“A Cup of Holiday Cheer?” Pre-hospital Alcohol Emergencies
Presence Regional EMS
December 2015
Objectives
Discuss the effects of ethyl alcohol on the human bodyDescribe delirium tremens, signs and symptoms,
complications and managementOutline physiological concerns specific to children
ingesting ethyl alcohol. List other emergency situations that might be masked by
alcohol intoxication Using a variety of scenarios discuss the assessment and
management of alcohol related emergencies
Alcohol and EMS Patients
The common alcohol encountered in patient interactions is Ethanol
Alcohol is the most common substance of abuse in the US and worldwide
75% of Americans have at least one alcoholic drink per year.
Between 15% and 40% of EMS patients have detectable levels of alcohol in their blood.
Alcohol and the Holiday Season
In American society, drinking alcohol is a tradition during the Holiday Season.
Actions of Alcohol on the Body
At low doses: excitatory and stimulating effects with depressing of inhibitionsAggressive behavior Inappropriate behavior
At higher doses: sedative effect, depresses the central nervous systemDulls sense of awarenessSlows reflexes, lack of coordinationReduces reaction timeStupor and coma
Physiology
Alcohol is completely absorbed from the GI tract in 30-120 minutes.Food in the GI tract slows absorption timeConcentrations in the brain rapidly approach
blood alcohol levelsAlcohol is broken down and eliminated
(metabolized) by the liverIntoxication occurs when alcohol enters the
bloodstream faster than the liver can break it down
Alcohol causes peripheral vasodilationFlushing of skinFeeling warmIncreased loss of body heat
Alcohol potentiates other drugs (prescription and non-prescription)
Physiology cont.
Alcohol inhibits the hormone responsible for conservation of water in the kidney (vasopressin)Increased urinationDehydration
Alcohol ingestion can cause vomitingDehydration Chance of aspiration
Blood Alcohol Concentrations
EMS providers have no way to determine blood alcohol levels in the pre-hospital setting.
Can sometimes estimate based on assessment and patient behavior
Patients with long term alcohol use will not have signs and symptoms until blood alcohol levels are much higher
Blood Alcohol Concentrations
0.02 – 0.05 gm/dl diminished fine motor coordination
0.05-- 0.10 gm/dl impaired judgment and coordination
0.08 gm/dl LEAGALLY INTOXICATED IN ILLINOIS
0.10 – 0.15 gm/dl difficulty with gait and balance
0.15 – 0.25 gm/dl lethargy, unable to sit upright without assistance
0.25 – 0.30 gm/dl coma in the non-habitual drinker
0.30 – 0.40 gm/dl respiratory depression
Scenarios
Alcohol (ethanol) ingestion can cause a variety of pre-hospital emergencies.
For each scenario, determine: what is important about the scene size up initial assessment (Mental status, Airway, Breathing,
Circulation)
SAMPLE history head to toe exam management of the patient (BLS & ALS)
Scenario 1
It is 2100 hours on New Year’s EveYou are called to a family home for an
unconscious male.
You are lead by an anxious middle aged woman to the basement family room.
You find 4 young men standing around Tony, an 18 year old male lying on the floor face down in vomit and blood.
The woman is Tony’s mother, she just got home from going out to dinner and found her son like this.
Initial Assessment
Level of Consciousness: Arouses to pain onlyAirway: occluded with vomit Breathing: labored and slowCirculation: pulse 90 at carotid strong, radial
pulse weaker, skin warm and sweatyChief Complaint: Altered level of consciousness
What do you do now??
What is Tony in immediate danger of?
SAMPLE
Allergies– noneMedications – none but vitaminsPast Medical History – none healthy young
senior in high schoolLast Meal – some chips and snacks since 7 pmEvents – to celebrate New Year’s Eve Tony had
a bottle of vodka. He has been drinking a shot with orange juice for each of his birthdays. He got to shot 10 and passed out flat on his face.
