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Drunk People – They Are out to Get to You

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Drunk People – They Are out to Get to You Drunk people – They are out to get to you Abe Markin Dec 2014 TBL Outline • Physiology • They’re out to get you • Management of intoxication in ED – ABCs etc. – Do you have to check BAC? – Alcoholic Ketoacidosis • Wernicke’s • Korsakoff’s • 4 Phases of withdrawal • Holiday Heart Physiology • Absorbed primarily in stomach (70%) and duodenum (25%) • Distributed evenly throughout all organ systems • Traditionally thought to be zero order kinetics • First order kinetics for high levels, especially in heavy drinkers – 10% in gastric mucosa (first pass) – Remaining 90% in liver – Inducible CYP-450 enzymes in microsomal ethanol oxidizing system (MEOS; 8–10%) – Catalase (0–2%) • Respiratory depression, decreased airway responsiveness cause death Rosen’s 7th Edition; Vonghia et al. (Eur J Intern Med, 2008) How Drunks Might Get You • Other causes of AMS – Other toxins (toxic alcohols, benzos) – Head bleed – Infection (meningitis, sepsis), – Metabolic disturbances (AKA, DKA, hypoglycemia, hyponatremia, hepatic encephalopathy, uremia, hypoxia/CO2 narcosis) – Seizures (post-ictal / status) – Withdrawal syndromes • Missed injuries – Orthopedic, – C-spine – Intra-abdominal • Vomiting while supine in 4 points All drunks deserve… • ABC, fluids, nutrition, consider withdrawal • Benzos if needed • Volume depletion – Give IVF (D5 0.9 NS) • Nutrition – D5/food (No glycogen stores) – Thiamine (100mg) – Electrolytes: replace magnesium (1-2g/0-60min), potassium – MVI Slovis. (AAEM, 2007); Li et al. (Am J Emerg Med, 2008) Should we get a BAC? • Rosen: “Discharge (after excluding significant abnormal laboratory values or suspected head injury) can be considered when a patient is clinically sober and able to dress, walk, and function independently.” • Tintinalli: “Patients with no other medical reason for admission may be discharged when their clinical intoxication has resolved to the extent that they do not constitute a danger to themselves or others. Clinical judgment should be used in deciding whether a patient is sober enough to discharge. As discussed above in Pathophysiology, intoxication does not correlate well with blood ethanol level in any given patient because there is such a wide range of tolerance.” • UTD: “…disposition of these patients should not be based solely on the measured (or calculated) serum alcohol concentration. Patients with mild intoxication can be safely discharged when no longer clinically intoxicated and deemed by the clinician to be no danger to themselves or others.” • Rate of clearance ranges from 9 - 36 mg/dL/hr • Assume 20 mg/dL/hr in intoxicated ED pt per Rosen’s Rosen's Emergency Medicine; Tintinalli’s Emergency Medicine; Uptodate.com Should we get a BAC? • Recent legal precedent – Kowalski v. St. Francis Hospital and Health Centers • Hospital has no right, and therefore no duty to restrain this person • But… – NY, not MI – Pt came in voluntarily, then pulled out IV and snuck out Should we get a BAC? True value is as a red flag if surprisingly low and as a reason to keep psych pts who have rescinded their story Hammond KB, Rumack BH, Rodgerson DO. "Blood ethanol: a report of unusually high levels in a living patient." JAMA 226.1 (1973): 63-64. Johnson RA, Noll EC, Rodney WM. Survival after a serum ethanol concentration of 1 1/2%. Lancet 1982;2:1394. Spontaneous bladder rupture Parker H et al. Spontaneous bladder rupture in association with alcoholic binge: a case report and review of the literature. J Emerg Med 37.4 (2009): 386-389. Alcoholic ketoacidosis: Features • Occurs in malnourished drinkers, esp after 1-3 days of abstinence, vomiting, poor PO • Features: – N/V, abdominal pain, tachypnea – Serum glucose usually < 200 – Ketones/BOHB present – 15% may have concomitant met alkalosis from vomiting, volume depletion • Requires: – Dehydration – Low glycogen stores – No available carbohydrate – No available alcohol – A precipitating event • Pathophys – Exact mechanism unknown – Acute on chronic starvation – Release of alcohol-induced block in ketogenesis – Increased NADH/NAD ratio predisposes to BOHB production and impairs metabolism of lactate Rosen’s Emergency Medicine, Medscape.com, Slovis (AAEM, 2007) Alcoholic ketoacidosis: Differential • DKA, starvation ketoacidosis • Ethylene glycol, other toxic alcohols • Renal failure • Sepsis Alcoholic ketoacidosis: Treatment • Fluids • Carbohydrate (IV glucose) • Vitamins, minerals • K, Mg • Identify and treat underlying cause • Slovis Pearls – No role for bicarbonate Unless pH <7.0, then r/o other causes of acidosis – No role for insulin in AKA Even with hyperglycemia unless glucose >500 – Follow K, phos, pH – If pH falls once treatment has begun, this is NOT just AKA! – If serum phosphorus