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Acute alcohol intoxication
Classification and external resources
ICD-10 F10.0
ICD-9 305.0

Contents

Acute alcohol intoxication can result from a high level of alcohol in the bloodstream, accompanied by extreme drunkenness. The term acute alcohol intoxication is used by healthcare providers, often in emergencies. Toxicologists also speak of alcohol intoxication to discriminate from other toxins researched in the field.

Epidemiology

A drunken male on the ground, Pichilemu, Chile.

The condition is frequently found in either young people who are being exposed to commonly available alcoholic beverages like beer, wine, and distilled liquor for the first time, and don't know their limits, or by people suffering from alcoholism who ingest much more than they usually do.

Pathophysiology

Ethanol is metabolised to acetaldehyde by ethanol dehydrogenase, which is found in many tissues, including the gastric mucosa. Acetaldehyde is metabolised to acetate by acetaldehyde dehydrogenase, which is predominantly found in liver mitochondria. However, it takes roughly 90 minutes for a healthy liver to metabolize a single ounce, approximately one hour per standard unit.

Ethanol's acute effects are largely due to its nature as a CNS depressant, and are dependent on blood alcohol concentrations:

  • 20–99 mg/dL - Impaired co-ordination and euphoria
  • 100-199 mg/dL - Ataxia, poor judgement, labile mood
  • 200-299 mg/dL - Marked ataxia, slurred speech, poor judgement, labile mood, nausea and vomiting
  • 300-399 mg/dL - Stage 1 anaesthesia, memory lapse, labile mood
  • 400+mg/dL - Respiratory failure, coma and death

As drinking increases, people become sleepy, or fall into a stupor. Ultimately, the respiratory system becomes depressed, and the person will stop breathing. This is a common cause of death on college campuses. The most important thing for friends who witness someone "passing out" from too much alcohol is to get them emergency medical treatment. Commonly, comatose patients aspirate their vomit (resulting in vomitus in the lungs, which may cause "drowning" and later pneumonia if survived). CNS depression and impaired motor co-ordination along with poor judgement increases the likelihood of accidental injury occurring. [1]. It is estimated that about half of alcohol related deaths are due to accidents (32%) or intentional injury (13.7%)[2].

In addition to respiratory failure and accidents caused by effects on the central nervous system, alcohol causes significant metabolic derangements. Hypoglycaemia occurs due to ethanol's inhibition of gluconeogenesis, especially in children, and may cause lactic acidosis, ketoacidosis and acute renal failure. Metabolic acidosis is compounded by respiratory failure. Patients may also present with hypothermia.

Avoidance of intoxication

Alcohol is metabolized by a normal liver at that rate of about one ounce (one "highball", a normal beer, a regular sized glass of wine) every 90 minutes. An "abnormal" liver, one with hepatitis, cirrhosis, gall bladder disease, cancer, etc, will have a slower rate of metabolism. One can delay the absorption of alcohol by drinking water and ingesting food, but it prolongs the un-metabolized alcohol in the body.

Diagnosis

In determining if someone is intoxicated it is necessary to observe their behavior while the subject is sober to establish a baseline, ruling out a preexisting condition such as hypoglycemia, narcotic usage, mental health issues, etc. Several well known criteria can be used to establish a probable diagnosis. For a physician in the acute treatment setting, acute alcohol intoxication can mimic other acute neurological disorders, or is frequently combined with other recreational drugs that complicate diagnosis and treatment. Definitive diagnosis relies on a blood test for alcohol, usually performed as part of a toxicology screen. Many patients are uninhibited, especially when legal consequences are unlikely (e.g., no police are present), so they disclose information that simplifies the diagnosis.

Treatment

Emergency treatment for acute alcohol intoxication strives to stabilize the patient and maintain a patent airway and respiration, while waiting for the alcohol to metabolize:[3] Also:

  • Protect vital signs by monitoring ABCs, or Airway, Breathing, and Circulation, ie., if the person is thought risk for severe respiratory depression, consider an Endotracheal tube to protect the airway and assist with breathing.
  • Protect the airway by aspirating stomach contents that could cause aspiration pneumonia.
  • Treat Hypoglycaemia (low blood sugar) with 50ml of 50% dextrose solution and saline flush, as ethanol induced hypoglycaemia is unresponsive to glucagon.
  • Administer the vitamin thiamine, to prevent Wernicke-Korsakoff syndrome, which can cause a seizure (more usually a treatment for chronic alcoholism, but in the acute context usually co-administered to ensure maximal benefit).
  • Check urea and electrolytes to guide fluid replacement.
  • Apply Haemodialysis if the blood concentration is dangerously high (>400 mg%), and especially if there is metabolic acidosis.