Head to Toe
Vomit on face and mouth, continues to vomit frequently requiring suction
Approximately 1 inch gash over right eyebrow that is bleeding
Pupils equal and slow to reactChest sounds are congested on right sideAbdomen soft but Tony groans to palpation.No injuries noted on arms and legs.Tony has been incontinent of urine.
Vital Signs
BP 100/70 Pulse 90 Respirations 6Oxygen saturation 90% on room airBlood Glucose 80
How do you manage Tony? What are your concerns?
Management??
BLSKeep airway open with suctioningAssist ventilations with BVM and high flow
oxygenControl bleeding of lacerationMonitor level of consciousness for potential
head injuryDetermine how to extricate from basementConsider spinal motion restrictionTransport/ call for intercept
ALSContinue BLSMonitor airway and breathing – lung congestion could
mean aspiration
Begin IV fluids for rehydrationMonitor blood glucose -- acute intoxication can cause
blood sugar to drop
Consider Zofran 4 mg for vomiting controlContinue to monitor neurological status for
head injury
Rule Out:
Other reasons Tony may have an altered level of consciousnessHead injurySeizureSepsisDrug overdoseHypoglycemiaStrokeHypoxiaHypothermiaHyperthermia
Binge Drinking
National Institute on Alcohol Abuse and Alcoholism: consuming alcohol to reach a blood alcohol level of 0.08 gm/dl in < 2 hours
One in six adults binge drinks 4 times a month with an average of 8 drinks
Although binge drinking is more common among young adults (18-24 years) drinkers 65 years and older binge more often (5-6 times a month)
Binge drinking is more common in high income households
In addition to acute alcohol poisoning, binge drinking is associated with: unintentional injuries
Motor vehicle crashesDrowningBurnsFalls
intentional injuriesDomestic violenceSexual assaultFirearms injures
medical emergenciesPoor control of diabetesLiver diseaseHypertension– cardiovascular disease and stroke
Scenario 2
You respond to a residence where a 3-year-old girl has been found unconscious.
The parents tell you that the child, Ellie was fine when put to bed at eight the night before. They awoke this morning to find Ellie “asleep” on the living room floor, they are unable to arouse her.
You note partially filled cocktail glasses on the coffee table and an open bottle of bourbon on its side on the floor. Some of the glasses have cherries in them. The parents admit that they were too tired to clean up after a party last night.
What could be going on? What happened to this Ellie? How sick is she?
General Assessment: PAT
Appearance Unresponsive, lying
sprawled in a pool of red vomit with cherry
stems
Work of Breathing Normal
Circulation to Skin
Normal
What is your general impression?
General Impression and Management Priorities
General impression: Ellie is SickBrain dysfunction; likely a
metabolic/toxic causeWhat else could cause this?
SeizureInfectionHead traumaOther toxic ingestion
What do you need to know to manage Ellie?
Initial Assessment: ABCDEsAirway — open, vomit in mouth – lips and tongue are
red and vomit contains bits of cherry and cherry stemsBreathing — RR 16; symmetric chest rise; clear lungs;
SaO2 94% Circulation — HR 90; skin moist; capillary refill 2
seconds; BP 80/60Disability — AVPU = P; pupils sluggish but equal;
decreased toneExposure — breath and clothes smell of alcohol; no
signs of traumaChief complaint – Altered level of consciousness
What is the most likely toxin?Sedative
SleepyCentral nervous system depressionDecreased respirations, heart rate and BPSuggested by open containers of alcohol and smell
of alcohol on child’s breath and clothingEating the sweet cherries out of the leftover drinks
could contain enough alcohol to incapacitate a small child
Management PrioritiesThe patient is in impending respiratory failure
because of alcohol ingestion.BLS:
Consider airway adjunct. (OPA)Prepare for bag-mask ventilation. Arrange for transport.
ALS:Check blood glucoseTreat documented hypoglycemia.Establish IV access.
