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Alcohol Poisoning, Emergency Medicine

Basics

Description

- Alcohol intoxication: - Directly depresses CNS function - Blood alcohol levels drop by 15-40 mg/dL/hr depending on individual variables and chronicity of alcohol use

- Early or minor withdrawal: - <8 hr after last drink: - Symptoms of a hangover - Headache - Nausea/vomiting

- 12-36 hr after last drink: - Irritability/agitation - Tachycardia/HTN - Tremors in hands and tongue

- Alcoholic withdrawal seizures: - 8-12 hr after last drink - Brief, spontaneously abating tonic-clonic activity - Precedes delirium tremens (DTs)

- Late alcohol withdrawal or major withdrawal: - 48 hr after last drink - DTs: - Clouded consciousness and delirium - Confusion/disorientation - Agitation/combativeness - Tachycardia/HTN - Hyperpyrexia - Diaphoresis

- CT of head if: - Alteration in mental status is out of proportion to expected AMS based on serum alcohol level - Suspected head trauma - Signs of increased intracranial pressure or focal findings on neurologic exams - New-onset seizure - Unimproved or deteriorating level of consciousness

- Alcohol withdrawal and seizures: - Sedative-hypnotic withdrawal - Acute intoxication or poisoning: - Carbon monoxide - Isoniazid (especially if prolonged seizures not responding to standard therapy) - Amphetamine - Anticholinergic - Cocaine

- Secondary seizure disorders: - Infection - Meningitis - Encephalitis - Brain abscess

- Alcohol withdrawal syndrome: - CIWA-Ar - Validated scale for assessing withdrawal severity - Guides initial pharmacotherapy - Gauges response to therapy and needs for repeat dosing ("symptom-triggered"Ł therapy)

- Benzodiazepines are the agent of choice: - Cross-tolerant with alcohol - Increases GABAA-mediated transmission - Anticonvulsant effect - Large, frequent doses required with significant withdrawal - May halt progression to DTs

- Propofol: - Agent of choice for intubated patients - Completely suppresses seizure activity - Requires intubation/ventilation - Caution if hypotensive

  • Alcohol is the most commonly abused recreational agent among emergency department patients
  • Alcohol is frequently associated with traumatic injuries

Etiology

  • Alcohol intoxication:Directly depresses CNS functionBlood alcohol levels drop by 15-40 mg/dL/hr depending on individual variables and chronicity of alcohol use
  • Alcohol withdrawal:Occurs in chronic alcohol abusers after partial or complete alcohol abstinenceMay occur despite a serum alcohol level >100 mg/dL (e.g., "intoxicated"Ł)Primarily due to loss of chronic CNS inhibition:Profound CNS excitationIncreased catecholamine release and adrenergic tone

Diagnosis

Signs and Symptoms

Acute Alcohol Intoxication

  • CNS effects occur on a spectrum:RelaxationEuphoriaSedationMemory lossImpaired judgmentAtaxiaSlurred speechObtundation/coma
  • May also cause GI upset

Alcohol Withdrawal Syndrome

  • Early or minor withdrawal:<8 hr after last drink:Symptoms of a hangoverHeadacheNausea/vomiting12 hr after last drink:Mild tremors/anxietyAnorexia, nausea, vomitingWeaknessMyalgiasVivid dreams/nightmares12-36 hr after last drink:Irritability/agitationTachycardia/HTNTremors in hands and tongue24-48 hr after last drink: Alcoholic hallucinosis:Visual hallucinations most common (bug crawling)Auditory hallucinations (buzz, clicks)Present in minor and major withdrawalAlcoholic withdrawal seizures:8-12 hr after last drinkBrief, spontaneously abating tonic-clonic activityPrecedes delirium tremens (DTs)
  • Late alcohol withdrawal or major withdrawal:48 hr after last drinkDTs:Clouded consciousness and deliriumConfusion/disorientationAgitation/combativenessTachycardia/HTNHyperpyrexiaDiaphoresis

History

  • Often provided by EMS, family, or friends
  • Beware the "frequent flyer"Ł in the ED:Can sometimes have other causes of AMS:Hepatic disease/encephalopathySeizures (postictal)HypoglycemiaHead injury or intracranial bleeding

