ACUTE ALCOHOL INTOXICATION

1. ACUTE ALCOHOL INTOXICATION . www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. “ drinking is a pause from thinking”

3. Different alcohol poisonings. • Acute ethanol intoxication • Acute methanol poisoning. • Acute ethylene glycol poisoning. • Acute isopropyl alcohol poisoning

4. Acute ethanol intoxication • Sources I. alcoholic drinks -beer (3.5-9%) -stout (4.2%) -wines (12.5-13.5%) -spirits (37-40%) -cider (5.5-8%) -sparkling or flavored alcoholic drinks II. non alcoholic beverages

6. One unit = 8 gm of alcohol • One oz = 30ml • Proof =2*%ethanol by volume • One drink = 44ml of whiskey(80%proof),3-5oz wine or 12 oz beer. • BAC –blood alcohol conc. • 0.1%BAC =100 mg alcohol in 100ml blood.

7. pharmacology • C2H5OH • Colorless, odourless liquid • M.Wt - 46 • Vd - 0.54 L/Kg • 1gm ethyl alcohol – 7.1 kcal energy

8. Absorption • GIT ,20% in stomach,rest in small intestine • 80%-90% absorption within 30-60mins. • Absorption also depends on other factors • Females attain higher blood alcohol level. • Inhalation –pulmonary vascular bed.

9. Distribution& elimination • Distributed to almost every tissue. peroxidase-catalase system Ethanol acetadehyde+NADH +NAD microsomal oxidase system acetate CO2+H2O acetyl coA

10. 1st order to zero order kinetics at 5 mg/ 100mlBAC. • 100-125 mg/ kg /hr • BAC decreases by 15-25 mg /100ml/ hr. • 2-10% unchanged in urine. • Appreciable but insignificant amount in respiration.

11. pathophysiology • GABA. Glutamate. • ↑NAD/NAD ratio. • ↑ketogenesis. • ↓gluconeogenesis • ↑glycogenolysis • Fluid & electrolyte imbalance.

12. Stages of intoxication • BAC STAGES 0.01-0.05 sobriety 0.03-0.12 euphoria 0.09-0.25 excitement 0.18-0.30 confusion

13. 0.27-0.4 stupour 0.35-0.5 coma 0.45+ DEATH

14. Asscociated acute problems. • Alcoholic ketoacidosis. • Alcoholic hypoglycemia. • Fluid & electrolyte imbalance. • Wernicke’s encephalopathy.

15. Acute effects on heart. • Acute GI efects. • Acute alcoholic myopathy. • Trauma • Associated other substance poisoining.

16. Alcoholic ketoacidosis: • Dillon et al • High anion gap acidosis • Normal or low glucose level • Chronic alcoholics • Binge drinking wks before symptoms • Dehydration, starvation due to vomiting ,gastritis

17. Alcohol poor food intake dehydration ↓ ↓ ↓ Acetaldehyde glycogenolysis ↑counter regulatory ↓ hormones Acetate ↓ ↓ ↓ ↑NADH/NAD ↑glucagon ratio ↓insulin ↓ • ↓gluconeogenesis ketogenesis

18. Altered mental status • Kussumal breathing • Ketotic breath • Lab finding high anion gap acidosis ↑beta hydroxybutyrate:acetoacetate ↓insulin level • Exclude other causes of ↑A;G acidosis

19. Alcoholic hypoglycemia • Chronic “street alcoholic” found unresponsive • Symptoms neuroglycopenic →confusion,fatigue,seizure, loss of consciousness→death autonomic responses → palpitation ,tremor , sweating • Signs pallor ,diaphoresis tachycardia,raised systolic B.P transient focal neurological signs

20. Water and electrolytes disorders • “all alcoholics are dehydrated” is false. • Immediate ↑ in urine volume followed by ↑ADH. • Hydration also depends on -diet,nonalcoholic fluids,type of drinks -vomiting, diarrhea,infection • Water intoxication & hyponatremia in severe chronic alcoholics→seizure& altered sensorium • Central pontine mylenolysis

21. Other electrolytes abnormalities • Hypomagnesemia • Hypophosphatemia • Hpokalemia • Hypocalcemia

22. Wernicke-korsakoff’s syndrome • As high as 12.5% in alcoholics. • Major reversible cause of death. • If untreated 10-20% mortality rate. • Thiamine deficiency is the root cause. • Magnesium deficiency in thiamin resistant cases. • Clinical features global confusion ocular abnormalities ataxia

23. Acute effect on heart • Direct negative inotropic effect & vasodilation. • PR & QT prolongation • Both supraventricular & venntricular arrythmia. • “holiday heart syndrome” • Various degree of heart block. • +ve correlation between and sudden cardiac death.

24. Acute alcoholic myopathy • Acute muscle necrosis mainly in binge drinkers • Alcoholism is the most common cause of rhabdomyelisis • Raised CKMM,myoglobinuria, • Acute tubular necrosis→↑urea ,creatinine • Conservative management

25. Acute gastrointestinal effect • Acute gastritis & esophagitis. • Epigastric distress and gastrointesinal bleeding. • Mallory-weiss tear. • Acute hepatitis & pancreatitis.

