Alcohol Related Presentations to the EDDR CANDICE HANSON

Overview

Some ED statistics

Pharmacology of ethanol

Acute Intoxication

Alcohol in trauma

Alcohol Withdrawal

Chronic alcoholism – special problems

Toxic Alcohols

Summary

Quiz

Some Statistics

3.3 million people world wide die from alcohol related illness p.a. (5.9%)

Over 5% of annual burden of disease as DALYs is due to alcohol

worldwide

25% of deaths in 20-39 yr olds world wide are attributable to ETOH

ETOH is implicated in over 200 different health conditions

1 in 3 presentations to the ED in Australia are related to alcohol

In 2010 estimates 3.5% Australian pop are dependent or use harmfully

Australian men drink 20L per yr, women drink 9L per yr of pure alcohol

Pharmacology of Ethanol

CNS depressant Potentiates action at GABA receptors and reduces NMDA activity (serotonin, NE)

Absorbed 20% gastric 80% small intestine; metabolised at liver & excreted by kidney. 5% unchanged via lung. Water soluble. Zero order kinetics.

Metabolism

Acute Intoxication

Signs of acute intoxication

Nystagmus, ataxia, slurred speech, CNS depression, respiratory depression

Treatment – largely supportive. Aspiration risk – nurse on side.

Patient must not be a danger to self or others before ED discharge (e.g. mobilise safely, responsible party will take home), passing urine

No evidence that IVT improves recovery time / hastens metabolism, or BAL, but adds to cost of admission*

If patient is not alcohol dependent, thiamine is not required

Alcohol in Trauma

Higher suspicion for significant injuries e.g head trauma, c-spine

If history / mechanism is unclear and patient has altered GCS, cannot

assume it is due to alcohol. Lowered index to scan.

If patient not improving or deteriorating during observation – look for

alternate explanation

Intoxication is a consideration in NEXUS c-spine rules, but not Canadian

Alcohol Withdrawal

Minor withdrawal 6-24 hrs

Tremor, anxiety, N&V, insomnia

Major withdrawal 10-72 hrs

Alcoholic hallucinosis, whole body tremor, vomiting, diaphoresis, HTN

Seizures 6-48 hrs

Brief and generalised, normal EEG, up to 60% not treated for withdrawal, up to 40% will progress to DT

Delirium Tremens 3-10 days

Medical emergency. Global confusion is hallmark; autonomic hyperactivity, risk of cardiovascular collapse, fluid / electrolyte disturbance. Large differential diagnosis.

Chronic Alcoholism – Special Problems

Alcohol effects every bodily system

Cardiovascular – HTN, alcoholic cardiomyopathy (direct toxic effect)

Haematological – anaemia, thrombocytopaenia, macrocytosis, risk of infections, bleeding risk

Neurological – cerebral atrophy, ?alcohol dementia (loose criteria, in DSM-IV, often overlaps with other forms of dementia, distinct from Korsakoff), head injuries / bleeds, cerebellar atrophy

Endocrine – hyperoestrogenism, hypoglycaemia, pancreatitis

Reproductive– spontaneous abortion, foetal alcohol sy, infertility (men & women), low birth wt

Misc – gout, Dupytreyn’s, myopathy

Psychosocial – financial, marital, violence, risk of sexual assault, employment.

Screening tools e.g. CAGE (cut down, annoyed, guilty, eye opener)

Thiamine Deficiency

Water soluble essential nutrient – Vitamin B1

Thiamine is phosphorylated in the gut to active coenzyme form, important in ATP production, normal nerve conduction & maintenance of neural membranes

Deficiency results from poor nutrition, decreased conversion to coenzyme, reduced storage in fatty liver, ethanol may inhibit intestinal transport, impaired absorption

Deficiency causes beriberi*

Dry beriberi – polyneuropathy (symmetrical, non-specific myelin degen, usually lower limbs, affects sensory, motor and reflexive arcs. Progressive)

Wet beriberi – affects the heart, leading to high output cardiac failure

Wernicke-Korsakoff Syndrome

Wernicke-Korsakoff Syndrome

Spectrum of disease

Wernicke typically precedes, reversible if identified early

Ophthalmoplegia (esp. lateral recti), nystagmus, ataxia

Deranged mental function, fluctuates. Confusion, apathy, sleep disturbance, disorientation, listlessness to coma

Korsakoff mostly irreversible

Retrograde (then anterograde) amnesia

Confabulation

Hepatic Disease

Fatty liver, hepatitis, cirrhosis, HCC

Hepatitis can range from mild with non-specific symptoms through to

jaundice and fulminant hepatic failure. Can also become chronic

Portal HTN – in setting of cirrhosis Ascites, portosystemic shunts,

congestive splenomegaly, hepatic encephalopathy

Hepatic failure – low albumin, low clotting factors, high ammonia,

peripheral stigmata, jaundice. Risk of SBP, hepatorenal &

hepatopulmoary syndromes (high mortality)

Hepatic Encephalopathy

Distinct from Wernicke’s; occurs in setting of pre-existing liver disease

Liver cannot cope with nitrogenous load (normally metabolises ammonium ammonia

urea, excreted via kidney).

