Acute Alcohol Intoxication (Slide 1)

Roberta Agabio

Prepared for the Alcohol Medical Scholars Program

 

 

I. Introduction (Slide 2)

            A. Alcohol use is common1

1. 90% ever drink in most countries

2. ~14% develop severe problems                           

            B. Most drinkers become intoxicated at times

1.  This can be dangerous

2.  Few people understand those dangers

            C. Intoxication dangers include2

1.   Accidents

a. ~50% car accidents related to alcohol

b.  Same for ~30% fatal car accidents

                        2. ~10% E.R. patients have alcohol problems

                        3. Violence

4. Impaired judgement and mood

                        5. Resulting in illness, lost work and death

            D. This lecture reviews details for alcohol intoxication including (Slide 3)

1.  The class of drugs where alcohol fits

2.  Alcohol's brain effects

3.  Signs and symptoms of intoxication

4.  Evaluation and treatment

5.  Unhealthy alcohol consumption       

II. Alcohol is a depressant drug3

            A. Drugs go into categories based on usual effects (Slide 4)

1. Depressants

2. Stimulants

3. Opioids

4. Cannabinols

5. Hallucinogens

6. Inhalants

7. Others

            B. Other depressant drugs include all prescription sleep meds (Slide 5)
                        1. Benzodiazepines (e.g., diazepam or Valium)

2. Benzodiazepine-like meds (e.g., zolpidem or Ambien)   

3. Barbiturates (e.g., secobarbitol or Seconal)

                        4. Others (e.g., chloral hydrate or Noctec)

            C. Clinical effects of depressants (Slide 6)

1. ↓ Anxiety

2. ↑ Sleep

3. Muscle relaxation

4. Anesthesia (deep and possibly dangerous sleep)

5. ↓ Seizure occurrence/severity 

D. Dangers of depressants

1. Sedation when drive

2. Impaired memory

3. Impaired motor coordination

4. Drug interactions (e.g., dangers if mix with opioids)

5. Potential for misuse (abuse and dependence- will define later)

6. Intoxication (Slide 7)

a. Medical problems (↓ vital signs, come, risk of death)

b. Temporary psychiatric syndromes

. Cognitive disorders (e.g. severe confusion)

. Psychosis (e.g., hear voices + paranoid thoughts without insight)

. Depression when use and anxiety when stop

III. How alcohol impacts on the brain4 (Slide 8)

A. Acute use interaction with the majority of brain neurotransmitters

a. ↑ Dopamine transmission of the reward brain system → pleasurable effects

(Slide 9: Image of the reward brain system)

b. ↑ Inhibition & ↓ excitation neurotransmissions → (Slide 10: Tables 1 and 2)  

. ↓ Anxiety

. ↑ Sedation

. Muscle relaxation

. Intoxication   

B. Chronic use → opposite changes in most neurotransmitter systems4

1. Tolerance (Slide 10: Table 3)  

a. ↓ Effects with the same dose or

b. Need ↑ dose to get same effect

2. Withdrawal syndrome when alcohol use is reduced or interrupted

(Slide 10: Table 4)

a. ↑ Anxiety, insomnia, pulse

b. Opposite of intoxication

C. Acute effects depend on the blood alcohol concentration (BAC)5 (Slide 11)

1. Standard drink ~10-14g alcohol = 355ml beer, 120ml wine, or 44ml gin

2. 1 drink BAC ~15mg% (mg alcohol/100ml blood, equivalent to 0.015 g/dl)

