Alcohol and substance misuse Flashcards
signs of glue and solvent intoxification
Perioral rash
Eurphoria, agiration, drowsiness, slurred speech, unsteady gait
benzodiazepine and CNS depressant intoxification
Nystagmus, diplopia, strabismus, hypotonia, clumsiness, dilated pupils
amphetamine, ecstacy, cocaine, mephredrone intoxification features
Hyperstimulation, restlessness, pyrexia, sympathomimetic effects
Paranoia, violent behaviour, seizures
Cocaine: chest pain, arrhythmias, MI
skin complications of substance misuse
Cellulitis, abscesses, extensive skin necrosis, necrotizing fasciitis, tetanus, boutilism, anthrax
vascular complications of substance misuse
Phlebitis, DVT, bacterial endocarditis
Femoral artery: false aneurysms, fistulae, peripheral emboli
Limb pain, skin pallor, mottling, paraesthesiae in the presence of palpable peripheral pulses
Diffuse soft tissue damage: compartment syndromes, rhabdomyolysis, renal failure, irreversible limb damage necessitating amputation
orthopaedic complications of substance misuse
Injecting drug users: acutely painful joints, septic arthritis
Analgesia, blood cultures
diseases associated with alcohol misuse
Increased rate of heart disease
Malignancy
Stroke
Injuries
Road traffic fatalities
Drownings
Burn deaths
short term risk of alcohol misuse
Accidents and injuries: head injury
Violent behaviour and being a victim of violence
Unprotected sex: STIs
Loss of personal possessions
Alcohol poisoning; vomiting, fits, falling unconscious
long term risk of alcohol misuse
Heart disease
Stroke
Liver disease
Liver cancer
Bowel cancer
Mouth cancer
Breast cancer
Pancreatitis
Unemployment, divorce, domestic abuse, homelessness
Alcoholism
drugs used in alcohol misuse
benzodiazepines
disulfiram
acamprosate
benzodiazepine for alcohol misuse management
acute withdrawal
disulfiram for alcohol misuse management
promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase.
Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms.
Contraindications include ischaemic heart disease and psychosis
acamprosate for alcohol misuse management
reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials
history for acute alcohol intoxification
Unreliable
GI upset/ bleeding
Withdrawal fits
Blackouts
Peripheral neuropathy
Low mood, hallucinations, delusions, memory problems
Marital, work, driving, debt, criminality
CAGE questionnaire
Cut down
Annoyed
Guilty
Eye-opener
differentials for acute alcohol intoxification
Head injury
Hypoglycaemia
Post-ictal confusional states
Hepatic encephalopathy
Meningitis
Encephalitis
Intoxification with other drugs
management of acute alcohol intoxification
violent patients
comatose: protect airway, exclude hypo, XRAY/CT head
alcohol induced hypoglycaemia
features of alcohol withdrawal: within 12 hours of stopping
Anxiety
Restlessness
Tremor
Insomnia
Sweating
Tachycardia
Ataxia
management of alcohol withdrawal
Diazepam 5-10mg
Or chlordiazepoxide 10-30mg
Inpatient detoxification
features of delirium tremens
> 48 hours after stopping
Significant autonomic hyperactivity
Tachycardia
Hyper-reflexia
Hypertension
Fever
Visual/ tactile hallucinations
Sinister delusions
Disorientation
Confusion
Deaths from arrhythmias, infection, fits or cardiovascular collapse
management of delirium tremens
Monitor
BMG
IV diazepam
Refer to medical team
alcohol withdrawal fits mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
features of alcohol withdrawal fits
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
Self-limiting grand mal seizures
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
management of alcohol withdrawal fits
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
Check BMG and treat fits
Examine for head injury
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
alcoholic ketoacidosis features
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
1-2 days after last binge with vomiting
Signs of chronic alcohol misuse
High anion gap for metabolic acidosis
management of alcoholic ketoacidosis
The most appropriate treatment is an infusion of saline & thiamine. Thiamine is required to avoid Wernicke encephalopathy or Korsakoff psychosis.
Monitor UE and glucose
wernicke encephalopathy features
nystagmus (the most common ocular sign)
ophthalmoplegia
ataxia
confusion, altered GCS
peripheral sensory neuropathy
invesitgations of wernicke encephalopathy
decreased red cell transketolase
MRI
management of wernicke encephalopathy
The treatment is with high-dose intravenous thiamine which is usually given as Pabrinex IV.
Left untreated, the condition can progress to Korsakoff’s syndrome. This syndrome affects the mammillary bodies to cause irreversible deficits in anterograde and retrograde memory.
korsakoff syndrome
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
Untreated, Wernicke’s encephalopathy can progress to Korsakoff’s syndrome.Korsakoff’s syndrome presents as profound anterograde amnesia with limited retrograde amnesia. Patients may therefore confabulate (fabricate memories to mask the memory deficit).
