Acute Alcohol Intoxication AAI Roberta Agabio M D

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Acute Alcohol Intoxication (AAI) Roberta Agabio, M. D. Department of Biochemical Sciences Section of Acute Alcohol Intoxication (AAI) Roberta Agabio, M. D. Department of Biochemical Sciences Section of Neuroscience University of Cagliari, Italy © AMSP 2012 1

Alcohol Use & Problems • 90% Ever drink • 14% Drinkers have 1+ problem: Alcohol Use & Problems • 90% Ever drink • 14% Drinkers have 1+ problem: Accidents Violence Mood swings Physical illness © AMSP 2012 2

AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 3

Drug Classes Based on Effects • Depressants • Hallucinogens • Stimulants • Inhalants • Drug Classes Based on Effects • Depressants • Hallucinogens • Stimulants • Inhalants • Opioids • Others • Cannabinols © AMSP 2012 4

Depressants Include Class Benzodiazepines Bz-like meds Barbiturates Others Example Diazepam Zolpidem Secobarbital Chloral hydrate Depressants Include Class Benzodiazepines Bz-like meds Barbiturates Others Example Diazepam Zolpidem Secobarbital Chloral hydrate Alcohol © AMSP 2012 5

Effects & Dangers Effects ↓ Anxiety Anesthesia ↑ Sleep ↓ Seizures Muscle relaxation Dangers Effects & Dangers Effects ↓ Anxiety Anesthesia ↑ Sleep ↓ Seizures Muscle relaxation Dangers Sedation Drug interact ↓ Memory Dependence ↓ Coordination Intoxication © AMSP 2012 6

Intoxication Medical problems ↓ Vital signs, coma, risk of death Temporary psychiatric syndromes Cognitive Intoxication Medical problems ↓ Vital signs, coma, risk of death Temporary psychiatric syndromes Cognitive disorders Psychosis Depression Anxiety © AMSP 2012 7

AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects Alcohol’s 3) AAI AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects Alcohol’s 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 8

Reward Brain System Alcohol ↑ dopamine transmission → Pleasurable effects © AMSP 2012 9 Reward Brain System Alcohol ↑ dopamine transmission → Pleasurable effects © AMSP 2012 9

Alcohol's Brain Effects 1. Homeostasis 2. Acute use ALCOHOL Inhibition on tati ci Ex Alcohol's Brain Effects 1. Homeostasis 2. Acute use ALCOHOL Inhibition on tati ci Ex Excitation on i ibit h In 3. Chronic use (tolerance) ALCOHOL 4. Withdrawal OPPOSITE CHANGES Inh ibit OPPOSITE CHANGES ion Inhibition Excitation Exc itat © AMSP 2012 ion 10

Blood Alcohol Concentration (BAC) • Standard drink = ~12 g alcohol • 1 drink Blood Alcohol Concentration (BAC) • Standard drink = ~12 g alcohol • 1 drink → BAC = ~15 mg% (0. 015 g/dl) • ↑ BAC with: • Female • ↓ Weight • Drink without food © AMSP 2012 11

BAC’s Effects BAC (mg%) Effects > 300 ↓ Vital signs, coma, death ≤ 300 BAC’s Effects BAC (mg%) Effects > 300 ↓ Vital signs, coma, death ≤ 300 Difficulty to awaken ≤ 200 Anger, moody, confusion ≤ 100 Sleepiness, ↓ coordination ≤ 50 (1 -3 drinks) Well-being, ↓ inhib © AMSP 2012 12

AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 13

Definition of AAI (DSM-IV) Recent ingestion Behavior changes (e. g. aggression) 1+ Slurred speech Definition of AAI (DSM-IV) Recent ingestion Behavior changes (e. g. aggression) 1+ Slurred speech ↓ Coordination Unsteady gait Nystagmus ↓ Attention or memory Stupor or coma © AMSP 2012 Nystagmus 14

AAI Medical Problems ↓ Vital signs • Body temperature • Respiratory rate • Blood AAI Medical Problems ↓ Vital signs • Body temperature • Respiratory rate • Blood pressure ↑ Risk of death • BAC > 300 mg% • Opioids or other depressants © AMSP 2012 15

