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Clin Tox Exam 1 > Alcohol > Flashcards

Alcohol Flashcards

1
Q

Common products with alcohol content

A

Aftershave lotions - 15-80%
Mouthwash - 15-25%
Perfumes/colognes - 25-95%

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2
Q

Alcohol Proof =

A

2X the percentage of alcohol per the volume

I.E. Everclear 185 proof = 95% alcohol

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3
Q

Standard drink =

A
  1. 6 fluid ounces or 14 grams of pure ethanol

- 12 oz beer, 8-9 oz malt liquor, 5 oz wine, 1.5 oz brandy, 1.5 oz shot of 80 proof spirits

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4
Q

“At-risk” or “heavy” drinking

A

Men: >4 drinks on any day or 14 per week
Women: >3 drinks on any day or 7 per week

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5
Q

Adipose + Alcohol

A

More adipose tissues, the decrease the volume of distribution which increases the blood volume concentraiton

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6
Q

Age + Alcohol

A

Decreased renal function with increased age = reduced elimination
Children = higher metabolic rate

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7
Q

Chronic use + Alcohol

A

Rate of elimination increases

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8
Q

Food + Alcohol

A

Delays absorption of alcohol

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9
Q

Ethanol Absorption

A

80% small intestine, remainder in the stomach

ETOF: 20% optimal - champaign (get you drunk quick)

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10
Q

***Ethanol Distribution

A

Adults 0.6L/kg

Children 0.7L/kg

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11
Q

Ethanol Metabolism and Elimination

A

Alcohol → acetaldehyde → acetate → purine acid synthesis
Zero order elimination - no matter how much you intake, it will continue to eliminate at the same rate (chronic alcoholism lead to 2E1 kicking in taking ethanol to acetaldehyde)
Catalase takes peroxide to water to acid aldehyde

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12
Q

All the pathways of ethanol metabolism lead to

A

Accumulation of acetaldehyde which blocks the production of glutathione and 2E1 is waht take APAP to NAPQI (toxic metabolite
Acetaldehyde causes → NADH accumulation → energy pathway is saturated → energy is stored as fat (glycogen stores) → Excess fats cause TG synthesis increase → fatty liver → cirrhosis

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13
Q

***Ethanol Metabolism Rate

A

Adults: 20mg/dL/hr

Chronic alcoholics: 40 mg/dL/hr

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14
Q

***Ethanol Calculation

A

Serum Concentration = (mL of ethanol X % ethanol X 0.8)/ (Vd (L/kg) X kg)

Vd = 0.6 for adults and 0.7 for kids

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15
Q

Ethanol’s effects on the brain

A

Acute: Depress inhibitory neurons which makes you feel good
Chronic: Depletes glutamate too so that high feeling doesn’t happen

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16
Q

***Acute Ethanol Toxidrome

A

Stage 1: Talkative, noisy, morose - Feel Good
Stage 2: Mental impairment - Drunk
Stage 3: N/V - Sick
Stage 4: Hypothermia, amnesia, anesthesia - Passing Out
Stage 5: Coma, respiratory failure - Dead

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17
Q

Nontolerant Individual + Blood Alcohol Level

A 
Less than 50mg % - Stage 1
50-100 mg% - Stage 2
100-200: Dangerous to drive
200-300: Stage 3
300-400: Stage 4
400-700: Stage 5
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18
Q

Osmolality Formula

A

2X Na + (glucose/18) + (BUN/2.8)

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19
Q

Osmolal Gap Formula

A

Measured should be +/- 5 (>5 = unmeasured alcohol) mOsm/kg

Osmolality measured - calculated

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20
Q

Ethanol MW

A

46

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21
Q

Isopropanol MW

A

60

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22
Q

Methanol MW

A

32

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23
Q

Ethylene Glycol MW

A

62

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24
Q

CAGE Questions

A

Felt like you should CUT down on your drinking?
Have people ANNOYED you by criticizing you?
Have you every felt bad or GUILTY
EYE-opener: drink first thinking in the morning?

