MedEd acute withdrawal Flashcards
What is alcohol withdrawal?
Physiological and physical symptoms that arise when someone with alcohol dependancy stops or reduces alcohol intake within hours or days of presentation
What 2 receptors are involved in alcohol withdrawal? Which is excitatory and which is inhibitory?
NMDA receptors- excitatory
GABA (type A) receptors- inhibitory
Are NMDA receptors excitatory or inhibitory?
Excitatory
Are GABA type a receptors excitatory or inhibitory?
inhibitory
In chronic alcoholism what receptors are upregulated/ downregulated?
NMDA receptors are upregulated
GABA type a are downregulated
In acute alcohol what is the receptor balance?
GABA type a receptors are a lot higher than NMDA
In alcohol withdrawal what is the receptor balance?
NMDA receptors are a lot higher than GABA type a
What are RF for alcohol withdrawal?
Alcohol use disorder
Hx of alcohol withdrawal
Poor physical health
What are signs of chronic or decompensated liver disease? What molecules cause these
High ammonia- encephalopathy
Albumin- causes ascites and peripheral oedema
Bilirubin- causes jaundice
Reduced clotting factors- causes bruising
What is the triad for wernicke’s encephalopathy and what acronym is used to remember?
CAN:
confusion
ataxia
nystagmus
What is deficient in wernicke’s encephalopathy?
B1 and thiamine
What does thiamine and B1 deficiency cause?
Wernicke’s encpehalopathy
What are the 4 stages of alcohol withdrawal over time?
minor withdrawal symptoms
alcoholic hallucinations
withdrawal seizures
withdrawal delirium
As time from presentation progresses what stages of alcohol withdrawal are reached and when?
6-12 hrs= minor withdrawal symptoms
12-24hrs= alcoholic hallucinations
24-48 hrs= withdrawal seizures
48-72 hrs= withdrawal delirium
What are minor alcohol withdrawal symptoms?
Anxiety
Agitation
GI upset
Sweating/tremor
What type of withdrawal seizures occur in alcohol withdrawal?
Generalised tonic clonic seizures
What is seen in withdrawal delirium in alcohol withdrawal?
Delirium tremens
Severe tremor
Fever
High BP and HR
What are differentials for alcohol withdrawal?
Hypoglycaemia
Hepatic encephalopathy
Meningitis
How does hypoglycaemia present?
Tremors Palpitations Anxiety Seizures Drowsiness
How does hepatic encephalopathy present?
tremors anxiety palpitations anxiety seizures
What is the triad for meningitis and what is the limitation of this triad?
Fever
Altered mental status
Nuchal rigidity
not all patients present with nuchal rigidity
What scale is used to assess severity of alcohol withdrawal?
CIWA-AR scale
What ix might you do bedside for alcohol withdrawal and what will you see?
Screening- use CIWA-AR to assess severity
ECG- electrolyte abnormalities cause changes
VBG- resp alkalosis or metabolic acidosis or metabolic alkalosis with a high anion gap
What is seen on bloods for alcohol withdrawal?
Glucose- hypoglycaemia FBC- high MCV, thrombocytopenia UEs- electrolyte deficiency LFT- elevated AST, ALT, GGT Coagulation studies- prolonged INR and PT
How is alcohol withdrawal managed?
Urgent= benzodiazepines, CT head, detect and treat co existing illness
Supportive treatments= rehydrate with IV fluids, pabrinex (vitamin B), glucose if hypoglycaemic, correct electrolyte imbalances
What is pabrinex and when is it given?
it is vitamin b and its given as supportive treatment eg alcohol withdrawal
When treating alcohol withdrawal what is it important to remember when giving glucose?
Only give it after thiamine but dont delay if hypoglycaemia is life threatening
What can you refer patients to for long term underlying alcohol dependance?
DALs, community services, therapy
How will someone with alcohol dependance present?- include the signs of which 2 conditions
Signs of chronic liver failure- jaundice, ascites/peripheral oedema, bruising
Signs of Wernicke’s encephalopathy- confusion, ataxia, nystagmus
What 3 molecules are associated with chronic liver failure and can help you remember what signs chronic liver failure causes?
Albumin
Bilirubin
Clotting factors
What benzodiazepines might be used in alcohol withdrawal? Include what is used in emergenices and then long term
Lorazepam- use in emergencies
Chlordiazepoxide- use long term to wean patients off alcohol
What benzodiazepine is used in emergency in alcohol withdrawal?
Lorazepam
What benzodiazepine is used in long term in alcohol withdrawal?
Chlodiazepoxide
If in A-E assessment breathing is an issue and o2 sats are low what should you do straight away?
15L oxygen via non rebreathe mask then reassess
If in A-E assessment circulation is an issue and BP is low/ cap refill is prolonged/ signs of hypovolemia what should you do straight away?
Ask a nurse to put in 2 wide bore 18g cannulas in each arm
What dose of adrenaline is given to adults and how is it administered?
500 microgram IM injection
What 2 skin changes are seen on exposure of a patient in anaphylaxis?
Utricarial rash and angioedema
How do you manage someone with anaphylaxis?