Additional medication may be indicated for treatment of nausea, tremor, and anxiety.

Prognosis

A normal liver detoxifies the blood of alcohol over a time that depends on the initial level and the patient's overall physical condition. An abnormal liver takes longer but still succeeds, as long as the alcohol doesn't cause liver failure. [4]

People who have been drinking heavily for several days or weeks may have withdrawal symptoms after the acute intoxication has subsided. [5]

References

  1. ^ McArdle, P (2004). Substance abuse by children and young people. Arch. Dis. Child. 89: 701-704
  2. ^ The World Health Organisation (2007) Alcohol and Injury in Emergency Departments
  3. ^ Devi, G., Castro, V. J., Huitink, J., Buitelaar, D., Kosten, T., O'Connor, P. (2003). Management of Drug and Alcohol Withdrawal. NEJM 349: 405-407
  4. ^ Management of alcoholic hepatitis, Drug and Therapeutics Bulletin 2003;41:49-52; doi:10.1136/dtb.2003.41749
  5. ^ DeBellis, R., Smith, B. S., Choi, S., Malloy, M. (2005). Management of Delirium Tremens. J Intensive Care Med 20: 164-173

Acute alcohol intoxication
Classification and external resources
ICD-10 F10.0, T51.
ICD-9 305.0, 980

Contents

Acute alcohol intoxication can result from a high level of alcohol in the bloodstream, accompanied by extreme drunkenness. The term acute alcohol intoxication is used by healthcare providers, often in emergencies. Toxicologists also speak of alcohol intoxication to discriminate from other toxins researched in the field.

Epidemiology

File:Borracho botado en la
A drunken male on the ground.

The condition is frequently found in either young people who are being exposed to commonly available alcoholic beverages like beer, wine, and distilled liquor for the first time, and don't know their limits, or by people suffering from alcoholism who ingest much more than they usually do.

Pathophysiology

Ethanol is metabolised to acetaldehyde by alcohol dehydrogenase (ADH), which is found in many tissues, including the gastric mucosa. Acetaldehyde is metabolised to acetate by acetaldehyde dehydrogenase (ALDH), which is predominantly found in liver mitochondria. Acetate is used by the muscle cells to produce Acetyl-CoA using the enzyme acetyl-CoA synthetase, and the Acetyl-CoA is then used in the Citric Acid Cycle[1]. It takes roughly 90 minutes for a healthy liver to metabolize a single ounce, approximately one hour per standard unit.

Ethanol's acute effects are largely due to its nature as a CNS depressant, and are dependent on blood alcohol concentrations:

  • 20–99 mg/dL - Impaired co-ordination and euphoria
  • 100–199 mg/dL - Ataxia, poor judgement, labile mood
  • 200–299 mg/dL - Marked ataxia, slurred speech, poor judgement, labile mood, nausea and vomiting
  • 300–399 mg/dL - Stage 1 anaesthesia, memory lapse, labile mood
  • 400+mg/dL - Respiratory failure, coma and death

As drinking increases, people become sleepy, or fall into a stupor. Ultimately, the respiratory system becomes depressed, and the person will stop breathing. This is a common cause of death on college campuses. The most important thing for friends who witness someone "passing out" from too much alcohol is to get them emergency medical treatment. Commonly, comatose patients aspirate their vomit (resulting in vomitus in the lungs, which may cause "drowning" and later pneumonia if survived). CNS depression and impaired motor co-ordination along with poor judgement increases the likelihood of accidental injury occurring.[2]. It is estimated that about a third of alcohol related deaths are due to accidents (32%) or intentional injury (13.7%)[3].