falls to below 1.5 - 1: Give 1/4 of potassium requirement as K2PO4 Wernicke’s Encephalopathy • Thiamine deficiency present in 80% of alcoholics. • Wernicke’s develops in 12.5% • Classic triad of ataxia, encephalopathy, oculomotor disturbance – May also have coma, miosis, hypothermia, hypotension, bradycardia • Develops over hours to days • Reversible, with resolution of MRI changes in 7 days • 5 groups at risk – Alcoholics, anorexia nervosa, hyperemesis gravidarum, malabsorption syndrome, chronic severe malnutrition – Don’t look for triad. Give thiamine based on risk factors • 10-20% case fatality, 80% of survivors develop Korsakoff’s • 100mg IV, 100mg PO QD x3d for possible case. Definite dx requires higher doses Agabio R. Thiamine administration in alcohol-dependent patients. Alcohol Alcohol. 40.2 (2005): 155-156. Martin, Singleton, Hiller–Sturmhöfel. The Role of Thiamine Deficiency in Alcoholic Brain Disease. http://pubs.niaaa.nih.gov/publications/arh27-2/134-142.htm Shrinkage Korsakoff’s Psychosis • “Alcohol amnestic disorder” • 13% of alcoholics at autopsy, 1 in 5 had prior dx • Behavioral abnormalities, memory impairment, disorientation, confabulation • Anterograde > retrograde amnesia • "The Lost Mariner” • Cerebellar degeneration distinct, more common (40% at autopsy) Harper C. J Neuropathol Exp Neurol 57:101–110, 1998. Harper C, Rodriguez M, Gold J, Perdices M. Med J Aust 149:718–720, 1988. The “French Paradox” The “French Paradox” The “French Paradox” Withdrawal – 4 phases • Tremulousness – 6-12 hrs post-cessation • Seizures – 1-2 days • Hallucinosis – 1-2 days – hallucinosis and Sz temporal overlap – up to 25% of drinkers who withdraw – usu. Visual – Auditory less likely to progress to DTs – Rx: benzos +/- haldol • DTs – previously common, now very rare Slovis C. Alcoholic Emergencies. AAEM. March 2007 Tremulousness • Most frequent • Hypersympathetic state like hyperthyroidism, cocaine intoxication, panic attack • +/- N&V • Choice of benzo: valium, ativan, versed. – Valium is longer acting, cannot be given IM (erratic absorption, not water soluble) • Don’t use beta blockers, benzos for tachycardia, hypertension, etc. Rapid ED Benzodiazepine Titration Valium Ativan 5 mgs IV 1 mg IV • may use Haldol 5 mg IV/IM early repeat 5 mgs IV in 5-10 min repeat 1 mg in 5-10 min in therapy for if still agitated if still agitated especially violent, mean or agitated wait 5-10 min wait 5-10 min patients 10 mgs IV 2 mgs IV • After 60 – 90 repeat 10 mgs IV in 5 – 10 min repeat 2 mgs IV in 5-10 min minutes of if still agitated if still agitated therapy in benzodiazepine refractory wait 5 – 10 min wait 5 – 10 min patients consider 20 mgs IV 4 mgs IV Propofol 25 mg/min slowly repeat 20 mgs IV in 5 – 10 min repeat 4 mgs IV in 5-10 min titrated to if still agitated if still agitated patients symptoms 20 mgs IV Q 5-10 min 4 mgs IV Q 5-10 min until VS stable and patient calm until VS stable and patient calm American Society of Addiction Medicine. Arch In Med. 2004. 164:1405-1412. via Slovis’ EM:RAP Hallucinations • Up to 10% of EtOH withdrawal pts • 10-30 hrs after last drink • Visual > auditory, olfactory or tactile • Insomnia, hyperactivity Seizures (Rum Fits) • 6-48 hrs post-cessation • Usually self-limited, generalized tonic-clonic, non-focal, non-status • 6% intracranial problem. CT ‘em all. • Status- ABCs NGT, benzo titration, start barbiturate, etomidate, or propofol • Don’t give Dilantin unless some other cause Earnest M, Feldman H, Marx J, et al. Intracranial lesions shown by CT scans in 259 cases of first alcohol related seizures. Neurology. 1988;38:1561-1565. Delirium Tremens • Abstinence day 3-5 • Medical emergency requiring ICU care • Features – Hypertension, tachycardia, hyperventilation, hyperthermia • Another time they’re out to get you – r/o PNA, GIB, hypoglycemia, other toxins/ metabolic causes, meningitis/sepsis, head bleed • If present in DTs: – Hypotension = dehydration – Bradycardia = overmedicated; elevated ICP – Hypoventilation = overmedicated; elevated ICP – Hypothermia = sepsis, CNS trauma, Wernicke's • Mortality from oversedation, electrolyte abnormalities Holiday Heart • In 1978 Philip Ettinger described "Holiday heart syndrome" • New ventricular and atrial tachyarrhythmia (esp. A fib) in non-alcoholics after acute ingestion • Usu. presents w/ palpitations, precordial pressure or pain, syncope, and dyspnea Tonelo, Providência, & Gonçalves. (Arquivos Brasileiros de Cardiologia, 2013) Holiday Heart: Proposed Mechanisms Lean AKA: Sizzurp, syrup, purple drank, drank, barre, purple jelly, Texas tea, and Tsikuni. Double cup. They say don't drink and sip that lean but I mix em up Turnt up to the max, real ratchet s*** - “Codeine cups” by Juicy Jay A Cure for Drunk? • Metadoxine: – Pyrrolidone carboxilate and pyridoxine – RCT showing single dose 900mg IV significantly faster
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