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25
Q

Ethanol Withdrawal Syndromes

A

Sharply decreased consumption or intercurrent illness - mild tremor and anxiety to hallucination/convulsions
Common in regular heavy drinkers
Abstinence syndrome (shake, tremors, HTN)
Alcoholic hallucinosis - tactile and visual not auditory
Seizures or delirium tremens

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26
Q

Intoxication Vital Signs

A

Normal or decreased temperature
Elevated pulse
Normal BP
Decreased RR!!!

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27
Q

Withdrawal Vital Signs

A

Normal or elevated temperature
Elevated pulse
Normal or elevated early and then orthostasis
Elevated RR!!!

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28
Q

Ethanol OD Treatment

A

Emergency Stabilization
Emesis up to 1 hour after ingestion
Hemodialysis (blood alcohol level > 500, hypotension)
Supporitve Care (ventilation, Mg, thiamine)

29
Q

Ethanol Withdrawal Treatment

A

Benzo- lorazepam (ONLY IF THEY HAVENT HAD ALCOHOL RECENTLY)

Haldol for hallucinaitons

30
Q

Isopropyl Alcohol main ingredient =

A

Rubbing alcohol and twice as potent as ehtanol

31
Q

Lethal dose of Isopropyl Alcohol

A

240 mL

32
Q

Isopropryl Alcohol Kinetics

A

Re-secreted in the saliva and stomach
Main toxin is the alcohol itself not the metabolites
Eliminated in the kidney and lungs (fruity breath)

33
Q

Isopropryl Alcohol TOxidrome

A
  1. GI effects (gastritis, vomiting)
  2. CNS Depression (dizziness), HYPOTENSION, respiratory depression
  3. Coma
  4. Toxic symptoms at level of 50 mg/100 mL and coma at 120 mg/100 mL
  5. Cross reacts with analytical methods to detect levels
34
Q

Treatment of Isopropyl ALcohol

A

Emergency Stabilization (ABCDEF)
GASTRIC LAVAGE!!!!
Hemodialysis ( Level >400 or hypotensive)
Supportive care = ventilation

35
Q

Methanol Produced and From

A

Distillation of wood

From contaminated moonshine in old radiators or windshield washer fluid

36
Q

Methanol Kinetics

A

Methanol –> Formaldehyde through alcohol dehydrogenase –> formic acid through aldehyde dehydrogenase –> metabolic acidosis or formate and broken down by folate

37
Q

Methanol Toxic Dose

A

15 mL of 40% solution but 30 mL is lethal

10 mL can cause blindness!!!

38
Q

Early Stages of Methanol Poisoning

A

Methanol to formaldehyde to formic acid to metabolic acidosis (fire ants use this)

39
Q

Formaldehyde causes what toxicity?

A

Pickles your brain and eyes

40
Q

Define circulus hypoxicus

A

Tissue hypoxemia from formaldehyde

41
Q

Methanol Toxidrome

A
  1. CNS: headache, coma convulsions
  2. GI: N/V, pancreatitis
  3. Ocular Toxicity: blurred vision, constricted visual fields, DILATED pupils (formaldehyde)
  4. Metabolic acidosis secondary to formic and lactic acids (formate > 20 mg/dL)
42
Q

ALL ALCOHOLS HAVE WHAT SYMPTOMS?

A

CNS depression and N/V

43
Q

Methanol and Formate concentrations

A

Methanol falls and formate increases over time

44
Q

Methanol: anion gap and osmolal gap?

A

Early: anion gap is low, osmolal gap is high
Later: switches

45
Q

Treatment of Methanol OD

A

Emergency Stabilizaiton

Emesis or lavage within 2 hours of ingestion and up to 4 hours if coma or co-ingestion

46
Q

Fomepizole (Antizol) MOA

A

Affinity for alcohol dehydrogenase that is 8000 times greater than ethanol
- Competitive inhibitor of alcohol dehydrogenase and CYP P450

47
Q

Fomepizole Distribution, Metabolism, Excretion

A

Low protein binding and Vd 0.6-1.2 L/kg
MM kinetics - induces its own metabolism
Extensively cleared by hemodialysis (increase dose)

