EMRAP: EMERGENCY MEDICINE REVIEWS AND PERSPECTIVES (EMRAP .US AND EMRAP .TV ) May, 2007 Page 1 Summary by Andrew Wittenberg, MD II. Fluids/Medications/Sedation • Fluid resuscitation should generally begin The Alcoholic Patient with D 5NS and be followed with the alcohol “cocktail” (glucose, magnesium, 100mg Corey Slovis, M.D. thiamine, MVI). • Magnesium can be added to the cocktail, I. Overview boluses at 1-2g over 0-60minutes, or given • Always start with A, B, C’s and N, G, T as maintenance at 0.5g – 1g per hour if (consider Narcan, Glucose, & Thiamine). needed. • • Be wary of underlying metabolic disorders, Maintenance fluids (D 5NS) should typically infections (including CNS), intracranial run at 200cc/hr. • bleeds, and extremity trauma. Benzodiazepines are the mainstay of • Alcohol metabolism occurs at approximately treatment. They should be titrated up every 25 mg% per hour. 5-10 minutes as needed. Benzo’s have been shown to reduce mortality and duration of • LD of alcohol is 400-500 (may be higher 50 delirium. in alcoholics). • Other protocols have a maximum level of • Alcohol withdrawal classically occurs in 4 Benzo’s given, at which point they change stages: to different medications, including 1. (6-12 hrs): Tremulousness Phenobarbital, Alcohol drip, or Propofol. 2. (12-48 hrs): Hallucination • 3. (12-48 hrs): Seizures Consider adding a small dose of Haldol for 4. (> 48 hrs): Delirium Tremens continued agitation. • • Always consider CT scan of the head – these Dilantin is never indicated unless the patient patients are prone to bleeds for multiple is on it at baseline for an underlying seizure reasons. disorder. • Diagnostic criteria for alcohol withdrawal (American Association of Addiction III. Wernicke’s Encephalopathy Medicine): Cessation or reduction of heavy (WE) or prolonged alcohol use resulting in the • The concept that glucose preceding thiamine development of two or more of the in an alcoholic can precipitate WE is following: unfounded/unproven. It is accepted that it • Autonomic hyperactivity, increased takes hours-days for this to occur, and so hand tremor, insomnia, n/v, thiamine given within a reasonable time of transient visual/tactile/auditory glucose administration (minutes-hours) is hallucinations, psychomotor acceptable. agitation, anxiety, grand mal • Groups at highest risk for Wernicke’s seizures, and/or affected global Encephalopathy: function. • Alcoholics, anorexia nervosa, • Diagnostic criteria for alcohol withdrawal hyperemesis gravidarum, with delirium includes: malabsorption syndrome, & chronic • Decreased consciousness or clarity, sever malnutrition. change in cognition, disorientation, and/or language/perceptual IV. Alcoholic Ketoacidosis disturbance. Any patient showing signs of medical shock (AKA) needs aggressive fluid resuscitation. • Usually occurs in alcoholic patients who are dehydrated, have low/no glucose stores, no available carbohydrates (i.e. not currently eating or drinking), often having entered this EMRAP: EMERGENCY MEDICINE REVIEWS AND PERSPECTIVES (EMRAP .US AND EMRAP .TV ) May, 2007 Page 2 state secondary to a precipitating event (ex: • Minimize disruptions to CPR except for seizure, police arrest, went broke). shock/cardioversion. • Treatment is with fluid resuscitation as • AED’s now approved for children. mentioned above (glucose, magnesium, • Post-resuscitation, avoid hyperthermia and thiamine, MVI, and potassium as needed). hyperventilation. • Search for the precipitating event (history, physical exam, EMS run sheet, etc.). II. Prehospital • Always consider ingestion of toxic alcohols. • Breslow tapes have improved prehospital • Do not hang your hat on the serum pH – it dosing in cardiac arrests, but may still be may be close to normal (even alkalotic). underestimating weight in our children. V. The Toxic Alcohols • Methanol (Windex, Sterno) • Conversion to formic III. Pediatric Fever acid/formaldehyde is the toxic • < 1month of age: full workup and admit metabolite. (unchanged). • Causes an acidosis and blindness • 1-2 months of age: workup with possible (papilledema and optic neuritis). discharge home and close follow-up if • Ethylene Glycol (Antifreeze) everything looks good (relatively • Conversion to oxylate crystals is the unchanged). toxic metabolite. • Viral testing becoming more prominent • Causes an acidosis and renal failure (RSV, Influenza) in fever workups. (clogs the kidney vs. opens the radiator). • Treatment of Methanol and Ethylene Glycol: See next section for abstracts and references • A, B, C, N, G, T. • Block conversion to toxic References and Abstracts: metabolites with antidote: Alcohol or Fomepizole. Alcoholism in the ED • Consider bicarbonate in severe acidosis. MANAGEMENT OF ALCOHOL WITHDRAWAL • Enhance elimination: consider DELIRIUM: AN EVIDENCE-BASED PRACTICE hemodialysis. GUIDELINE • Isopropyl Alcohol (Rubbing Alcohol) • Mayo-Smith, M.F., et