Page 234 - TNFlipTest

ER54 Emergency Medicine
Toxicology
Toronto Notes 2019
Alcohol levels correlate poorly with intoxication
Alcohol intoxication may invalidate informed consent
Common Deficiencies
• Thiamine
• Niacin
• Folate
• Glycogen
• Magnesium • Potassium
CIWA Withdrawal Symptoms
• N/V
• Tremor
• Paroxysmal sweats
• Anxiety
• Agitation
• Visual disturbances
• Tactile disturbances
• Auditory disturbances
• Headache
• Disorientation
10 symptoms each scored out of 7 except orientation, which is scored out of 4
Alcohol Related Emergencies
• seePsychiatry,PS23
Acute Intoxication
• slurredspeech,CNSdepression,disinhibition,lackofcoordination • nystagmus,diplopia,dysarthria,ataxia,mayprogresstocoma
• hypotension(peripheralvasodilation)
• ifobtunded,ruleout
■ head trauma/intracranial hemorrhage ■ associated depressants,, toxic alcohols
◆ may also contribute to respiratory/cardiac depression ■ hypoglycemia (screen with bedside glucometer)
■ hepatic encephalopathy: confusion, altered LOC, coma
◆ precipitating factors: GI bleed, infection, sedation, electrolyte abnormalities, protein meal ■ Wernicke’s encephalopathy (ataxia, ophthalmoplegia, delirium)
■ post-ictal state, basilar stroke
Withdrawal
• bewareofwithdrawalsigns • treatment
■ diazepam10-20mgIV/POorlorazepam2-4mgIV/POq1huntilcalm
◆ frequency of dosing may have to be increased depending on clinical response
■ may use CIWA protocol and give benzodiazepines as above until CIWA <10 ■ thiamine 100 mg IM/IV then 50-100 mg/d
■ magnesium sulfate 4 g IV over 1-2 h (if hypomagnesemic)
■ admit patients with delirium tremens or multiple seizures
Table 35. Alcohol Withdrawal Signs
Time
6-8 h 1-2 d 8 h-2
3-5 d
Since Last Drink
d
Syndrome
Mild withdrawal Alcoholic hallucinations Withdrawal seizures
DT
Description
Generalized tremor, anxiety, agitation, but no delirium Autonomic hyperactivity (sinus tachycardia), insomnia, N/V
Visual (most common), auditory, and tactile hallucinations Vitals often normal
Typically brief generalized tonic-clonic seizures May have several within a few hours
CT head if focal seizures have occurred
5% of untreated withdrawal patients
Severely confused state, fluctuating LOC
Agitation, insomnia, hallucinations/delusions, tremor Tachycardia, hyperpyrexia, diaphoresis
High mortality rate
Cardiovascular Complications
• HTN
• cardiomyopathy: SOB, edema
• dysrhythmias(“holidayheart”)
• AFib(mostcommon),atrialflutter,SVT,VTach(especiallyTorsadesifhypomagnesemic/hypokalemic)
Metabolic Abnormalities
• alcoholicketoacidosis
■ antigen metabolic acidosis, urine ketones, low glucose, and normal osmolality
■ history of chronic alcohol intake with abrupt decrease/cessation
■ malnourished, abdominal pain with N/V
■ treatment: dextrose, thiamine (100 mg IM/IV prior to dextrose), volume repletion (with NS) ■ generally resolves in 12-24 h
• otheralcohols
■ ethylene glycol: CNS, CVS, renal findings
■ methanol
◆ early: lethargy, confusion
◆ late: headache, visual changes, N/V, abdominal pain, tachypnea
■ both ethylene glycol and methanol produce severe metabolic acidosis with anion gap (as the alcohol
is metabolized) and osmolar gap (initially after ingestion but before metabolism)
■ EtOHco-ingestionisprotective