AAI Temporary Psychiatric Symptoms Cognitive problems Psychosis Depression and/or anxiety © AMSP 2012 16 AAI Temporary Psychiatric Symptoms Cognitive problems Psychosis Depression and/or anxiety © AMSP 2012 16

AAI Cognitive Problems Confusion ↓ Memory ↨ Alertness ↓ Judgment Disorientation © AMSP 2012 AAI Cognitive Problems Confusion ↓ Memory ↨ Alertness ↓ Judgment Disorientation © AMSP 2012 17

AAI Psychosis Suspiciousness Hallucinations Paranoid thoughts All without insight © AMSP 2012 18 AAI Psychosis Suspiciousness Hallucinations Paranoid thoughts All without insight © AMSP 2012 18

AAI Depression Sad all day Every day for 2+ weeks Can be suicidal AAI AAI Depression Sad all day Every day for 2+ weeks Can be suicidal AAI Anxiety Syndromes Meet criteria for anxiety disorders (e. g. , panic disorder) © AMSP 2012 19

AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 20

AAI Evaluation • Other med/psych illness • Other intox/withdrawal • Smell of alcohol • AAI Evaluation • Other med/psych illness • Other intox/withdrawal • Smell of alcohol • AAI signs & symptoms • Laboratory tests • Toxicological screen © AMSP 2012 21

Toxicological Screen Check BAC & use of other drugs • BAC > 300 mg% Toxicological Screen Check BAC & use of other drugs • BAC > 300 mg% → potential death • BAC ↓ by ~15 mg%/h • Opioids or other depressants ↑ risk How to do • Draw ~ 50 cc blood sample • Collect ~ 50 ml urine sample © AMSP 2012 22

Rule Out Other Problems Bleeding Shock Electrolyte disturbances Cardiac disorders Infections Consequences of brain Rule Out Other Problems Bleeding Shock Electrolyte disturbances Cardiac disorders Infections Consequences of brain trauma © AMSP 2012 23

Test for blood sugar Use a fingerstick If ↓ administer • 50 cc of Test for blood sugar Use a fingerstick If ↓ administer • 50 cc of 50% glucose IV & • 100 mg vit. B 1 (IV or IM) if needed © AMSP 2012 24

Medical Treatment If↓vital signs = EMERGENGY PROBLEM © AMSP 2012 25 Medical Treatment If↓vital signs = EMERGENGY PROBLEM © AMSP 2012 25

Support Vital Signs Measure vital signs frequently Address life-threatening problems = ABCs Of Emergency Support Vital Signs Measure vital signs frequently Address life-threatening problems = ABCs Of Emergency Care • Airway • Breathing • Circulation NO MEDS until are sure they are needed © AMSP 2012 26

Airway & Breathing Assure adequate ventilation • Straighten head (if no neck injury) • Airway & Breathing Assure adequate ventilation • Straighten head (if no neck injury) • Remove obstructions in mouth • If needed intubate • Use respirator (~12 breaths/min) © AMSP 2012 27

Circulation Maintain adequate blood pressure • Start IV line • Use large-gauge needle • Circulation Maintain adequate blood pressure • Start IV line • Use large-gauge needle • Use a slow drip until know if need fluids © AMSP 2012 28

Other Drugs: ↓ Absorption Inducing vomiting (oral ipecac syrup) Patient awake & stable pulse Other Drugs: ↓ Absorption Inducing vomiting (oral ipecac syrup) Patient awake & stable pulse Gastric lavage Patient not awake Took drugs within 12 h Not corrosive, kerosene, strychnine, oils If comatose, only© after intubation AMSP 2012 29

Gastric Lavage: How to do • Nasogastric tube • Patient on his/her left side Gastric Lavage: How to do • Nasogastric tube • Patient on his/her left side • Head slightly over the edge of the table • Evacuate stomach • Isotonic saline lavage until fluid clear • Repeat up to 10 -12 times • Sample of washings for drug analysis © AMSP 2012 30

Specific Drugs: Antidotes Opioids → naloxone Monitor possible opioid abstinence syndrome BDZ → flumazenil Specific Drugs: Antidotes Opioids → naloxone Monitor possible opioid abstinence syndrome BDZ → flumazenil Monitor possible seizures & ↑ intracran press Atropine-like drugs→ physostigmine Barbiturates → No antidote Forced diuresis & alkalinization of urine © AMSP 2012 31