Fluid bolus of 20 ml/kg or 10 ml/pound for dehydration Perform electronic monitoring.Consider intubation for airway protection if ALOC and
absent gag reflex.
Blood glucose is 30 mg/%.IV started on scene.10% Dextrose 1-2 ml/pound (2-4 ml/kg) IV
administered.Patient becomes somewhat more
responsive, but she remains sleepy.If problem was hypoglycemia alone she
should wake up quickly. She is depressed because of the sedative effects of alcohol. There is no antidote for alcohol
Case Progression
Key Concept: Hypoglycemia
Hypoglycemia is common complication of alcohol ingestion in young children.
If the patient is awake, ask the caregiver to give oral glucose (soda or juice).
If patient is not alert or the gag reflex is depressed, give 10% Dextrose IV.
Key Concept: Risk Assessment of Poisoning
Determine: The substance ingested. ToxicityDose ingested: mg toxin ingested per/kg
body weight. Time since exposure.
Call:Poison center (1-800-222-1222) or medical
oversight to help with risk assessment.
Key Concept: Ingestions by Toddlers
Toddlers frequently ingest household products: solvents, cosmetics, plants, and cleaning liquids.
Most ingestions in this age group involve single toxins.
Few ingestions require charcoal or any specific treatment.
Case Progression
En route: patient remains stable, with progressive improvement in the level of consciousness.
ED Course
In the ED: repeat blood glucose 58. IV glucose infusion started, electrolytes, blood gas, and blood alcohol level sent. Social work consult obtained to evaluate home safety.
Diagnosis: alcohol ingestion; hypoglycemiaOutcome: social work call to children’s
protective services (CPS) reveals an open case, with a past report of child neglect. Child is discharged the following day in the care of the maternal grandmother, pending CPS investigation.
Toddlers are highly susceptible to the metabolic effects of alcohol, particularly hypoglycemia.
Accidental ingestions peak in the 2- to 3-year age group.
Prevention of poisoning in the home requires constant vigilance by caregivers and multiple rounds of “childproofing!”
Scenario 3
You are dispatched at 2230 hours to a local tavern for an altercation
On arrival you find 32 year old Dale sitting at the bar with a bloody towel to his face.
What issues do you need to consider in this scene as you are approaching Dale?
Dale states he got “sucker punched” in the nose.
Police are on the way.The person who hit Dale has left the bar.
Initial Assessment
Mental Status: Dale is awake with slow measured speech
Airway: mouth is clear, but nose is grossly deformed and swollen with blood coming from both nostrils
Breathing: Unlabored at about 20/minuteCirculation: Face flushed, skin warm and sweaty.
Radial pulse strong and regular at 92/minuteChief Complaint: “I think that #&^* broke my nose”
SAMPLE
Signs/Symptoms: pain and swelling of the noseAllergies: noneMedications: nonePast Medical History: noneLast Meal: supper at about 6:30 p.m. and has been at
the tavern since about 8 p.m. He says he has had about 4 beers and 1 “Jack and coke”. (confirmed by bartender)
Events: Dale got into an argument with another patron and Dale got punched in the face. Bystanders state he did not lose consciousness
Head to Toe
Pupils equal and reactAlert to person, place, time and eventsNose is swollen and deformed with
bleeding from both nostrilsNo other injuries found: chest, abdomen,
arms, legs
BP 150/96Pulse 92/minuteRespirations 20/minuteOxygen saturation 94% room air
Refusal??
Dale says he doesn’t want to go to the hospital. He just wants to get in his truck and go home?
Can he do that?
Autonomy
All patients have the right of autonomy or the right to make decisions about their care.
A patient does not lose their right to autonomy simply because they have been drinking alcohol.
The challenge is to determine if the patient is competent to make these decisions.
EMS providers are familiar with the signs of alcohol intoxication:Diminished fine motor coordinationDecreased social inhibitions
As alcohol intoxication increasesImpaired judgementImpaired coordination, difficulty walkingAgitation and combativenessAltered mental stateSlurred speechWarm flushed skin
Quick Confusion Scale
A tool will soon be available to help providers determine how confused someone is due to alcohol.