48
Q

Fomepizole Efficacy

A

Essentially replaced ethanol but NEED HIGHER DOSE in HD

49
Q

Fomepizole Indication

A

Methanol > 20 mg/dL
History of methanol ingestion and OG > 10 mOsm/kg
History of strong clinical suspicion and 2 of the following: arterial pH less than 7.3, bicarbonate less than 20, OG > 10, visual changes

50
Q

***Fomepizole Dosing

A

LD = 15 mg/kg
MD: 10 mg/kg Q12H X 4 doses then 15 mg/kg Q12H until the methanol concentration is less than 20 and patient is asymptomatic with a normal pH
- HD: increase MD to Q4H during HD or continuous infusion of 1-1.5 mg/kg/hr

51
Q

Ethanol MOA

A

Alcohol dehydrogenase attaches to ethanol with 20 X more affinity than methanol (ethanol levels maintained at above 100 mg/dL)

52
Q

Indication for Ethanol over Fomepizole?

A

Unavailable or hypersensitive to fomepizole

53
Q

Leucovorin and Folic Acid Dosing

A

Symptomatic: 1 mg/kg (up to 50 mg X 1) then folic acid 1 mg /kg (up to 50mg) Q4H X 6 doses
Asymptomatic: 1 mg/kg folic acid Q4H X 6 doses
- Increase during HD or chronic alcoholics

54
Q

When to use leucovorin?

A

ALWAYS FIRST LINE IF SYMPTOMATIC

55
Q

Hemodialysis Indications

A

Methanol > 50 mg/dL (continue until less than 25)
Metabolic acidosis not immediately correctable with bicarb
Visual Impairments
Deteriorating vital signs
Renal failure
Electrolyte imbalance

56
Q

Supportive Care

A

Correct metabolic acidosis with sodium bicarbonate (correct up to 15)
Monitor for sever hypoglycemia, hypocalcemia, myogloinuria (pancreatitis)
Phenytoin for seizures

57
Q

Ethylene Glycol From and Letahl Dose

A

Antifreeze/Coolant
Dose: 1-1.5 mL/kg
As much as one swallow can kill a small child

58
Q

Ethylene Glycol Kinetics

A

EG –> glycoaldehyde via alcohol dehydrogenase –> glycolic acid via aldehyde dehydrogenase –> glyoxylic acid via lactate dehydrogenase –> oxalic acid or alpha/beta ketoadipic acid through thiamine or glycine through pyridoxine Mg

59
Q

Primary metabolite for ethylene glycol

A

Glycolic acid

60
Q

Cystals from ethylene glycol?

A

Oxalic acid + Calcium form crystals that can deposit in the cardiopulmonary tree

61
Q

Ethylene Glycol Toxidrome

A
  1. CNS depression (N/V, coma)
  2. Tachycardia, HTM, edema (crystals)
  3. Kidney stones due to crystals, acute renal failure
  4. Metabolic acidosis
62
Q

Ethylene Glycol Labs

A

Hypocalcemia –> tetany and ST prolongation
Sever metabolic acidosis
Eleavted osmolal gap

63
Q

**What labs do you always get for EG?

A

Ca, EKG, chesty X-ray

64
Q

EG Treatment

A

Emergency Stabilization
Supportive care (correct acidosis-bicarb)
Antidote (thiamine, pyridoxine, fomepizole, ethanol)
Hemodialysis

65
Q

EG Antidote Need when:

A

Conc > 20
Recent history of ingesting toxic amounts of EG and OG > 10
History of strong suspicion of EG poisoning and at least 2 of the following: arterial pH less than 7.3, bicarb less than 20, osmolal gap . 10, crystal spresent

66
Q

Thiamine Dose

A

100 mg IV daily

67
Q

Pyridoxine Dose

A

100 mg IV daily

68
Q

Hemodialysis in EG OD

A

Mainstay - dramatically increases the clearance of EG

69
Q

Hemodialyis in EG Indication

A

Deteriorating vital signs
Metabolic acidosis 7.25-7.3
Renal failure or electrolyte imbalance
Continue fomepizole until concentration less than 20 and the patient is asymptomatic with normal pH

Clin Tox Exam 1 (5 decks)

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