3. Factors that ↑ BAC

a. ↑ Number of drinks

b. Female gender

c. ↓ Body weight

d. Consumption without food

D. BAC's and usual effects are6 (Slide 12):

1. 15-50mg% (1-3 drinks)= begin feel intoxication          

a. Relaxation, feelings of well-being

b. ↓ Inhibition

c. Outgoing behaviors

d. ↓ Alert, judgement, memory, and reasoning

2. 50-100mg%= ↑ ing motor impairment and sleepiness

a. ↑ Euphoria and pleasure

b. Nausea

c. ↑ Sleepiness

d. ↓ Coordination and ↑ reaction time

3. 100-200mg%= intoxication may induce memory impairment 

a. Anger

b. Moody

c. ↑ Confusion

d. Impaired reasoning

e. Nausea and vomiting

f. Inappropriate social behaviour

g. Severely impaired judgement

h. Severe memory impairment, blackouts (forget all or part of an evening)

4. 200-300mg%=  difficult to awaken 

a. ↑ Aggression

b. ↑ Depression

c. ↓↓ Balance

d. Disorientation

e. Loss of consciousness, stupor

e. ↑↑ Nausea and vomiting

5. > 300mg% can → death

a. Loss of bladder control

b. Difficult breathing

c. Slowed heart rate

d. Unconsciousness, coma, potential death

6. For each value, level of impairment is higher at rising BAC than at falling one

IV. Signs and symptoms of acute alcohol intoxication (Slide 13)

A. DSM-4 definition of acute alcohol intoxication7 (Slide 14)

1. Recent ingestion

2. Behavior changes (e.g. aggression)

3. One or more:

a. Slurred speech

b. Incoordination

c. Unsteady gait

d. Nystagmus (eyes snap back to middle in lateral gaze)

e. Impaired attention or memory

f. Stupor or coma

4. Symptoms not due to other conditions

B.  Medical problems with acute alcohol intoxication3 (Slide 15)

                        1. ↓Vital signs

a. Body temperature

b. Respiratory rate

c. Blood pressure

                        2. Risk of death

a. Alcohol alone: ↑ 300 mg% BAC → potential death

b. Combination with opioids or other depressants: ↑ risk of death

            C. Psychiatric syndromes with acute alcohol intoxication3 (Slide 16)

1.  Cognitive problems (e.g., confusion) (Slide 17)

a. Symptoms

. Confusion, fluctuating alertness, disorientation

. ↓ Judgment, memory, and performance

b. Before you Dx, must rule out (R/O)

. Intoxication from other drugs

a’. Other depressants

b’. Atropine-type drugs (e.g.,  benztropine or Cogentin)

c’. Inhalants (e.g., gasoline)

. Withdrawal from depressants

a’. ↑ Pulse, blood pressure, etc.

b’. ~ 1% very confused (withdrawal delirium)

. Medical problems (e.g., diabetic coma)

. Psychiatric disorders (e.g., dementia)

c. Course of cognitive problems usually benign

. Symptoms disappear within hours to days

. ↑ Severity and duration in/if

a’. Older people

b’. Prior brain damage

2. Psychosis (e.g., hear voices, paranoid thoughts without insight) (Slide 18)

a. ~ 3% with alcohol dependence

b. Define only if seen outside withdrawal delirium

c. Symptoms

. Suspiciousness/paranoia without insight

. Auditory (visual, or tactile) hallucinations

d. Rule out

.  Stimulant (amphetamine or cocaine) psychosis

. Preexisting psychiatric disorders (e.g. schizophrenia)

e. Course usually benign: symptoms disappear within 1 month of abstinence

3.  Depression (Slide 19)

a. Symptoms: sad all day, every day for 2+ weeks

b. Can be suicidal

c. Rule out

. Intoxication with other depressants

. Stimulant withdrawal

. Psychiatric disorders unrelated to substances (e.g., major depression)

d. Lasts as long as heavy drinking continues

e. Likely gone in < 1 month abstinence

4. Major anxiety syndromes

a. Meet criteria for panic disorder, social phobia, etc.