Ammonia XBBB into astrocytes for metabolism, osmotic load cerebral oedema

Clinical features: hepatic flap, confusion, altered cognition / coma

Prevention – minimise protein / nitrogen load e.g. low protein diet, enemas, Aims for 3-4 soft

stools daily. Antibiotics ***

Lactulose – decreases transit time through gut (less absorption) and reduces production of

nitrogenous waste by gut flora. (PO or PR 30mls tds)

Varices

Oesophageal varcies – lower 1/3 of oesophagus venous drainage via gastric vein vein to portal system. Develop in setting of portal HTN

Treatment of acute bleed

Careful resuscitation (Hb 70-80)

Terlipressin on suspicion of varices (don’t wait for confirmation) 2mg IV (4 hrly up to 3-5 days)

Endoscopy – banding ligation > sclerotherapy within 12 hrs presentation

Antibiotic to prevent gram negative infection – quinolone or 3rd gen ceph

Balloon tamponade with Blakemore tube (pt is intubated). Risk of oesophageal necrosis / rupture http://www.youtube.com/watch?v=imFCMWeWDpU

TIPSS / surgery

Toxic Alcohols

Methanol: >0.5ml/kg can be lethal

metabolised to formic acid, toxic to ocular tissues; CNS effects; initially elevated osmolar gap, then HAGMA (although normal values don’t exclude significant toxicity)

Chemical thinners, paints, wood spirits, varnishes (not found in methylated spirits in Australia)

Ethylene glycol: >1mg/kg can be lethal

Metabolised to oxalic acid; HAGMA & osmolar gap; rapid CNS depression; formation calcium oxalate crystals in tissues with hypoCa++ & renal failure, cardiorespiratory failure

Solvents, coolants, anti-freeze, brake fluids

* Treatments include ethanol, fomepizole (ADH inhibitor), NaHCO3, haemodialysis.

Summary

Alcohol related illness is a huge part of the ED workload burden

Management of acute intoxication is largely supportive

Higher risk, higher suspicion in trauma with alcohol on board

Acute withdrawal – manage with benzos and thiamine supplementation

Disease associated with thiamine deficiency – may be reversible

Chronic disease related to alcohol – every bodily system. Emergencies to

consider include liver failure, encephalopathy, bleeding varices

Toxic alcohol ingestions can be potentially lethal if not managed early

“

”QUIZ

HOORAY!

WINNER TAKES ALL…

Question 1

Who coined the following phrase?

“Alcohol – the cause and solution to all of life’s problems”

Question 2 & 3

2) What city was the bar from this TV show set it?

3) The theme song was Where Everybody Knows You Name. What was the name of the bar’s proprietor?

Question 4

Who is this handsome fella, and what is his contribution to alcohol related medicine?

(Hint: he produced a thesis entitled Alcoholic Paralysis)

Question 5

This unfortunately named singer famously sang about her refusal to enter rehab.

What was her cause of death?

Question 6

This well loved Australian icon reportedly died from alcohol related dementia (or HIV according to Derryn Hinch).

Who is he and why was he booted off Australian television in 1975?

(I will give bonus points for an impression of the event)

Question 7

What are the alcoholic components of a traditional Long Island Iced Tea?

(Hint: there are five)

Question 8

On September 19, 1975, the Star Hotel in Newcastle was closed down

by police resulting in an infamous riot (ordinary fare in Newie, really).

Which famous Australian band wrote the song ‘Star Hotel’ about this

event?

Question 9

For Game of Thrones Fans…

What type of drink does Tyrion Lannister like with his breakfast?

Question 10

Robert Downey Jnr is quoted as saying he has an allergy to alcohol. What does he break out in if he drinks?

Question 11 & 12

11) Tom Cruise starred in the 1988 movie Cocktail. What style of bartending did he help make famous?

12) Which Beach Boys song was the title track to the film?

Question 13

You can get it any old how, matter o’ fact, I’ve got it now!

Which famous Aussie beer is this the advertising slogan for?

Question 14

On which day of the year is St Patrick’s Day celebrated?

(Bonus point if you know why)

Question 15

What is Barney’s last name?

Quiz Answers

1 Homer Simpson

2 Boston, Massachusetts

3 Sam Malone

4 Sergei Korsakoff (Russian neuropsychaiatrist)

5 Amy Winehouse, acute alcohol poisoning

6 Graham Kennedy, crow impersonation “Faaarck”

7 Tequila, white rum, vodka, gin,

triple sec

8 Cold Chisel

9 Black beer

10 Handcuffs

11 Flair or flairing

12 Kokomo

13 VB

14 March 17 (he died on this day)

15 Gumble

The Winner is…THANK YOU!