
  • Neurologic
  • Miscellaneous
  • Trauma
management
Management
  • Airway
  • Breathing
  • Circulation
  • Intubate if poor gag reflex
  • Fingerstick glucose , iv dextrose
  • Thiamin 100 mg im/ iv stat.
  • magnesium
slide29
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.
slide30
Blood alcohol conc (BAC)
  • Enhanced elimination

evacuation after 1 hr little benefit

activated charcoal.

fructose

haemodialysis

metadoxine (300-900mg iv)

methanol poisoning
Methanol poisoning
  • CH3OH(wood alcohol)
  • Solvent ,antifreeze, paint remover.
  • Epidemics of methanol toxicity.
  • Poisoning mainly by ingestion
slide32
Methanol + NAD+ formaldehyde +

NADH

( alcohol dehydrogenase)

formate

(folate)

CO2 + H2O

clinical effects
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.
slide34
Physical examination

constricted visual field,fixed &dilated pupils,

retinal edema &hyperemia of disk

resp apnea ,opisthotonus,& seizure in pts dying of

Methanol intoxication

slide35
Lab finding

high anion gap acidosis (correlates with

mortality)

high osmolar gap

serum methanol> 20 mg/dl symptoms

> 50 mg/ dl serious

> 100 mg/ dl ocular signs

slide36
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 >20 mg/100ml,symptomatic

acidosis, need for HD.

ingestion >o.4ml/kg

slide37
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:

methanol>20-50mg/100ml

acidosis not responsive to bicarbonate

formate levels > 20 mg/100ml

visual impairment

renal impairement

  • Dialysis till methanol level≈0mg/100ml and acidosis clears.
ethylene glycol poisoning
Ethylene glycol poisoning
  • Colourless, odourless ,nonvolatile,water soluble.
  • Paints,polishes, cosmetics,antifreeze.
  • Viscous & sweet –poorman’s substitute for alcohol.
  • Minimal lethal dose 1-1.5ml/kg.
  • Peak level 1-4 hr.
slide39
Eth glycol + NAD+ glycoldehyde +NADH

alc dehydrogenase

glycolate

lactate

oxalate glyoxylate

hypocalcemia

renal failure

myocardial deprssion

clinical effects1
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)

slide41
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

isopropyl alcohol poisoning
Isopropyl alcohol poisoning
  • 2-propanol,isopropanol.
  • Clear, volatile ,bitter taste,aromatic odour
  • Solvent, & disinfectant.
  • 2nd to ethanol as most commonly ingested alcohol.
slide43
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.
slide44
isopropyl alcohol acetone

alc dehydrogenase

acetate+

formate

  • Very few ketoacids
  • CNS depressant.
  • NAD/NADH ratio ↑ed.
slide45
Clinical effects

within 30-60 mins.

lacking euphoria

nausea,vomiting,haemorrhgic gastritis.

ocular signs

sweet ,pungent odor of acetone

coma, hypoventilation resp arrest

slide46
Diagnosis

inebriated with –ve or low ethanol.

elevated osmolar gap

ketosis without acidosis

  • >50mg/dl toxic,200-400mg/dl lethal.
  • Treatment:

GI evacuation.

dialysis if 3-4 ml /kg of 70% solution

blood level >400mg/dl

unrespnsive hypotension

renal failure,coma.

anesthetic management in acute alcohol intoxicated pts
Anesthetic management in acute alcohol intoxicated pts.
  • acute problems

altered sensorium & poor assesment.

.

fluid & electrolytes derangements.

acid –base disorders

full stomach & aspiration.

slide48
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

slide49
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.

slide50
Unpredictable awakening from anaesthesia
  • Withdrawal syndrome in postop period.
  • Long term hospitization.
alcohol withdrawal syndrome in surgical patients
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.
slide52
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.

slide53
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.

slide54
Recognition of alcohol misuse in surgical pts.

- history &physical examination.

-CAGE questionnaire.

-laboratory markers

CDT, GGT, MCV.

slide55
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 .
slide56
Treatment of alcohol misuse in ward pts..

prophylaxis.

1st line tt : diezepam, lorazepam, chlordizepoxide

alternative: chlormethimazole, ethanol.

therapy:

establish diagnosis & CIWA score

CIWA score >20 ICU & start treatment.

10-20 start treatment

<10 watch

slide57
Start with benzodiazepines.

symptom-triggered regimen.

fixed –schedule regimen

  • Additional medications as needed

beta blockers, clonidine, haloperidol.

  • Monitor pt every 4hr by CIWA score.
slide58
Intravenous tt for AWS in surgical ICU pts.

prophylaxis

start with benzodiazepines

add additional medications.

monitor every hr by CIWA score.

maintain score <10 for 24 hrs.

therapy

start with benzodiazepines

add additional medications.

titrate medications to decrease score <10.

monitor every hr by CIWA score.

until <10 for 24 hrs.

slide59
WISHING U

HAPPY VALENTINE DAY

LOVE MAY B LESS INJURIOUS THAN

ALCOCHOL

slide60

thank You

www.anaesthesia.co.inanaesthesia.co.in@gmail.com