AAI Psychiatric Symptoms Medical Treatment Protect & reassure Should improve < 1 month Consider AAI Psychiatric Symptoms Medical Treatment Protect & reassure Should improve < 1 month Consider inpatient Observe & provide general support Meds should be avoided BDZ or antipsyc meds for sedation No antidepressants 2012 © AMSP 32

AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 33

Unhealthy Drinking 1) Alcohol Abuse and Dependence k 2) At-risk Drinking Consider this in Unhealthy Drinking 1) Alcohol Abuse and Dependence k 2) At-risk Drinking Consider this in all patients © AMSP 2012 34

Abuse Dependence 1+ 3+ • Role failure • Tolerance • Withdrawal • Unable to Abuse Dependence 1+ 3+ • Role failure • Tolerance • Withdrawal • Unable to limit • Risk of harm • Run-ins with law • Relationship trouble In same 12 months • Unable to cut down • ↑ Time with alcohol • ↓ Time elsewhere • Use in spite of problems © AMSP 2012 35

At-Risk Drinking > 14 drinks per week ≥ 5 drinks per occasion > 7 At-Risk Drinking > 14 drinks per week ≥ 5 drinks per occasion > 7 drinks per week ≥ 4 drinks per occasion © AMSP 2012 36

ID Unhealthy Drinking 1) Ask • How many drinks per occasion? • How many ID Unhealthy Drinking 1) Ask • How many drinks per occasion? • How many drinks per week? 2) Blood markers* MCV > 90 µ 3 GGT > 35 U/l CDT > 2. 0 U/l ALT > 35 U/l AST > 33 U/l © AMSP 2012 37

Questionnaires • CAGE Cut down Annoyed Guilty Eye-opener • AUDIT (Alcohol Use Disorders Identification Questionnaires • CAGE Cut down Annoyed Guilty Eye-opener • AUDIT (Alcohol Use Disorders Identification Test) 10 items about Alcohol consumption Drinking behavior Alcohol-related problems © AMSP 2012 38

Rx Abuse/Dependence 1 st step: 2 nd step: 3 rd step: Intervention Detoxification Rehabilitation Rx Abuse/Dependence 1 st step: 2 nd step: 3 rd step: Intervention Detoxification Rehabilitation Rx At-Risk Drinkers Help patients ↓ drinking Brief Intervention © AMSP 2012 39

st 1 Step: Intervention Help patients to • Recognize problems • ↑ Motivation to st 1 Step: Intervention Help patients to • Recognize problems • ↑ Motivation to change • ↓ Future difficulties Motivational interview Brief intervention © AMSP 2012 40

Motivational Interview • Feedback • Responsibility • Advice • Menu • Empathy • Self-efficacy Motivational Interview • Feedback • Responsibility • Advice • Menu • Empathy • Self-efficacy Brief Intervention • • Education Dangers Suggest ↓ alcohol use Avoid risky situations © AMSP 2012 41

nd 2 Step: Detoxification ~ ½ Patients need it Reassurance temporary nature Meds • nd 2 Step: Detoxification ~ ½ Patients need it Reassurance temporary nature Meds • Oral multivitamins • Benzodiazepines for ~1 week © AMSP 2012 42

rd 3 Step: Rehabilitation Help patients to • Keep motivation high • A lifestyle rd 3 Step: Rehabilitation Help patients to • Keep motivation high • A lifestyle free of alcohol • ↓ Risk of relapse Counseling Self-help groups (AA) Meds © AMSP 2012 43

Rehabilitation Meds 1. Disulfiram 2. Oral naltrexone 3. Slow release naltrexone 4. Acamprosate © Rehabilitation Meds 1. Disulfiram 2. Oral naltrexone 3. Slow release naltrexone 4. Acamprosate © AMSP 2012 44

AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 45

Conclusions on AAI 1) May be a life-threatening 2) Other depressants ↑ risk of Conclusions on AAI 1) May be a life-threatening 2) Other depressants ↑ risk of death 3) May → temporary psych symptoms 4) Rx: support vital signs until • Alcohol has been metabolized • Psych symptoms disappear 5) Evaluate unhealthy alcohol use © AMSP 2012 46




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