b. Define only if seen outside alcohol withdrawal

c. Rule out

. Withdrawal from other depressants

. Stimulant intoxication

. Panic, social phobia, etc unrelated to substances

d. Likely gone in < 1 month abstinence

V. Evaluation & treatment of acute alcohol intoxication conditions3 (Slide 20)

A. Evaluation (Slide 21)

1. Evaluate medical problems and/or use of other drugs

a. From the patient

b. From other persons

2. Smell of alcohol

3. Observe DSM-IV signs & symptoms of acute alcohol intoxication

4. Laboratory tests to exclude other causes (e.g., blood sugar)

5. Toxicological screen (blood or urine) for alcohol and other drugs (Slide 22)

a. Measure blood concentration of alcohol (BAC) & other drugs

. BAC: 300 mg% BAC → potential death

. BAC ↓ by ~15 mg% per hour

. Concomitant use of opioids or other depressants: ↑ risk of death

b. How to do:

. Draw blood sample 

a’. 10 cc for  toxicological screen

b’. 30-40 cc for blood count, electrolytes, etc.

c’. E.g. of  blood toxicology levels

1’’. Diazepam (Valium): ≥0.5 mg/dl

2’’. Meperidine (Demerol): ≥100-500 g/dl

3’’. Phenobarbital: ≥3-10 mg/dl

. Collect urine sample

a’. Catheterize bladder if needed

b’. Send 50 ml  urine for toxicological screen

B. Rule out other serious life-threatening problems (Slide 23)

1. Bleeding

2. Shock

3. Electrolyte (sodium, potassium, etc.) disturbances

4. Cardiac disorders (e.g., beating irregularities)

5. Infections

6. Consequences of accidents with brain trauma

C. Test for blood sugar (Slide 24)

1. Use a fingerstick

2. If blood sugar is : administer 50 cc of 50% glucose IV

3. 100 mg thiamine (vitamin B1) IV or IM if suspect its deficiency

D. Medical treatment of severe alcohol intoxication

1.  Unstable or serious ↓ vital signs = EMERGENGY PROBLEM (Slide 25)

a.   Support vital signs until alcohol has been metabolized (Slide 26)

. Measure vital signs frequently

a’. Every 15 min for the first 4 h

b’. Every 2-4 h over the next 24-48 h

. Address life-threatening problems = ABCs of emergency care

a’. Airway and Breathing: assure adequate ventilation (Slide 27)

1’’. Straighten head (if no neck injury)

2’’. Remove obstructions in mouth 

3’’. Intubate if needed

4’’. Use  respirator if needed (10-12 breaths per min)

b’. Circulation: maintain adequate blood pressure (Slide 28)

1’’. Start  IV line

2’’. Use  large-gauge needle

3’’. Use a slow drip until you know if need fluids

b. Do not prescribe meds until are sure are needed

2. If ingestion of other drugs (e.g., opioids) (Slide 29)

a. Recent oral ingestion: to absorption

. Consider inducing vomiting if patient

a’. Awake and cooperative patients

b’. Stable pulse

c’. How to do:

1’’. Administer ipecac syrup (10-30 mg, orally)

2’’. If vomiting does not occur

3’’. Repeated ipecac syrup once in 15-30 min

. If emesis not work, consider gastric lavage if patient

.  Not awake and cooperative 

. Took drugs within 12 h

c’. NOT take  corrosives, kerosene, strychnine, or mineral oils

d’. If comatose: ONLY after intubation

e’. How to do: (Slide 30)

1’’. Use nasogastric tube

2’’. Place patient on  left side

                                                        3’’. Place  head slightly over the edge of the table

                                                        4’’. Then evacuate  stomach

5’’. Give an isotonic saline lavage until fluid clear

6’’. Repeat lavage up to 10-12 times

7’’. Save  sample of washings for drug analysis

. Consider giving activated charcoal

a’. 1 g/Kg or more in water

b’. Administered every 4 h

b. In case of ingestion of  specific drugs: (Slide 31)

