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Roberta Agabio, M.D. Department of Biochemical Sciences Section of Neuroscience University of Cagliari, Italy

Roberta Agabio, M.D. Department of Biochemical Sciences Section of Neuroscience University of Cagliari, Italy. Acute Alcohol Intoxication (AAI) . © AMSP 2012 1. Alcohol Use & Problems. 90% Ever drink 14% Drinkers have 1+ problem: Accidents

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Roberta Agabio, M.D. Department of Biochemical Sciences Section of Neuroscience University of Cagliari, Italy

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

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

  3. AAI: Lecture Focus 1) Alcohol’s drug class 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

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

  5. Depressants Include Alcohol © AMSP 2012 5

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

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

  8. AAI: Lecture Focus 2) Alcohol’s brain effects 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 8

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

  10. 2. Acute use ALCOHOL Excitation Inhibition 3. Chronic use (tolerance) 4. Withdrawal OPPOSITE CHANGES OPPOSITE CHANGES ALCOHOL Inhibition Inhibition Excitation Excitation Alcohol's Brain Effects 1. Homeostasis Inhibition Excitation © AMSP 2012 10

  11. Blood Alcohol Concentration (BAC) • 1 drink → BAC = ~15 mg% (0.015 g/dl) • ↑ BAC with: • Female • ↓ Weight • Drink without food Standard drink = ~12 g alcohol © AMSP 2012 11

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

  13. AAI: Lecture Focus 3) AAI signs and symptoms 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

  14. 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 Nystagmus Nystagmus © AMSP 2012 14

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

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

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

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

  19. 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

  20. AAI: Lecture Focus 4) Evaluation and treatment of AAI 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

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

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

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

  24. Test for blood sugar • Use a fingerstick • If ↓ administer • 50 cc of 50% glucose IV • & • 100 mg vit. B1 (IV or IM) if needed © AMSP 2012 24

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

  26. 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

  27. 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

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

  29. 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

  30. 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

  31. 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

  32. 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 © AMSP 2012 32

  33. AAI: Lecture Focus 5) Unhealthy alcohol consumption 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

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

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

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

  37. ID Unhealthy Drinking • Ask • How many drinks per occasion? • How many drinks per week? 2) Blood markers* © AMSP 2012 37

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

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

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

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

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

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

  44. Rehabilitation Meds • Disulfiram • Oral naltrexone • Slow release naltrexone • Acamprosate © AMSP 2012 44

  45. 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

  46. 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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