Adapted from: Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: Comparison with the mini-mental state examination. Am J Emerg Med 2001;19:461-464
The Quick Confusion Scale
Item Scoring System
# Correct X weight = Total
What year is it now? 0 or 1 (score 1 if correct and 0 if incorrect)
2 =
What month is it? 0 or 1 2 =
Present memory phrase: “Repeat this phrase after me and remember it: John Brown 42 Market Street, New York.”
About what time is it? 0 or 1 2 =
Count backward from 20 to 1. 0, 1, or 2 1 =
Say the months in reverse. 0, 1, or 2 1 =
Repeat the memory phrase.(each underlined portion correct is worth 1 point)
0, 1, 2, 3, 4 or 5 1 =
Final score is the sum of the totals:
=
Explanation of Scoring for Quick Confusion Scale
The highest number in category indicates correct response; decreased scoring indicates increased number of errors
What year is it now? Score 1 if answered correctly, 0 if incorrect.
What month is it? Score 1 if answered correctly, 0 if incorrect.
About what time is it? Answer considered correct if within one hour: score 1 if correct, 0 if incorrect
Count backward from 20 to 1. Score 2 if correctly performed; score 1 if one error, score 0 if two or more errors
Say the months in reverse. Score 2 if correctly performed; score 1 if one error, score 0 if two or more errors
Repeat the memory phrase: John Brown 42 Market Street, New York.”
Each underlined portion correctly recalled is worth 1 point in scoring; score 5 if correctly performed; each error drops score by one.
Final Score is sum of the weighted totals; items one, two, and three are multiplied by 2 and summed with the other item scores to yield the final score.
Max score = 15. Score 11 likely cognitive impairment; score 7 = substantial impairment.
Irons MJ, Farace E, Brady WJ, Huff JS: Mental status screening of emergency department patients: Normative study of the Quick Confusion Scale. Acad Emerg Med 2002; 9:989-994.
What About Refusal?
Complete the refusal form.Explain the benefits of medical treatment and
the risk of refusing treatmentStrongly encourage Dale to seek treatmentIf he continues to refuse, contact Medical
Control.Involve local law enforcement to insure Dale is
safe.
Dale scores 12 on the confusion scale (he cannot repeat all of the memory phrase)
Dale’s speech is progressively more slurredHe was drinking when you arrived at the tavern
Local law enforcement help you encourage Dale to seek treatment.
Scenario 4
It is December 26 at 1330 hours.Bill has just arrived to visit his 88 year old
mother Emma. Bill is from out of town and has not seen his mother since August.
When she answered the door her gait was not steady. Bill helped her to her recliner and thought her speech was slurred and she was “dopey” so he called 911 thinking she has had a stroke.
Scene Size Up
Emma lives in a well kept house in an older neighborhood.
The house is clean and tidy but full of “collectables” and books.
Emma is sitting in a recliner in the living room. The table next to her has an empty glass and a wastebasket full of papers and other trash is next to the chair.
Initial Assessment
Mental Status: Emma is awake but slow to respond, with slightly slurred speech
Airway: Open and clearBreathing: Respirations easy and deep at
16/minute. Breath smells of peppermintOxygen saturation 93% room airCirculation: pulse is irregular at 88/minute, skin is
warm and dryChief Complaint: “I’m fine Sweetie, just a little
tired.”
SAMPLE
Signs/symptoms: unsteady gait and slurred speech
Allergies: morphineMedications: Vasotec 5 mg twice a day,
potassium 20 meq daily, Lipitor 30 mg daily, Micronase 5 mg daily, Aspirin 81 mg daily
Past Medical History: hypertension, high cholesterol and Type II diabetes
Last meal: Unknown for sure. Emma said she had lunch at 11:00 am
Events: Unknown
Head to Toe Exam
Pupils hard to evaluate due to cataracts.Mouth has green/blue discoloration of the
tongue, lips and tongue are dry.Chest has some congestionAbdomen softMultiple bruises on bilateral lower arms and
shinsAnkles have bilateral edemaBlood Sugar 280
FAST Assessment
Face – both sides move equallyArms – both arms raise equallySpeech – slurred, Emma giggles when
she has trouble speakingTime – Bill has not seen his mother since
August and has not talked to her on the phone for 2 days.