27. Differential diagnosis in acutely intoxicated patient. • Toxic • Metabolic • Infectious diseases • Neurologic • Miscellaneous • Trauma

28. Management • Airway • Breathing • Circulation • Intubate if poor gag reflex • Fingerstick glucose , iv dextrose • Thiamin 100 mg im/ iv stat. • magnesium

29. 2 mg naloxone • Exclude other causes of intoxication • ABG • Osmolar gap. • 2Na+ + BUN/2.8 + Glu/18 + Eth/4.6 • Serum electrolytes • Anion gap. • Correct other electrolyte abnormalities • Dilantin • CT scan.

30. Blood alcohol conc (BAC) • Enhanced elimination evacuation after 1 hr little benefit activated charcoal. fructose haemodialysis metadoxine (300-900mg iv)

31. Methanol poisoning • CH3OH(wood alcohol) • Solvent ,antifreeze, paint remover. • Epidemics of methanol toxicity. • Poisoning mainly by ingestion

32. Methanol + NAD+ formaldehyde + NADH ( alcohol dehydrogenase) formate (folate) CO2 + H2O

33. Clinical effects • Inebriated but lack of euphoria. • 1-72 hrs of latent period. • Fatal dose 60-240 ml. • Vertigo ,nausea,vomiting, diarrhea,abdominal pain,dyspnea,agitation. • Blurred vision,photophobia,↓ visual acuity • Bradycardia, blindness, seizures,coma.

34. Physical examination constricted visual field,fixed &dilated pupils, retinal edema &hyperemia of disk resp apnea ,opisthotonus,& seizure in pts dying of Methanol intoxication

35. Lab finding high anion gap acidosis (correlates with mortality) high osmolar gap serum methanol> 20 mg/dl symptoms > 50 mg/ dl serious > 100 mg/ dl ocular signs

36. Specific treatment aggressive tt of acidosis ethanol achieve BAC of 100- 150mg /100ml loading 0.8gm/ kg of 5 – 10% ethanol followed by 130mg/kg/hr. oral loading if no iv preparation if dialysis,250-350 mg/kg/hr. ethanol indications methanol >20 mg/100ml,symptomatic acidosis, need for HD. ingestion >o.4ml/kg

37. Folic acid 30 mg iv every 4 hrly • Leucovorin 1-2mg/kg iv • 4-methyl pyrazole(fomepizole ) 15-20 mg/kg iv • Haemodialysis not haemoperfusion • Haemodialysis indications: methanol>20-50mg/100ml acidosis not responsive to bicarbonate formate levels > 20 mg/100ml visual impairment renal impairement • Dialysis till methanol level≈0mg/100ml and acidosis clears.

38. Ethylene glycol poisoning • Colourless, odourless ,nonvolatile,water soluble. • Paints,polishes, cosmetics,antifreeze. • Viscous & sweet –poorman’s substitute for alcohol. • Minimal lethal dose 1-1.5ml/kg. • Peak level 1-4 hr.

39. Eth glycol + NAD+ glycoldehyde +NADH alc dehydrogenase glycolate lactate oxalate glyoxylate hypocalcemia renal failure myocardial deprssion

40. Clinical effects • Described by pons & custer • Stage 1– inebriated without odour of alcohol. (1-12hrs) other CNS symptoms. • Stage 2-- CVS changes (12-24 hrs) • Stage3-- ARF (24-72 hrs)

41. Lab finding: oxalate crystals in urine. hypocalcemia ↑A: G acidosis tt mainly on history & clinical symptoms. • Specific treatment: ethanol pyridoxine thiamine magnesium 4-methyl pyrazole HD

42. Isopropyl alcohol poisoning • 2-propanol,isopropanol. • Clear, volatile ,bitter taste,aromatic odour • Solvent, & disinfectant. • 2nd to ethanol as most commonly ingested alcohol.

43. Twice potent than ethanol as CNS depressant. • Toxic dose--- 1ml/kg of 70 % solution. • Lethal dose---2-4ml/kg. • 80% absorbed from GIT in 30 mins. • Dermal absorption & inhalation.

44. isopropyl alcohol acetone alc dehydrogenase acetate+ formate • Very few ketoacids • CNS depressant. • NAD/NADH ratio ↑ed.

45. Clinical effects within 30-60 mins. lacking euphoria nausea,vomiting,haemorrhgic gastritis. ocular signs sweet ,pungent odor of acetone coma, hypoventilation resp arrest

46. Diagnosis inebriated with –ve or low ethanol. elevated osmolar gap ketosis without acidosis • >50mg/dl toxic,200-400mg/dl lethal. • Treatment: GI evacuation. dialysis if 3-4 ml /kg of 70% solution blood level >400mg/dl unrespnsive hypotension renal failure,coma.

47. Anesthetic management in acute alcohol intoxicated pts. • acute problems altered sensorium & poor assesment. . fluid & electrolytes derangements. acid –base disorders full stomach & aspiration.

48. hypothermia. consent. ↓MAC of anesthetic gases & analgesia. multiple trauma with airway involvement. Problems due to chronic alchoholism hypoproteinemia liver dysfunction. cardiomyopathy. haematological abnormalities. increase infections

49. other substance abuser. • HIV ,hepatitis. • Altered drug metabolism CYP2E1 . long term consumption induces MEOS. ↑metabolism of certain drugs. conversion of many foreign substances into highly toxic metabolites. perianesthetic plasma fluoride kinetics. short term consumption has opposite effects.

50. Unpredictable awakening from anaesthesia • Withdrawal syndrome in postop period. • Long term hospitization.