Alcohol-related Emergencies

Be it a pint of cold beer on hot summer’s day or a glass of peppery shiraz after a day of hard work—my preferred poison is alcohol! So of course I’m going to hate covering this topic!

Alcohol intoxication

·      Slurred speech, disinhibition, lack of coordination, CNS depression

·      Hypotension (peripheral vasodilation)

·      Nystagmus, diplopia, dysarthria, ataxia, sometimes can progress to coma

·      If obtunded, need to rule out

o   head trauma/intracranial hemorrhage

o   Other drugs

o   Hypoglycemia

o   Hepatic encephalopathy: confusion, altered LOC, coma

o   Wernicke’s encephalopathy: ataxia, ophthalmoplegia, delirium

o   Postictal state

o   Basilar stroke

Complications of alcohol intoxication:

·      Cardiovascular

o   Hypertension

o   Cardiomyopathy: SOB, edema

o   Dysrhythmia “holiday heart”

§  Atrial fibrillation most common

§  Atrial flutter

§  SVT and VT (especially Torsade’s if hypomagnesemic or hypokalemic)

·      Metabolic

o   Alcoholic ketoacidosis

§  History of chronic alcohol intake and abrupt cessation/decrease

§  Malnutrition

§  Abdominal pain with nausea and vomiting

§  Classic combo: metabolic acidosis with big anion gap, urine ketones, low glucose, and normal osmolality

§  Treatment: thiamine 100mg IM/IV, dextrose, volume replenishment with normal saline

§  Usually resolves in 12~24 hours

o   Ingestion of other alcohols—produces severe metabolic acidosis with anion gap while ethanol co-ingestion has a protective effect

§  Ethylene glycol

·      CNS, CVS, renal abnormalities

§  Methanol

·      Early: lethargy, confusion

·      Late: headache, visual disturbances, nausea and vomiting, abdominal pain, tachypnea

§  Treatment

·      Urgent hemodialysis

·      Fomepizole IV bolus OR ethanol 10% IV bolus and infusion

·      Reduce active metabolites by giving folic acid for methanol ingestion and pyridoxine and thiamine for ethylene glycol ingestion

o   Other abnormalities associated with alcohol (CKPMS)

§  Hypocalcaemia (C)

§  Hypokalemia (K)

§  Hypophosphatemia (P)

§  Hypomagnesaemia (M)

§  Hypoglycemia (S)

·      Gastrointestinal

o   GI bleeds

o   Gastritis

o   Pancreatitis

o   Hepatitis

o   Spontaneous bacterial peritonitis

Beware of alcohol withdrawal!

Time since last drink	Syndrome	Description
6~8 hours	Mild withdrawal	Generalized tremor, anxiety, agitation, no delirium, autonomic hyperactivity such as sinus tachycardia, insomnia, nausea, vomiting
1~2 days	Alcoholic hallucinations	Visual (most common), auditory, and tactile hallucinations Vitals often normal
8 hours ~ 2 days	Withdrawal seizures	Typically brief generalized tonic-clonic seizures that may occur in clusters within a few hours CT head if focal seizures have occurred
2~5 days	Delirium tremens	Occurs in 5% of untreated withdrawal patients and has a high mortality rate Severely confused state, fluctuating LOC, agitation, insomnia, hallucinations/delusions, tremor, tachycardia, fever, diaphoresis

Treatment:

·      Diazepam or lorazepam IV/PO every hour until calm

·      Frequency of dosages vary depending clinical response

·      Thiamine IM/IV

·      If hypomagnesemic, give magnesium sulfate IV over 1~2 hours

·      Admit patients with delirium tremens or multiple seizures

Before letting the patient leave the ER ensure that his vital signs are stable and that he is fully oriented and can walk unassisted. Social service referral can be made to help seek shelter or detox program. Ensure the patient can obtain any medications prescribed and complete any necessary followup.

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