Difference between revisions of "Ethanol toxicity"

(Diagnosis)
(Clinical Features)
 
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==Background==
 
==Background==
*AMS that doesn't improve after few hrs is due to alternative cause until proven otherwise
+
*Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcohol intake)
*Blood Alcohol Level
 
**Correlates poorly with degree of intoxication
 
**Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcoholism)
 
  
 
==Clinical Features==
 
==Clinical Features==
#Classic Features
+
[[File:The Alcohol Flushing Response.png|thumb|Alcohol flushing reaction: before (left) and after (right) drinking alcohol.]]
##Slurred speech
+
===Classic Features===
##Nystagmus
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*Diminished fine motor control
##Ataxia
+
*Impaired judgement and coordination
##N/V
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*Slurred speech
##Respiratory depression
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*Nystagmus
##Coma
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*[[Ataxia]]
#Other Features (if malnourished)
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*[[Nausea and vomiting]]
##Hypoglycemia
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*Alcohol odor on breath
##Ketoacidosis
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*Respiratory depression
##Lactic acidosis
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*Lethargy
##Epigastric pain (pancreatitis)
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*[[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==
 
==Differential Diagnosis==
 +
{{Ethanol DDX}}
 
{{Sedatve/hypnotic toxicity types}}
 
{{Sedatve/hypnotic toxicity types}}
 +
{{AMS DDX}}
  
==Diagnosis==
+
==Evaluation==
#Blood sugar
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''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:''
#BAL
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*Fingerstick glucose (recommended as minimum workup in all patients with [[AMS]])
#*Appropriate if AMS is due to unknown cause
+
*Consider blood alcohol level (BAL) when a good history cannot be obtained or patient fails to improve as expected
#*Not necessarily required in mild-mod intoxication or if no other abnormality suspected
+
**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>
#Elevated osmolar gap
+
*Maintain low threshold for imaging in intoxicated patient with signs of trauma
  
==Treatment==
+
==Management==
#GI decontamination
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*Supportive care is mainstay of ED treatment and is based on clinical presentation
##Activated charcoal ineffective (ETOH is too rapidly absorbed)
+
**Manage ABCs
#Hypoglycemia
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**[[Benzodiazepines]] or [[haloperidol]] for agitation
##Give glucose immediately (do not have to wait to give thiamine first)
+
*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>
#"Banana Bag"
+
 
##IV form is not justified
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{{Vitamin prophylaxis for ETOH}}
##Likelihood of vitamin deficiency (except for thiamine) is low
 
##IVF does not hasten ETOH elimination
 
  
 
==Disposition==
 
==Disposition==
*Most pts require observation only
+
*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 road test successful
+
*Can be discharged once patient at baseline mental status, able to tolerate PO and ambulate without assistance
  
 
==See Also==
 
==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]]
 
*[[Sedative/Hypnotic]]
*[[Alcohol Withdrawal]]
 
*[[Beer Potomania Syndrome]]
 
  
==Source==
+
==References==
*Tintinalli
+
<References/>
  
[[Category:Tox]]
+
[[Category:Toxicology]]

Latest revision as of 14:42, 16 November 2019

Background

  • Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcohol intake)

Clinical Features

Alcohol flushing reaction: before (left) and after (right) drinking alcohol.

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 related disease processes

Sedative/hypnotic toxicity

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

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
  • 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]

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

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  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.
  6. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.