. Opioids: consider  antidote: naloxone (Narcan)

a’.  0.2-0.4 mg (1 ml) IM or IV

b’. If no improvement, repeat same dose in 3-10 min

c’. If effective, repeat every 30 min (short half-life) 

d’. If not available, use nalorphine (Nalline): 3-5 mg IV

e’. Monitor possible opioid abstinence syndrome

. BDZ: consider the antidote flumazenil (Romazicon)

a’: Dose: 0.2 mg IV

b’. Repeat every min up to 3 mg until sedation reverses  

c’. If effective, repeated in 20-30 min (short half-life)

d’. Monitor possible seizures and/or ↑ intracranial pressure

. Atropine-like drugs: physostigmine 1-4 mg, by slow IV

. Barbiturates:

a’. Consider forced diuresis

1’’. Furosemide (Lasix): 40-120 mg IV

2’’. Repeat as often as needed to maintain 250 ml/hour

3’’. IV fluids (saline and water with glucose)  

b’. Consider alkalinization of urine

1’’. Bolus of 1-2 mEq/kg of sodium bicarbonate

2’’. 50-100 mEq of sodium bicarbonate added to 500 ml of a 5% dextrose solution

 3. Observe the patient in a safe place until he/she gets sober

4. Provide appropriate nutrition

           E. Treatment of aggressive behaviour or psychiatric syndromes (Slide 32)

1. Aim: protect patient until psychiatric symptoms resolve

2. Offer reassurance on temporary nature of psychiatric symptoms

3. Most  psychiatric symptoms/aggression improve within 1 month

4. Consider inpatient to protect patient from harming her/himself of others

a. From acting out delusions

b. From acting out suicidal plans

c. If can’t take care of him/herself

5. Observe and provide general support

6. Do not prescribe meds until are sure are needed

7. Relevant psychiatric symptoms must be addressed

a. For aggressive patients

Consider a forced intervention (show of force and isolation)

. If it does not work, consider pharmacological sedation

a’. Short-acting BDZ

1’’. Lorazepam 1-2 mg PO or IV

2’’. Repeat if needed

b’. Antipsychotic meds

1’’. Haloperidol (Haldol) 0.5-5 mg PO or IM

2’’. Repeat every 4-8 as needed

3’’. Or Olanzapine (Zyprexa) 2.5-10 mg IM

4’’. Repeated at 2 and 6 h if needed   

c’. Take care of possible synergic sedative effects

b. For hallucinations and/ or delusions, consider antypsychotic meds

. Haloperidol (1-5 mg/day per mouth)

. Risperidone (1-3 mg/twice a day per mouth)

. Until delusions/hallucinations resolve (2-4 weeks)

c. For depressive syndromes, antidepressants are not indicated

. Depressive symptoms usually gone within 4 weeks of abstinence

. Antidepressants may require 2-4 weeks before working

. Antidepressant effects may start when depressive symptoms are gone

VI.  Unhealthy alcohol consumption (Slide 33)

A. Consider  in all patients11

B.  Definitions (Slide 34)

1. Unhealthy alcohol consumption11

a. Alcohol dependence or alcohol abuse

b. At-risk drinking

2. Alcohol Abuse: 1 or more recurrent in same  12 months7 (Slide 35)

a. ↓ Ability fulfill role obligation

b. Use in hazardous situations

c. Legal problems

d. Social or interpersonal problems

e. Never dependent

3. Alcohol Dependence: 3 or more recurrent in same 12 months7

a. Tolerance (need ↑ dose to get same effect)

b. Withdrawal (↑ anxiety, insomnia, pulse---opposite of intoxication)

c. Use longer or higher doses than intend

d. Desire to cut down

e. ↑ Time spent on alcohol-related activities

f. Activities ↓ due to alcohol use

g. Ongoing use despite consequences

4. At-risk drinking11 (Slide 36)

a. Weekly alcohol consumption

. Men: >14 drinks

. Women: >7 drinks

b. Alcohol consumption per occasion

. Men: ≥ 5 drinks

. Women: ≥ 4 drinks

            C. Tools to detect subjects with unhealthy alcohol consumption3

1. Ask patient drinks per occasion and per week (Slide 37)

2. Blood markers of heavy drinking

a. MCV (mean corpuscular volume)

