Ethanol and Toxic Alcohols Flashcards
Alcohol withdrawal
Onset 6-24 hours
Unopposed CNS and sympathetic stimulation:
SYMPATHETIC:
Tremor
Anxiety
Agitation
Sweating
Tachycardia, HTN, hyperthermia
Nausea and vomiting
Then, NEUROEXCITATION:
Hyperreflexia
Vivid dreams, hallucinations
Gen. Tonic clonic seizures
—> Delirium tremens (day 3) FLORID DELIRIUM
Delirium tremens: about
Mortality 8%
Usually day 3
Heralded by sudden, global FLORID DELIRIUM and HYPERADRENERGIC state
(In addition to other autonomic and neuroexcitation features of etoh withdrawal)
Differentials for confusion in alcoholic:
ALCOHOL RELATED:
Intoxication
Withdrawal (DTs)
Wernicke’s
Alcoholic ketoacidosis
Toxic alcohol
OTHER:
Post ichtal
Encephalopathy
CNS infection
TBI
Cerebrovascular (more likely focal)
Other toxic/ OD
Metabolic: Na, glycaemia, oxia, carbia, thermia
Treatment of alcohol withdrawal
Admit- peak is day 3
AWS
Regular BZD:
—> Eg. 5-20mg oral diazepam as per AWS
Thiamine 200mg IV diazepam, TDS. Then 100 PO daily
Monitor BSL and electrolytes
Link with D&A (if consent)
Delirium tremens:
- Resus room, IV access etc.
- IV diazepam until seizure and agitation controlled.
—> 10mg IV stat, then repeat and increase Q5min. 20, 20, 30, 30, 40, 40.
- If refractory seizure (reach 200mg): tube and give Barbiturate (eg. Thiopentone or Phenobarbitone) or Propofol
Blood alcohol level correlation with symptoms:
For non-dependant:
11 / .05% disinhibition/ euphoria
22 / .1% slurring, impaired judgement, poor coordination
44 / .2% potential for coma
88 / .4% comatose, resp depression, hypotension
** tolerance varies hugely
ETHYLENE GLYCOL
Antifreeze
Coolant
Car oil
Brake fluid
Paints and solvents
R
Deliberate presumed lethal
>1ml/kg can be lethal
Mouthful+ dangerous in kids
Toxicity from metabolites: glycolic acid and lactate. Calcium oxylate crystals form in kidneys, heart, brain.
Ie.
1-2 hours, presents like ethanol.
4+ hours:
RAGMA
LACTIC ACIDOSIS
HYPOCALCAEMIA
HIGH OSMOLAR GAP
(Pathognomic)
—> renal failure.
concurrent ethanol delays the onset of symptoms. BEWARE.
Check:
Ethanol level
Gas: pH, lactate, Ca (pathhognomic)
Urine for CaOx crystals
OSMOLAR GAP >10
EG level (if available)
Mx:
AC not useful
Tx hypoCa only if ECG change/ refractory seizure
ETHANOL (or fomepizole)
—> bridging only
—> 3x40ml vodka shots PO/NG as load (unless coingestant)
—> 1x40ml shot hourly as maintenance
PYRIDOXINE, THIAMINE
HAEMODIALYSIS (specific criteria)
Observe at least 4 hours.
* if concurrent ethanol, KEEP LONGER
Indications for haemodialysis in ethylene glycol poisoning:
Proof of toxicity!
1ml/kg ingestion (>mouthful) and Osmolar gap >10
PH <7.3
Acute renal failure
EG level >3.2mmol/L (if available)
*use lactate free dialysate with added HCO3. Check gases 4-hourly post ?need to redialyse.
ISOPROPYL ALCOHOL (isopropanol):
Hand sanitiser
Disinfectants
Window cleaner
Perfume
Similar syndrome to ethanol but MORE POTENT: more rapid onset, smaller doses required, and enebriated for longer.
> 3ml/kg adults, >3ml full stop children (incl transdermal)
Deliberate is high risk of coma
Danger is airway, resp depression, coma.
Causes ACETONES and KETOSIS without significant acidosis.
Check:
Gas: OSMOLAR GAP WITHOUT SIGNIF ACIDOSIS
Ketones
Acetate level
Mx:
Supportive
Observe at least 2 hours
METHANOL
Home distillery
Solvents
Dyes/ stains
Racing car fuel
NOT METHYLATED SPIRITS
> 0.5ml/kg lethal
Deliberate presumed to be lethal
Mouthful+ dangerous in kids
Metabolite is formic acid —> direct cytotoxicity.
coingested ethanol can mask clinical and ABG findings
Initial enebriation same as ethanol
Okay for 12-24 hours, then:
- Headache
- Vertigo
- Blurred/ “snowstorm” vision —> PAPILLOEDEMA —> Blindness
- Coma and seizure
Long term: permanent blindness, EPS
Check:
Ethanol level
Gas: RAGMA with raised LACTATE and OSMOLAR GAP
CTB: basal ganglia isch/haemorrhage
Mx:
Supportive
FOLINIC/FOLIC ACID
ETHANOL (or fomepizole) bridging
HAEMODIALYSIS (specific criteria)
Observe at least 8 hours
What MUST be considered in the drunk patient with a metabolic acidosis?
TOXIC ALCOHOL INGESTION
Methanol
Ethylene glycol
Either as DDx, or as coingestant
Toxic alcohol + ethanol = delayed symptom onset, and some masking on ABG.
CHECK OSMOLAR GAP.
Why must alcoholics be given thiamine
BEFORE glucose?
Thiamine 200mg IV initially
Required for glucose metabolism. Glucose load when deficient can cause overt Wernicke’s encephalopathy.
Identifying hazardous drinking: CAGE
Have you ever tried to Cut down?
Have you been Annoyed by comments about your drinking?
Do you feel Guilty?
Do you need an Eye-opener?
Osmolar gap?
- toxic alcohol
Osmolar gap + lactic acidosis?
- Ethylene glycol
Or
- Methanol
Osmolar gap + lactic acidosis + hypoCa?
- Ethylene glycol
