Alcoholism and alcohol abuse

1. Alcoholism and alcohol abuse

2. Ethanol dependence- tolerance to the drug and the likelihood of withdrawal symptoms if intake is suspended. More common in men. • Alcohol abuse and dependence in 2.7% of all ED visits.

3. More than 40 percent of fatal MVA’s are associated with ethanol. • Alcoholics have shorter life span, increased mortality from heart and liver disease, cancer, and trauma.

4. Alcohol is an important predisposing factor for trauma of all types. • Serious head injuries are easily overlooked in intoxicated patients. Intoxicated patients should undergo CT, if there is a history of head injury and the Glasgow Coma Score is less than 15; for any worsening of mental status while under observation; or if there is no improvement in mental status by 3 h after admission.

5. Ethanol withdrawal • Symptoms and signs include tremor, anxiety, agitation, cardiac dysrhythmias, seizures, hallucinations. Reach peak intensity at 48 h after the patient's last drink. • Look for complicating medical conditions or injury. For patients who have experienced seizures, CT examination is indicated when focal seizures have occurred, when a focal neurologic finding is elicited if there has been head trauma, or when the patient has a persistent postictal defect in consciousness. • Treat with benzos. • The initial dose of lorazepam is 2 to 4 mg IV, followed by doses of 2 to 4 mg every 15 to 30 min until a condition of light sedation is attained. Give 1 L of D5NS with 100 mg of thiamine and 4 g of magnesium sulfate is given over 1 to 2 h.

6. Patients with alcohol withdrawal or complicating medical problems should be admitted. Patients who fail to respond to one or two doses of sedative medications also should be admitted. Patients with mild alcohol withdrawal that responds to treatment may be discharged.

7. Women are less likely than men to abuse alcohol but are more prone to alcohol-associated health problems. • Women who drink during pregnancy predispose their children to growth retardation in utero, fetal alcohol syndrome, characterized by facial dysmorphology, and mental and growth retardation after birth.

8. If you suspect abuse • C: Have you ever felt that you should cut down on your drinking?  A: Have people ever annoyed you by criticizing your drinking?  G: Have you ever felt bad or guilty about your drinking?  E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?  • Each question gets a point, 2 or more = alcohol dependence. • If a patient is ready to accept referral do so.

9. Injection Drug Users • The use and the lifestyle of the injection drug user (IDU), place the individual at risk for a wide variety of infectious and noninfectious complications such as HIV, hepatitis, and STD’s and increased risk of trauma. • Patients should be asked about drug type(s) and amount, preparation, needle sharing, use of antibiotics, and coincident illness. Drug rehabilitation should always be offered.

10. Complications of the IDU may be obvious, such as a painful mass caused by a skin abscess. However, other symptoms such as weakness, anorexia, body pains, weight loss, and fever are common and may be the only subtle signs of serious underlying disease. • Fever in IDUs is associated with infection in more than two-thirds of pts. • Because no reliable markers are available to exclude serious illness in the febrile IDU, common practice has been to obtain blood cultures and admit such patients for observation. In clinically well patients for whom follow-up can be ensured, outpatient evaluation is reasonable as long as an adequate cultures are obtained.

11. There are many causes of dyspnea and cough in IDUs including pneumonia and septic pulmonary emboli. If febrile, place in isolation until TB is ruled out. • Noninfectious causes of dyspnea-pneumothorax, hemothorax, toxic reactions to injected substances, and hypersensitivity reaction, noncardiogenicpulmonary edema. • Drug intoxication or withdrawal, stroke, hypoxia, infectious diseases, and secondary trauma may all cause altered mental status in the IDU. • Back pain may be the result of an epidural abscess, vertebral osteomyelitis, or complications from trauma. Get CT or MRI.

12. HIV in IDUs has expanded the spectrum of diseases associated with IV drug use to include those typically associated with HIV infection. IDUs have more cryptococcal disease, PCP, tuberculosis, and wasting syndrome, and significantly less cytomegalovirus (CMV) infection, non-Hodgkin lymphoma, and Kaposi sarcoma.

13. Increased incidence of endocarditis in the IDU - typically right-sided . • Patients with IDU-related endocarditis usually have no evidence of prior valve damage. The tricuspid valve is susceptible to mechanical damage because it is the first valve exposed to these substances.

14. Presenting signs and symptoms include fever, cardiac murmur, cough, pleuritic chest pain, and hemoptysis. • Blood cultures will be positive in more than 98 percent of IDU-related endocarditis patients if three to five sets are obtained. S. aureus most common Strep second most common. • The classic findings of embolic phenomena, Janeway lesions and Roth spots, are usually not observed.

15. Transthoracic echocardiography (TEE) is the most sensitive imaging modality for vegetations, myocardial and ring abscesses, and tricuspid valve involvement. • Get at least two sets of blood, followed by hospital admission. Treat against S. aureus and Streptococcus. • Community-acquired pneumonia caused by S. pneumoniae and H. influenzae is the most common pulmonary infection in the IDU.

16. Skin infections in the IDU include a high rate of skin and pharyngeal colonization with S. aureus and streptococcal species. Tap water, toilet water, or saliva often are used to dissolve narcotics. • Presenting signs and symptoms of cutaneous infections, are fever, pain, localized erythema, and edema. Pulsatile masses must be imaged with ultrasonography. Plain radiographs can demonstrate air in the soft tissues. Whenever crepitus or subcutaneous air is detected call surgery. • Coverage should include penicillinase-resistant synthetic penicillin or vancomycin plus an antipseudomonalaminoglycoside, antipseudomonal penicillin, or cephalosporin.

17. Vascular injury associated with IDU includes arterial injection with vasospasm or thrombosis, septic thrombophlebitis, venous and arterial pseudoaneurysms, and infected hematomas. • When limb ischemia is suspected, call a vascular surgeon. • Because of the hemorrhagic consequences of attempted incision and drainage, all painful masses, particularly in the groin, should be imaged.

18. Bone and joint infections usually occur from either contiguous spread from an overlying skin or soft tissue infection. • Nonpyogenic organisms may cause osteomyelitis and septic arthritis in IDUs. Mycobacterial infections usually involve the ribs and vertebral column (Pott disease). • IDU-related osteomyelitis involves the vertebral column in approximately 50 percent of cases • Septic arthritis in the IDU usually involves the knee or hip. Bone scans are often positive. The most sensitive but nonspecific finding on synovial fluid analysis is a WBC greater than 20,000/L, with a neutrophil predominance.