Your partner looks in the waste basket and finds 2 large bottles of blue mouthwash that are empty.
Emma tells you that she will admit she has been drinking more since her friend Betty died this fall because it makes her feel “happy”. She ran out of Tequila and the weather was bad, so she has been drinking mouthwash because it was in the house and it tastes better.
Mouthwash???
Ethanol is not only found in alcoholic beverages but is a main ingredient in mouthwash, over the counter cold medications (Nyquil™) and perfume.
Individuals who want to hide their ethanol intake or who are unable to obtain alcohol may drink other forms of ethanol.
Household ethanol is also a danger for accidental pediatric overdose.
Medical Side Effects of Ethanol
Poor control of diabetesHypertensionLiver diseaseStrokeCardiovascular disease
What are your concerns about Emma?How do you want to manage her care?
Management
BLS careMonitor airway and breathingOxygen by cannula to an O2 Saturation of 94%
ALS care IV access and fluid bolus (monitor lungs)EKG monitoring for dysrhythmias
Her monitor shows
What is this?What else does Bill need to consider
regarding his mother?
Bill needs to seek help to find other ways for his mother to deal with the loss of her friend other than drinking.
Scenario 5
Dispatched at 0730 hours For a middle aged woman who is “out of
her mind”
Scene Size Up
Upscale neighborhoodWell kept houseSmall barking dog is held by husband who
answers the door.
General Impression
Disheveled middle aged woman, Edie, sitting on kitchen floor
Hitting the floor with her slipperAppears very anxious and frightened
Initial Assessment
Mental Status: awake but is distracted and does not follow commands
Airway: open with very dry mucus membranes
Breathing: 28, deep and rapidCirculation: skin pale, cool and moist
Radial pulse fast, weak and threadyChief Complaint: “There are too many bugs”
Focused History
Allergies: codeineMedications:
Alprazolam 1 mg BIDInderal for blood pressureSynthroid 150 mg Ambien at nighttime for sleep
Past HistoryHypothyroidism“bad nerves”Social drinker (averages 2 bottles of
Chardonnay or other wine every evening)
Last Meal 24 hours ago
Events: Edie wanted to surprise her son for Christmas, so she quit drinking 2 days ago. She started feeling ill yesterday with feeling weak and no appetite. This morning Edie is shaky and confused. She says she sees black bugs all over the kitchen (no one else can see them). She feels them crawling all over her skin and she is trying to rub them off.
Focused Physical
VS: BP 100/60, P 120, R 28Pulse Ox: 94% on room air EtCO2 34Blood Sugar: 70Has trembling of armsRubs on arms and legs trying to brush off bugsRed raw abrasions on both armsPoor skin turgor, and dry mucus membranesVery poor attention span. Does not listen to you. Edie’s husband says “she’s lost it and has gone
crazy”
Cardiac Rhythm What is this?
Long Term Alcohol Abuse
General Alcoholic ProfileDrinks early in the day, alone, or secretly.Binges, blackouts, GI problems, chronic
flushing of face and palms.Cigarette burns, tremulousness, and odor of
alcohol.
Alcohol Abuse
Consequences of Chronic Alcohol Ingestion Poor nutrition Alcohol hepatitis Liver cirrhosis, pancreatitis Sensory loss in hands/feet Loss of balance and
coordination Upper GI hemorrhage Hypoglycemia Falls (fractures and
subdural hematoma)
Alcohol Withdrawal Syndrome
Alcohol (ethanol) withdrawal syndrome can begin as early as 6 hours after the fall of blood alcohol levels and usually peaks between 24 and 36 hours. It can take up to 5 days after the termination of drinking to resolve.