Physical Exam

  • Vital signs:Acute intoxication: Normal or depressedWithdrawal: Usually elevated
  • Mental status:Acute intoxication: Somnolent, obtunded, or comatoseWithdrawal: Hyperalert, agitated
  • Signs of hepatic injury:JaundiceIcterusSpider angiomataAsterixisHepatomegaly
  • Signs of malnutrition:AlopeciaPoor dentitionPoor muscle massAbdominal wastingTemporal wasting

Essential Workup

  • Obtain accurate alcohol ingestion and abstinence history
  • Investigate for life-threatening causes of seizures:Hypoglycemia (get rapid bedside glucose)Intracranial hemorrhageCNS infectionElectrolyte abnormalities
  • Evaluate for occult trauma
  • Monitor all vital signs frequently:Hyperthermia predicts poorer outcomes

Diagnosis Tests & Interpretation

Lab

  • Alcohol level if abnormal mental status
  • Urine toxicology panel to screen for coingestants
  • Electrolytes, BUN, creatinine, and glucose
  • CBC
  • Magnesium, calcium, and phosphate
  • PTT, PT/INR if coagulopathy suspected
  • LFTs if liver disease suspected
  • Ammonia level if hepatic encephalopathy suspected
  • Urinary ketones or serum acetone if alcoholic ketoacidosis suspected

Imaging

  • CT of head if:Alteration in mental status is out of proportion to expected AMS based on serum alcohol levelSuspected head traumaSigns of increased intracranial pressure or focal findings on neurologic examsNew-onset seizureUnimproved or deteriorating level of consciousness
  • EEG differentiates alcohol withdrawal seizures from idiopathic epilepsy
  • Chest radiograph if suspected aspiration or pneumonia

Differential Diagnosis

  • Acute alcohol intoxication:HypoglycemiaCarbon dioxide narcosisMixed-drug overdoseEthylene glycol, methanol, or isopropanol poisoningHepatic encephalopathyPsychosisSevere vertigoPsychomotor seizure
  • Alcohol withdrawal and seizures:Sedative-hypnotic withdrawalAcute intoxication or poisoning:Carbon monoxideIsoniazid (especially if prolonged seizures not responding to standard therapy)AmphetamineAnticholinergicCocaineSecondary seizure disorders:InfectionMeningitisEncephalitisBrain abscessTraumaIntracranial hemorrhageCVATumorAnticonvulsant noncomplianceThyroid disorder

Treatment

Pre-Hospital

  • Administer benzodiazepines for seizures
  • Give naloxone, oxygen, and dextrose for comatose individuals
  • Intubate as necessary for airway protection to prevent aspiration
  • C-spine immobilization if suspected trauma

Initial Stabilization/Therapy

  • Airway, breathing, circulation (ABCs)
  • Evaluate C-spine if suspected trauma
  • Initial IV rehydration with 0.9 NS, then D5 0.45 NS
  • Administer naloxone, thiamine, and glucose (or Accu-Chek) if altered mental status
  • Benzodiazepines if seizing (may require large doses)
  • Young children have decreased hepatic glycogen reserves
  • Cannot mount an appropriate response to increased glucose needs
  • Rapid bedside glucose (Accu-Chek) is ESSENTIAL:Administer dextrose if indicated with D5 (10 mL/kg), D10 (5 mL/kg), or D25 (2 mL/kg) depending on age and size

Ed Treatment/Procedures

  • Alcohol intoxication:Rehydrate with IV fluidsCorrect electrolyte abnormalities:MagnesiumPotassiumFolateThiamineMultivitamins
  • Alcoholic ketoacidosis:Aggressive rehydration with D5 0.9 NSExclude other causes of wide anion-gap metabolic acidosis
  • Alcohol withdrawal syndrome:CIWA-ArValidated scale for assessing withdrawal severityGuides initial pharmacotherapyGauges response to therapy and needs for repeat dosing ("symptom-triggered"Ł therapy)Benzodiazepines are the agent of choice:Cross-tolerant with alcoholIncreases GABAA-mediated transmissionAnticonvulsant effectLarge, frequent doses required with significant withdrawalMay halt progression to DTsBarbiturates (phenobarbital):Useful if severe withdrawal or DTs refractory to large doses of benzodiazepinesPropofol:Agent of choice for intubated patientsCompletely suppresses seizure activityRequires intubation/ventilationCaution if hypotensiveβ-blocker (labetalol, esmolol, or metoprolol):Normalizes vital sign abnormalitiesDoes not treat CNS complications of alcohol use or withdrawal╬▒-agonist (clonidine):Centrally acting ╬▒2-adrenergic agonistsNormalizes vital sign abnormalitiesDo not treat CNS complications of alcohol use or withdrawalPhenytoin:Not indicated in seizures primarily due to alcohol withdrawalIndicated if seizures secondary to idiopathic epilepsy, posttraumatic, or status epilepticus

