Ethanol toxicity: Difference between revisions
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==Background== | ==Background== | ||
*Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcohol intake) | |||
==Clinical Features== | ==Clinical Features== | ||
===Classic Features=== | |||
*Diminished fine motor control | |||
*Impaired judgement and coordination | |||
*Slurred speech | |||
*Nystagmus | |||
*[[Ataxia]] | |||
*[[Nausea and vomiting]] | |||
*Alcohol odor on breath | |||
*Respiratory depression | |||
*Lethargy | |||
*[[Coma]] | |||
== | ===Other Features (if malnourished)=== | ||
*[[Hypoglycemia]] | |||
*[[Alcoholic ketoacidosis|Ketoacidosis]] | |||
*[[Lactic acidosis]] | |||
*[[Epigastric pain]] ([[pancreatitis]]) | |||
== | ===Mellanby effect=== | ||
*Impairment is greater at a given blood alcohol concentration when the level is rising than when it is falling. <ref>Wang MQ, Nicholson ME, Mahoney BS, et al. Proprioceptive responses under rising and falling BACs: a test of the Mellanby effect. Percept Mot Skills. 1993 Aug;77(1):83-8.</ref> | |||
==Differential Diagnosis== | |||
{{Ethanol DDX}} | |||
{{Sedatve/hypnotic toxicity types}} | |||
{{AMS DDX}} | |||
==Evaluation== | |||
''Clinical diagnosis. No specific workup required when there is clear evidence of alcohol intake, but the following may be considered based on clinical picture/gestalt:'' | |||
*Fingerstick glucose (recommended as minimum workup in all patients with [[AMS]]) | |||
*Consider blood alcohol level (BAL) when a good history cannot be obtained or patient fails to improve as expected | |||
**Correlates poorly with degree of intoxication<ref>Olson KN, Smith SW, Kloss JS, et al. Relationship between blood alcohol concentration and observable symptoms of intoxication in patients presenting to an emergency department. Alcohol Alcohol. 2013 Jul-Aug;48(4):386-9. doi: 10.1093/alcalc/agt042.</ref> | |||
*Maintain low threshold for imaging in intoxicated patient with signs of trauma | |||
==Management== | |||
*Supportive care is mainstay of ED treatment and is based on clinical presentation | |||
**Manage ABCs | |||
**[[Benzodiazepines]] or [[haloperidol]] for agitation | |||
*IV fluids are commonly used but do not hasten ETOH elimination or reduce length of stay<ref>Perez SR, Keijzers G, Steele M. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151.</ref><ref>Li J, Mills T, Erato R. Intravenous saline has no effect on blood ethanol clearance. J Emerg Med. 1999 Jan-Feb;17(1):1-5.</ref> | |||
{{Vitamin prophylaxis for ETOH}} | |||
==Disposition== | ==Disposition== | ||
* | *Caution should be taken when BAL is measured on arrival as clinical exam cannot be used alone for discharge | ||
*Can be discharged once patient at baseline mental status, able to tolerate PO and ambulate without assistance | |||
==See Also== | ==See Also== | ||
*[[Beer Potomania Syndrome]] | *[[Beer Potomania Syndrome]] | ||
*[[Alcoholic ketoacidosis]] | |||
*[[Alcohol withdrawal]] | |||
*[[Alcohol withdrawal seizures]] | |||
*[[Altered mental status]] | |||
*[[Delerium tremens]] | |||
*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]] | |||
*[[Sedative/Hypnotic]] | |||
== | ==References== | ||
<References/> | |||
[[Category: | [[Category:Toxicology]] |
Revision as of 11:31, 1 September 2019
Background
- Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcohol intake)
Clinical Features
Classic Features
- Diminished fine motor control
- Impaired judgement and coordination
- Slurred speech
- Nystagmus
- Ataxia
- Nausea and vomiting
- Alcohol odor on breath
- Respiratory depression
- Lethargy
- Coma
Other Features (if malnourished)
Mellanby effect
- Impairment is greater at a given blood alcohol concentration when the level is rising than when it is falling. [1]
Differential Diagnosis
- Ethanol toxicity
- Alcohol use disorder
- Alcohol withdrawal
- Electrolyte/acid-base disorder
Sedative/hypnotic toxicity
- Absinthe
- Barbiturates
- Benzodiazepines
- Chloral hydrate
- Gamma hydroxybutyrate (GHB)
- Baclofen toxicity
- Opioids
- Toxic alcohols
- Xylazine toxicity
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
Clinical diagnosis. No specific workup required when there is clear evidence of alcohol intake, but the following may be considered based on clinical picture/gestalt:
- Fingerstick glucose (recommended as minimum workup in all patients with AMS)
- Consider blood alcohol level (BAL) when a good history cannot be obtained or patient fails to improve as expected
- Correlates poorly with degree of intoxication[2]
- Maintain low threshold for imaging in intoxicated patient with signs of trauma
Management
- Supportive care is mainstay of ED treatment and is based on clinical presentation
- Manage ABCs
- Benzodiazepines or haloperidol for agitation
- IV fluids are commonly used but do not hasten ETOH elimination or reduce length of stay[3][4]
Vitamin Prophylaxis for Chronic alcoholics
- At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
- Give multivitamin PO; patient at risk for other vitamin deficiencies
Banana bag
The majority of chronic alcoholics do NOT require a banana bag[5][6]
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- Multivitamin 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- Normal saline as needed for hydration
Disposition
- Caution should be taken when BAL is measured on arrival as clinical exam cannot be used alone for discharge
- Can be discharged once patient at baseline mental status, able to tolerate PO and ambulate without assistance
See Also
- Beer Potomania Syndrome
- Alcoholic ketoacidosis
- Alcohol withdrawal
- Alcohol withdrawal seizures
- Altered mental status
- Delerium tremens
- EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
- Sedative/Hypnotic
References
- ↑ Wang MQ, Nicholson ME, Mahoney BS, et al. Proprioceptive responses under rising and falling BACs: a test of the Mellanby effect. Percept Mot Skills. 1993 Aug;77(1):83-8.
- ↑ Olson KN, Smith SW, Kloss JS, et al. Relationship between blood alcohol concentration and observable symptoms of intoxication in patients presenting to an emergency department. Alcohol Alcohol. 2013 Jul-Aug;48(4):386-9. doi: 10.1093/alcalc/agt042.
- ↑ Perez SR, Keijzers G, Steele M. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151.
- ↑ Li J, Mills T, Erato R. Intravenous saline has no effect on blood ethanol clearance. J Emerg Med. 1999 Jan-Feb;17(1):1-5.
- ↑ Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
- ↑ Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.