. > 90 cubic microns

. Accuracy: adequate (not great)

b. GGT (gamma glutamyltransferase)

. > 35/30 U/l (men/women)

. Accuracy: very good

c. CDT (carbohydrate deficient transferrin or %CDT)

. > 2.0/2.6 U/l (men/women)

. Accuracy: very good

d. ALT (alanine aminotransferase)

 . > 46/35 U/l (men/women)

Accuracy: not sensative unless liver affected

e. AST (aspartate aminotransferase)

. > 40/33 U/l (men/women)

. Accuracy: same as ALT

f. Uric acid

. > 8.0/6.2 mg/dl (men/women)

. Accuracy: fair

3. Questionnaires (Slide 38)

a. CAGE

. 4 questions: Have you ever:

a’. Felt the need to Cut down on drinking?

b’. Felt Annoyed by criticising about drinking?

c’. Felt Guilty about drinking?

d’. Needed a drink on awakening (Eye-opener)?

. Score to suspect alcohol dependence: 1+ positive answer

b.   AUDIT (Alcohol Use Identification Test)

. 10 items about

a’. Alcohol consumption

b’. Drinking behavior

c’. Alcohol-related problems

. Scores from 0 to 40

. Score to suspect at-risk drinkers12

a’. Men: ≥ 8

b’. Women: ≥ 4

D. How to help  (Slide 39)

1. For alcohol dependence or alcohol abuse3

a. First step: intervention (Slide 40)

. Aims: help patients to

a’. Recognize their problems

b’. ↑ Motivation to change

c’. ↓ Future difficulties  

. Tools (Slide 41)

a’. Motivational interview: FRAMES

1’’. Feedback: address concerns about use
2’’. Responsibility: change is up to patient
3’’. Advice: give specific goals

4’’. Menu: offer alternatives to advice
5’’. Empathy
6’’. Self-efficacy

b’. Brief intervention

1’’. Educate about consumption  
2’’. Emphasize dangers of heavy drinking

3’’. Suggest how to ↓ alcohol consumption

4’’. Help to avoid risky situations

. Duration of sessions: 15-30 min

b. Second step: detoxification, if needed (Slide 42)

. ~ ½ patients develop relevant withdrawal symptoms

a’. Brain has adapted to  presence of  depressant drug

b’. Cannot function adequately without the drug

. Education and reassurance that symptoms temporary

. Pharmacological treatment

a’. Oral multivitamins (including thiamine: up to 800 mg/day)

b’. Benzodiazepines for  ~ 1 week

1’’. Short-acting drugs (e.g., lorazepam or Ativan)

2’’. Long-acting drugs (e.g., chlordiazepoxide or Librium)

a’’. Day 1: chlordiazepoxide 25 mg every 4-6 hours
b’’. Day 2:
↓ dose of ~20% (20 mg every 4-6 hours)

c’’. Day 3: ↓ dose of ~20% (15 mg every 4-6 hours)

d’’. Day 4: ↓ dose of ~20% (10 mg every 4-6 hours)

e’’. Day 5: ↓ dose of ~20% (5 mg every 4-6 hours)

f’’. Day 6: no further meds

c. Third step: rehabilitation (Slide 43)

. Aims: help patients to

a’. Keep motivation high

b’. Develop  lifestyle free of alcohol

c’. ↓ Risk of relapse  

. Setting

a’. Inpatients or residential-based care

1’’.  For more severe alcohol problems
2’’. For additional severe med or psych problems

3’’. Gives better outcome

4’’. More expensive

b’. Outpatients 

1’’. Indicated for less severe alcohol problems
2’’. Often successful

3’’. Less expensive

. Rehab to change cognition and behavior

a’. Counseling

1’’. Individual/group/family sessions

2’’. Cognitive-behavioural steps: help  

a’’. Change thinking about alcohol
b’’. Change thinking on alcohol  role in lives

c’’. Learn new behaviours

d’’. Avoid relapses

b’. Self-help groups (e.g., Alcoholics Anonymous)