Medication

  • Dextrose: D50W 1 amp (50 mL or 25 g; peds: D25W 2-4 mL/kg) IV
  • Diazepam (Valium): 5-10 mg IV q5-10min until patient calm
  • Lorazepam (Ativan): 0.5-4 mg IV/IM q5-10min until patient calm
  • Naloxone (Narcan): 0.4-2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  • Phenobarbital: 10-20 mg/kg IV (loading dose) monitor for respiratory depression
  • Phenytoin: 15-18 mg/kg not to exceed 25 mg/min:May give Fosphenytoin at 15-20 mgPE/kg at a maximum rate of 150 mgPE/min
  • Propofol: 25-75 ╬╝/kg/min IV (loading dose) then 5-50 ╬╝g/kg/min (maintenance dose)
  • Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM

Follow-Up

Disposition

Admission Criteria

  • Inability to control seizures or withdrawal symptoms with oral medications
  • Hepatic failure, infection, dehydration, malnutrition, cardiovascular collapse, cardiac dysrhythmia, or trauma
  • Hallucinations, abnormal vital signs, severe tremors, or extreme agitation
  • Wernicke encephalopathy
  • Confusion or delirium

Discharge Criteria

  • Clinically sober
  • Seizure free for 6 hr (with negative workup if 1st seizure)

Issues for Referral

Discuss with social worker and/or police and/or department of family services for pediatric patients. á

Followup Recommendations

Substance abuse referral for patients with recurrent alcohol intoxication/use á

Pearls and Pitfalls

  • Failure to appreciate AMS due to nonalcoholic causes in chronic alcoholics:Serum levels should drop by 15-40 mg/dL/hrIf mental status not improving (or worsening) need to investigate further
  • Failure to adequately treat with benzodiazepines:May require massive doses (e.g., 200-300 mg of diazepam) to controlIf unable to control, consider other GABAergic agents (phenobarbital, propofol)
  • Failure to appreciate hypoglycemia as a common entity in these patients:Can masquerade as "intoxication"ŁCan result in poor outcomesFrequently occurs in chronic alcoholics and children

Additional Reading

  • D'Onofrio áG, Degutis áLC. Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review. Acad Emerg Med. 2002;9:627-638.
  • Mayo-Smith áMF, Beecher áLH, Fischer áTL, et al. Management of Alcohol Withdrawal Delirium: An Evidence-based Practice Guideline. Arch Int Med. 2004;164:1405-1412.
  • McKeon áA, Frye áMA, Delanty áN. The Alcohol Withdrawal Syndrome. J Neurol Neurosurg Psychiatry. 2008;79(8):854-862.
  • Nelson áLS, Gold áJA. Chapter 78. Ethanol Withdrawal. In: Hoffman áRS, Nelson áLS, Goldfrank áLR, et al., eds. Goldfranks Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill; 2011.
  • Pitzele áHZ, Tolia áVM. Twenty per hour: Altered mental state due to ethanol abuse and withdrawal. Emerg Med Clin N Am. 2010;28:683-705.

See Also (Topic, Algorithm, Electronic Media Element)

  • Ethylene Glycol, Poisoning
  • Methanol, Poisoning

Codes

ICD9

  • 303.00 Acute alcoholic intoxication in alcoholism, unspecified
  • 305.00 Alcohol abuse, unspecified
  • 980.0 Toxic effect of ethyl alcohol

ICD10

  • T51.0X1A Toxic effect of ethanol, accidental (unintentional), init
  • T51.0X1D Toxic effect of ethanol, accidental (unintentional), subs
  • T51.0X1S Toxic effect of ethanol, accidental (unintentional), sequela
  • F10.129 Alcohol abuse with intoxication, unspecified
  • T51.0X Toxic effect of ethanol

SNOMED

  • 82782008 Toxic effect of ethyl alcohol (disorder)
  • 216633005 accidental poisoning by alcoholic beverages (disorder)
  • 25702006 Alcohol intoxication (disorder)