al, Arch Intern Med 164:1405, Conversion to Acetone is non-toxic. July 12, 2004 • Causes hemorrhagic gastritis and a ketosis without an acidosis. METHODS: The authors describe a literature-based • Treatment is supportive, as with guideline for the management of alcohol withdrawal ethanol (fluids, glucose, vitamins, etc.). syndrome (AWD), developed by a multidisciplinary group commissioned by the American Society of Pediatric Literature Update – Part I. Addiction Medicine. Maureen McCollough, M.D. RESULTS: Use of medications should be triggered I. PALS by development of agitation. Sedative/hypnotic agents are more effective than neuroleptics in • The definition of a child now goes up to reducing the duration of delirium and mortality in puberty as opposed to a specific age. patients with AWD, and produce fewer • LMA’s and cuffed tubes now approved in complications. As such, they are considered the children, uncuffed tubes for neonates. primary agents of choice (grade A recommendation supported by randomized trials). No • High dose epinephrine is still out (except if sedative/hypnotic agent has been found to be superior given via ETT). EMRAP: EMERGENCY MEDICINE REVIEWS AND PERSPECTIVES (EMRAP .US AND EMRAP .TV ) May, 2007 Page 3 to others, but benzodiazepines have the most enzymes were within normal limits in a significantly favorable therapeutic/toxic index and are most greater number of patients treated with magnesium commonly recommended. Diazepam (oral or IV) has than in controls. Unlike controls, patients treated with a rapid onset of action, as well as a long duration of magnesium also exhibited statistically significant action. Agents with a shorter duration of action increases in serum sodium (from 137 to 139mmol/l), (lorazepam) might be associated with a lower risk calcium (from 2.32 to 2.44mmol/l) and phosphate when there are concerns about prolonged sedation. (from 1.01 to 1.13mmol/l), and slight increases in The addition of pentobarbital or propofol, or a serum magnesium (from 0.86 to 0.88mmol/l) and neuroleptic, might be useful for patients not potassium (from 4.3 to 4.4mmol/l). Patients treated controlled by very large doses of benzodiazepines with magnesium also exhibited a significant increase (grade C recommendation supported by data other in maximal hand grip strength, while hand grip than prospective controlled trials). Doses should be strength remained unchanged or decreased in individualized and titrated to maintain light controls. somnolence (grade C recommendation). With the exception of lorazepam, the IM route is not CONCLUSIONS: Oral magnesium supplementation recommended for benzodiazepines due to erratic in chronic alcoholics appears to have a beneficial absorption (grade C recommendation). Beta- effect on liver function tests, electrolyte balance and antagonists are not recommended for routine use but muscle strength. 46 references might be considered for patients with persistent hypertension or tachycardia (grade C Copyright 1993 by Emergency Medical Abstracts - recommendation). 70 references (Michael.Mayo- All Rights Reserved 03/93 - #32 [email protected]) PEDIATRIC LITERATURE REVIEW Copyright 2005 by Emergency Medical Abstracts - All Rights Reserved 3/05 - #36 PALS Update 2005 Circulation Dec 2005 ORAL MAGNESIUM SUPPLEMENTATION Green Acad Emerg Med Jun 2006 IMPROVES METABOLIC VARIABLES AND Analysis of pediatric arrests - Ontario MUSCLE STRENGTH IN ALCOHOLICS Smith Acad Emerg Med May 2006 Gullestad, L., et al, Alcoholism: Clin Exp Res Analysis of Pediatric arrests – Washington 16(5):986, September/October 1992 Kaji Pediatric Oct 2006 BACKGROUND: Previous studies have indicated LA study comparing Epi dosing in peds arrest that 20-30% of chronic alcoholics are hypomagnesemic. Beneficial effects of magnesium Nieman Acad Emerg Med Oct 2006 supplementation have been reported in acute Breslow tape comparing actual versus predicted withdrawal, encephalopathy, serious ventricular weights dysrhythmias, and refractory hypokalemia and hypocalcemia, but the effects of long-term Sacchetti Acad Emerg Med May 2005 magnesium supplementation have not been clearly Family presence during procedures defined. Pediatric Fever METHODS: The authors of this random, double- Levine Pedatrics June 2004 blind, controlled Scandinavian study examined Melendez Ped Inf Dis J Dec 2003 findings in 49 chronic alcoholics treated for six Smitherman Pediatrics May 2005 weeks with either magnesium- lactate-citrate tablets Hsiao Pediatrics May 2006 (5mmol three times daily) or placebo. Lyer Acad Emerg Med Dec 2006 Abanses Pediatric Emerg Care March 2006 Cruz Annals Emerg med March 2006 RESULTS: Patients treated with magnesium Grijalva Pediatrics Jan 2007 exhibited significant decreases in gamma-glutamyl- transpeptidase (GGT) levels, as well as decreases in aspartate-aminotransferase (ASAT) and alanine- aminotransferase (ALAT). Post-treatment liver .