In addition to respiratory failure and accidents caused by effects on the central nervous system, alcohol causes significant metabolic derangements. Hypoglycaemia occurs due to ethanol's inhibition of gluconeogenesis, especially in children, and may cause lactic acidosis, ketoacidosis and acute renal failure. Metabolic acidosis is compounded by respiratory failure. Patients may also present with hypothermia.

Avoidance of intoxication

Alcohol is metabolized by a normal liver at that rate of about one ounce (one "highball", a normal beer, a regular sized glass of wine) every 90 minutes.[citation needed] An "abnormal" liver, one with hepatitis, cirrhosis, gall bladder disease, cancer, etc, will have a slower rate of metabolism. One can delay the absorption of alcohol by drinking water and ingesting food, but it prolongs the un-metabolized alcohol in the body.[citation needed]

Diagnosis

In determining if someone is intoxicated it is necessary to observe their behavior while the subject is sober to establish a baseline, ruling out a preexisting condition such as hypoglycemia, usage of narcotics besides alcohol, mental health issues, etc. Several well known criteria can be used to establish a probable diagnosis. For a physician in the acute treatment setting, acute alcohol intoxication can mimic other acute neurological disorders, or is frequently combined with other recreational drugs that complicate diagnosis and treatment. Definitive diagnosis relies on a blood test for alcohol, usually performed as part of a toxicology screen. Many patients are uninhibited, especially when legal consequences are unlikely (e.g., no police are present), so they disclose information that simplifies the diagnosis.

Signs and symptoms

The signs and symptoms of alcohol poisoning include:

  • confusion
  • vomiting
  • dangerous anger
  • seizures (fits)
  • slow breathing (less than eight breaths a minute)
  • pale, bluish skin
  • cold and clammy skin[4]

Treatment

Emergency treatment for acute alcohol intoxication strives to stabilize the patient and maintain a patent airway and respiration, while waiting for the alcohol to metabolize:[5] Also:

  • Protect vital signs by monitoring ABCs, or Airway, Breathing, and Circulation, ie., if the person is thought risk for severe respiratory depression, consider an Endotracheal tube to protect the airway and assist with breathing.
  • Protect the airway from aspirating stomach contents that could cause aspiration pneumonia.
  • Treat Hypoglycaemia (low blood sugar) with 50ml of 50% dextrose solution and saline flush, as ethanol induced hypoglycaemia is unresponsive to glucagon.
  • Administer the vitamin thiamine, to prevent Wernicke-Korsakoff syndrome, which can cause a seizure (more usually a treatment for chronic alcoholism, but in the acute context usually co-administered to ensure maximal benefit).
  • Check urea and electrolytes to guide fluid replacement.
  • Apply Haemodialysis if the blood concentration is dangerously high (>400 mg%), and especially if there is metabolic acidosis.
  • Provide oxygen therapy as needed via nasal cannula or non-rebreather mask.

Additional medication may be indicated for treatment of nausea, tremor, and anxiety.

Prognosis

A normal liver detoxifies the blood of alcohol over a time that depends on the initial level and the patient's overall physical condition. An abnormal liver takes longer but still succeeds, as long as the alcohol doesn't cause liver failure.[6]

People who have been drinking heavily for several days or weeks may have withdrawal symptoms after the acute intoxication has subsided.[7]

References

  1. ^ Smith, C., Marks, Allan D., Lieberman, Michael, 2005, 'Marks' Basic Medical Biochemistry: A Clinical Approach, 2nd Edtn, Lippincott Williams & Williams, USA, p. 458
  2. ^ McArdle, P (2004). Substance abuse by children and young people. Arch. Dis. Child. 89: 701-704
  3. ^ The World Health Organisation (2007) Alcohol and Injury in Emergency Departments
  4. ^ http://www.nhs.uk/conditions/alcohol-poisoning/Pages/Introduction.aspx
  5. ^ Devi, G., Castro, V. J., Huitink, J., Buitelaar, D., Kosten, T., O'Connor, P. (2003). Management of Drug and Alcohol Withdrawal. NEJM 349: 405-407
  6. ^ Management of alcoholic hepatitis, Drug and Therapeutics Bulletin 2003;41:49-52; doi:10.1136/dtb.2003.41749
  7. ^ DeBellis, R., Smith, B. S., Choi, S., Malloy, M. (2005). Management of Delirium Tremens. J Intensive Care Med 20: 164-173

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