1’’. Offers support
2’’. Emphasizes change

3’’. Helps  rebuild life without alcohol

4’’. ↓ Use of more expensive care

. Pharmacotherapy12 (Slide 44)

a’. Disulfiram (Antabuse)

1’’. Dose: 250 mg/day

2’’.  Oral

3’’. 1 per day

4’’. Mechanism of action: fear of get sick if drink

a’’. Alcohol is metabolized to acetaldehyde

b’’ Acetaldehyde metabolized by aldehyde dehydrogenase

c’’. Med inhibits aldehyde dehydrogenase

d’’. If person drinks

1’’’. Acetaldehyde ↑

2’’’. → Vomit and feel sick

5’’. Patients should avoid alcohol because of fear

6’’. Main disadvantage: poor compliance

7’’. Better if take under supervision (e.g., by spouse)

b’. Oral naltrexone (ReVia)

1’’.  50-150 mg per day

2’’.  Oral

3’’.  1 per day

4’’. Mechanism of action: 

a’’. Alcohol release of endogenous opioids

b’’. Endogenous opioids induce pleasant effects

c’’. Med is an opioid antagonist

d’’. Med ↓ pleasant effects of drinking

5’’. Main disadvantage: poor compliance

c’. Extended-release naltrexone (Vivitrol)

1’’.  380 mg per month

2’’.  IM

3’’.  1 per month

4’’. Main advantage: optimizes compliance

5’’. Main disadvantage: more expensive

d’. Acamprosate (Campral)

1’’.  2,000 mg per day

2’’.  Oral

3’’. Dived dose into 3 per day

4’’. Action:  ↓ glutamate hyperactivity

2.  For non-dependent subjects who need to cut back11

a. Aims: Help patients ↓ drinking to moderate limits

b. Tools: brief intervention (as explained before)

3. Efficacy of treatments3,11

a.   Medical treatment is effective in ~50% of alcohol dependent patients

b.  Brief interventions ↓ alcohol consumption of at-risk drinkers13

IX. Summary (Slide 45)

            A. Topics reviewed

1. Main features of alcohol and other depressants

2. Signs and symptoms of acute alcohol intoxication

3. Psychiatric symptoms induced by acute alcohol intoxication

4. Treatment of acute alcohol intoxication

5. Unhealthy alcohol use

            B. Take-home message on acute alcohol intoxication (Slide 46)

1. Acute alcohol intoxication may be  life-threatening

2. Concomitant use of other depressants ↑ risk of death

3. Acute alcohol intoxication may → temporary psychiatric syndromes

4. Treatment of severe intox: support vital signs until

a. alcohol has been metabolized

b. psychiatric symptoms disappear

5. Unhealthy alcohol consumption should be evaluated and discouraged  

     

References:

 

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9.  Pechlaner C, Joannidis M, Wiedermann C (2000). Acute alcohol intoxication. In: Handbook of alcoholism. Zernig G, Saria A, Kurz M, O’Malley SS (eds). CRC Press, Boca Raton, FL, USA; 49-64.

 

10.  Saitz R (2005). Clinical practice. Unhealthy alcohol use. N Engl J Med. 352:596-607.

 

11.  National Institute on Alcohol Abuse and Alcoholism and National Institute of Health (2005). Helping Patients Who Drink Too Much. Department of Health and Human Services, Public Health Service, National Institutes of Health, www.niaaa.nih.gov

 

12.  Garbutt JC (2009). The state of pharmacotherapy for the treatment of alcohol dependence. J Subst Abuse Treat. 36(1):S15-S23.

 

13. Kaner E, Beyer F, Dickinson H, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B (2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. (2):CD004148.