Call for help
Remove trigger eg IV abx
Lie the patient flat and raise their legs
Give 500 microgram IM adrenaline asap- do not delay
Reassess their airway and see if its patent
Then later on 15L/min via non rebreather mask o2, monitor obs, IV fluids and Im or slow steroids
What is anaphylaxis?
A life threatening systemic hypersensitivity reaction characterised by sudden onset life threatening airway/ breathing/ circulation problems with or without skin changes after exposure to a trigger
What are common triggers of anaphylaxis?
Food- nuts, shellfish, eggs
Drugs/chemicals- penicillin, NSAIDs, latex
Toxins- bee/wasp sting, venom
What are RF for anaphylaxis?
hx of atopy
Describe the pathophysiology behind and anaphylactic reaction
b cells are sensitised by an antigen they produce IgE antibodies IgE causes mast cell degranulation mast cell degranulation causes release of cytokines and histamines cytokines produce white cells there is vessel dilation vessels become leaky there is bronchospasm
What will be elevated on bloods in anaphylaxis?
Serum typtase and plasma histamine
How will anaphylaxis present?
resp symptoms: SOB, stridor, wheeze
circulation symptoms: pale and clammy, hypotension
skin/mucosal symptoms: flushing, urticaria, angioedema
What steroids might be given in anaphylaxis?
Chlorphenamine
Hydrocortisone
What aftercare is done for someone post anaphylaxis?
Observe
Safety net
Give epipen
refer to allergy services
How much aspirin needed for an OD? How is needed for severe OD?
> 150mg/kg
>500mg/kg is severe
What are differentials for aspirin OD?
DKA
Paracetamol OD
What do you need to get in a hx for aspirin OD?
What was the amount/ how was it prepped?
Was in intentional or accidental?
Was it isolated to mixed with something?
What is seen on examination of someone with aspirin OD?
Warm peripheries Bounding pulse Tachypnoea Hyperventilation Cardiac arrhythmia Acute pulmonary oedema
How does aspirin OD present? Describe the early and late symptoms?
Early= tinnitus, hyperpnoea, hyperthermia and sweating, NV, diarrhoea Late= Low BP and heart block, pulmonary oedema, low GCS, seizures
What bedside ix are done for aspirin OD and what would you see?
ECG- monitor arrhythmias
ABG- hyperventilation causes resp alkalosis wich progresses to high anion gap metabolic acidosis
What clinical ix would you do for aspirin OD? Why are they done and what would you see?
Plasma salicylate conc- do at least 2 hrs after ingestion and then repeat every 2 hrs until peak conc is reached
Plasma paracetamol conc- to check if its a mixed OD
FBC- to exclude infectious aetiology
UEs- check for hyperkalemia as this is common
LFT- to see if theres hepatic dysfunction
Coagulation- check INR and PT
What imaging might you do for aspirin OD and why?
CT head if theres altered mental status
How is an aspirin OD classified? Give specific ranges
Mild toxicity= <300mg/L
Moderate toxicity= 300-700 mg/L
Severe toxicity= >700 mg/L
How is aspirin OD managed?
There is no antidote
Mainly supportive management
Consider ITU admission if moderate or severe
What dose is needed for paracetamol OD and what dose is fatal?
OD is >150mg/kg
12g can be fatal
What are differentials for paracetamol OD?
Hep A/B
Ischaemic hepatitis
How will someone with paracetamol OD present if within 24 hrs?
Usually asymptomatic
They may have mild NV and lethargy
How will someone with paracetamol OD present within 24-72 hrs?
RUQ pain
Vomitting
Hepatomegaly
How will someone with paracetamol OD present after 72 hrs?
Acute liver failure
There will be jaundice
What will symptoms be in someone who has ODed on paracetamol over time?
Under 24hrs= mild NV, lethargy
24-72hrs= vomitting, hepatomegaly, RUQ pain
Over 72 hrs= acute liver failure with jaundice
How will acid base balance progress in aspirin OD?
First hyperventilation will cause respiratory alkalosis
This will then progress to metabolic acidosis
What bedside ix are done for paracetamol OD and what will you see?
ABG- lactic acidosis is a bad sign
Urinalysis- may show heamaturia or proteinuria which indicates kidney failure
What lab ix are done for paracetamol OD? Why are they done and what would you see?
Serum paracetamol conc- to stratify risk of liver injury and see if acetylcysteine is needed
LFTs- check liver function, ALT would be high
Blood glucose- liver failure can cause hypoglycaemia
UE- high creatinine if there is acute kidney or liver injury
FBC- leukocytosis, anaemia, thrombocytopenia
What happens to INR and PT in liver failure?
Both increase
What happens to glucose levels in liver failure?
Hypoglycaemia
How is paracetamol OD managed?
IV N-acetylcysteine
Liver transplant
What is the difference between opiods and opiates?
Opiate- naturally occuring
Opioid- synthetically made
Give examples of opiates
Morphine
Codeine
Give examples of opioids
fentanyl
oxycodone
What are some differentials for opiate OD?
Hypoglycaemia
Head injury
What are early and late symptoms of opiate OD?
early= reduced consciousness, respiratory depression, miosis, bardycardia, hypotension late= low GCS, coma
How do you remember what miosis is?
Miosis= mini= pupils get small/ constrict
