Alcohol and alcohol abuse Flashcards
What is an alcohol unit?
1 unit of alcohol is 10 ml or 8g of pure ethanol
The total volume of alcohol multiplied by % of alcohol divided by 1000
What are the safe units of alcohol consumption for both genders?
14 units per week.
What is alcohol withdrawal syndrome (AWS)?
This is caused by abstinence from alcohol in people with alcohol dependence.
What is the pathophysiology of AWS?
Chronic alcohol use results in up-regulation of NMDA receptors and downregulation of GABA receptors.
Characterised by signs of overactivity of the nervous system.
What are the signs and symptoms of AWS?
A mild AWS includes tremor, weakness, headache, sweating, hyperreflexia and GI symptoms.
Tachycardia may be present and BP may be slightly elevated.
Symptoms usually begin about 6h of cessation.
Alcoholic hallucinosis follows abrupt cessation from prolonged excessive alcohol use, usually within 12-24 hours. Hallucinations are usually visual.
Delirium tremens usually begins 48-72 hours after alcohol withdrawal.
What is delirium tremens?
This is an acute confusional state which results when someone who drinks excess alcohol daily, suddenly stops drinking.
Untreated it results in seizures and even death.
Symptoms include anxiety attacks, increasing confusion, poor sleep with frightening dreams or nocturnal illusions, profuse sweating, and severe depression also occur.
This is why patients are advised to reduce their drinking gradually, which allows receptors in the brain to adapt, or they are started on detoxification regimens.
Diagnosis of AWS
Blood Alcohol content.
Evaluation to rule out hypoglycaemia and occult trauma and possible co-ingestion.
With chronic use, FBS, magnesium, liver function tests and PT/PTT should be done.
Evaluation to rule out CNS injury and infection.
How should you assess AWS?
- Risk assessment tools such as CIWA–Ar scale should be used to identify hospitalised patients who are at risk of developing complicated AWS.
- As well as clinical judgement.
- The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome and to monitor and medicate patients throughout withdrawal.
What is the DSM-5 criteria for AWS?
- A: Cessation of or reduction in alcohol intake, which was prolonged/heavy.
- B: A + any on 2 of the following symptoms developing within several hours to a few days: autonomic hyperactivity, worsening tremor, insomnia, vomiting and nausea, hallucinations, psychomotor agitation, anxiety, generalised tonic-clonic seizures.
- C: The above symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
- D: The above symptoms are not due to other causes.
DSM-5 criteria for delirium tremens?
A: Decreased attention and awareness
B: Disturbance in attention and awareness (a change from normal level)
C: Disturbance in memory, orientation, language, visuospatial ability or perception
D: No evidence of a coma
E: History indicates that the disturbance is due to alcohol withdrawal.
What is the CAGE tool?
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?
What is the FAST tool?
FAST is an alcohol harm assessment tool. It consists of a subset of questions from the full alcohol use disorders identification test (AUDIT).
FAST was developed for use in emergency departments but can be used in a variety of health and social care settings.
1) How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
2) How often during the last year have you failed to
do what was normally expected from you because of your drinking?
3) How often during the last year have you been unable to remember what happened the night before because you had been drinking?
4) Has a relative or friend, doctor or other health
worker been concerned about your drinking or
suggested that you cut down?
An overall total score of 3 or more on the first or all 4 questions is FAST positive.
What to do next?
If your score is FAST positive, complete remaining AUDIT alcohol screening questions;
What are the health effects of Alcohol?
Cardiac arrhythmias.
Hypoglycaemia due to excess NADH.
Fetal alcohol syndrome
Lactic acidosis impairs renal excretion of uric acid which can cause gout.
Cirrhosis
Alcohol hepatitis
Wernicke’s encephalopathy (thiamine- vitamin B and C deficiency)
Increased risk of head & neck cancers
Pancreatitis
Erosive gastritis
Decreased effects of therapeutic drugs such as warfarin and antibiotics
Systemic HTN and peripheral neuropathy
ALD
Mallory-Weiss syndrome
Treatment of AWS
CIWA–Ar score > 10 and suspected alcohol withdrawal:
First line:
Supportive care + treatment of concurrent acute medical illness (Fluids, correct metabolic abnormalities, check for signs of liver disease)
Benzodiazepine or carbamazepine or clomethiazole (Chlordiazepoxide is usually used)
Thiamine to prevent or treat Wernicke’s encephalopathy
CIWA-Ar score < 10:
First line:
Supportive care + treatment of concurrent acute medical illness (Fluids, correct metabolic abnormalities, check for signs of liver disease)
Thiamine
Benzodiazepine or carbamazepine or clomethiazole
Treatment of psychosis (including refractory delirium tremens) in AWS
Add an antipsychotic if the patient still has psychotic symptoms after receiving approximately ≥130 mg chlordiazepoxide in the first hour of treatment.
Haloperidol and olanzapine are commonly used.
Consider phenobarbital if psychotic symptoms continue despite the use of a benzodiazepine and an antipsychotic.
Consider rapid tranquillisation if psychotic symptoms continue despite high doses of a benzodiazepine and addition of an antipsychotic or phenobarbital. Involve critical care.
Use midazolam or ketamine or propofol. Decide which drug to use based on your choice/training and according to local protocols.