Delirium Tremens (DTs) is a life threatening manifestation of ethanol withdrawal characterized by tremors, hallucinations and hypovolemic shock. DTs appear in 48-96 hours and can persist up to 7 days.
Withdrawal Syndrome DTs
Signs & SymptomsCoarse tremor of hands, tongue, eyelidsNausea, vomiting, general weakness, anxietyTachycardia, sweating, Hallucinations – frightening or threatening visual
(seen) auditory (heard) and/or tactile (felt)
Signs and Symptoms cont.
Increased sympathetic tone -- seizures Orthostatic hypotension (BP drops when patient
stands up)OR hypertension Dehydration – hypovolemic shock Irritability or depressed mood, poor sleep
DTs are a serious medical
emergency!!
Alcohol Abuse
BLS TreatmentEstablish and maintain the airway.Determine if other drugs are involved.Prevent self harm. Be alert for seizuresDo not “buy into” the hallucinations
• Do not say that you see the hallucinations too• Do not tell Edie that there are no bugs there• Acknowledge that Edie is afraid and that she sees
bugs but that you can’t see them.
Treatment cont. ALSEstablish IV access.
• Replace fluids at 20 ml/kg for dehydration • 25g D50W if hypoglycemic or • 1-2 ml/pound (in 50 ml boluses) of D10W if hypoglycemic• Versed 0.1 mg/kg for shaking or seizures
Transport, maintaining a sympathetic attitude, and reassure the patient.
ReviewAnswer the following questions as a group.If doing this CE individually, please e-mail your
answers to:
[email protected] “December 2015 CE” in subject box.You will receive an e-mail confirmation. Print
this confirmation for your records, and document the CE in your PREMSS CE record book.
IDPH site code # 067100E1215
1. How does alcohol (ethanol) effect the body?
a. Hallucinogen
b. Stimulant
c. Sedative
d. Opiate
2. How does a person usually respond to low doses of alcohol?
a.
b.
3. How does a person usually respond to higher doses of alcohol?
a.
b.
c.
4. Why do people get warm when they drink?
5. Why do people wake up very thirsty after drinking alcohol?
6. Name some other emergency conditions that might be masked by alcohol intoxication?
a.
b.
c.
7. What specific medical problem occurs when children drink alcohol?
8. True/False Patients with alcohol on their breath lose all their ability to make decisions and must be transported to the hospital.
9. If a person has no access to alcohol, what other household items contain ethanol and can be used to get intoxicated?
10.Why are DTs dangerous?
Answers
1. How does alcohol (ethanol) effect the body?
a. Hallucinogen
b. Stimulant
c. Sedative
d. Opiate
2. How does a person usually respond to low doses of alcohol?
a. depression of inhibitions
b. aggressive or inappropriate behavior
3. How does a person usually respond to higher doses of alcohol?
a. dulled sense of awareness
b. decreased coordination
c. decreased reaction time
stupor and coma
4. Why do people get warm when they drink?
Alcohol ingestion causes peripheral vasodilation which increases sense of being warm and loss of body heat
5. Why do people wake up very thirsty after drinking alcohol?
Alcohol is dehydrating and increases removal of water through urination.
6. Name some other emergency conditions that might be masked by alcohol intoxication?
a. head injury
b. low blood sugar
c. infection
seizures/ post ictal state
hypoxia
7. What specific medical problem occurs when children drink alcohol?
hypoglycemia (low blood sugar)
8. True/False Patients with alcohol on their breath lose all their ability to make decisions and must be transported to the hospital. False
9. If a person has no access to alcohol, what other household items contain ethanol and can be used to get intoxicated?
mouthwash, perfume, liquid cold medicine
10. Why are DTs dangerous?
DTs can lead to seizures, hypotension and hypovolemic shock.