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Roberta Agabio, M.D. Department of Biochemical Sciences Section of Neuroscience University of Cagliari, Italy Acute Alcohol Intoxication (AAI) © AMSP 2012 1
Alcohol Use & Problems 90% Ever drink 14% Drinkers have 1+ problem: Accidents Violence Mood swings Physical illness © AMSP 2012 2
AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption 1) Alcohol’s drug class © AMSP 2012 3
Drug Classes Based on Effects Depressants Stimulants Opioids Cannabinols Hallucinogens Inhalants Others © AMSP 2012 4
Depressants Include ClassExample BenzodiazepinesDiazepam Bz-like medsZolpidem BarbituratesSecobarbital OthersChloral hydrate Alcohol © AMSP 2012 5
Effects & Dangers Effects ↓ Anxiety Anesthesia ↑ Sleep ↓ Seizures Muscle relaxation Dangers Sedation Drug interact ↓ MemoryDependence ↓ Coordination Intoxication © AMSP 2012 6
Intoxication Medical problems ↓ Vital signs, coma, risk of death Temporary psychiatric syndromes Cognitive disorders Psychosis Anxiety Depression © AMSP 2012 7
AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption 2) Alcohol’s brain effects © AMSP 2012 8
Alcohol ↑ dopamine transmission Reward Brain System → Pleasurable effects © AMSP 2012 9
InhibitionExcitation 1. Homeostasis Alcohol's Brain Effects 3. Chronic use (tolerance) InhibitionExcitation ALCOHOL OPPOSITE CHANGES Inhibition Excitation OPPOSITE CHANGES 4. Withdrawal Inhibition Excitation ALCOHOL 2. Acute use © AMSP 2012 10
Blood Alcohol Concentration (BAC) Standard drink = ~12 g alcohol ↑ BAC with: Female ↓ Weight Drink without food 1 drink → BAC = ~15 mg% (0.015 g/dl) © AMSP 2012 11
BAC’s Effects ≤ 50 (1-3 drinks) BAC (mg%) Well-being, ↓ inhib ≤ 100Sleepiness, ↓ coordination ≤ 200Anger, moody, confusion ≤ 300Difficulty to awaken > 300 ↓ Vital signs, coma, death Effects © AMSP 2012 12
AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption 3) AAI signs and symptoms © AMSP 2012 13
Definition of AAI (DSM-IV) Recent ingestion Behavior changes (e.g. aggression) Nystagmus 1+Slurred speech ↓ Coordination Unsteady gait Nystagmus ↓ Attention or memory Stupor or coma Nystagmus © AMSP 2012 14
AAI Medical Problems ↓ Vital signs Body temperature Respiratory rate Blood pressure ↑ Risk of death BAC > 300 mg% Opioids or other depressants © AMSP 2012 15
AAI Temporary Psychiatric Symptoms Cognitive problems Psychosis Depression and/or anxiety © AMSP 2012 16
AAI Cognitive Problems Confusion ↓ Memory ↨ Alertness ↓ Judgment Disorientation © AMSP 2012 17
AAI Psychosis Suspiciousness Hallucinations Paranoid thoughts All without insight © AMSP 2012 18
Sad all day Every day for 2+ weeks Can be suicidal AAI Depression AAI Anxiety Syndromes Meet criteria for anxiety disorders (e.g., panic disorder) © AMSP 2012 19
AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption 4) Evaluation and treatment of AAI © AMSP 2012 20
AAI Evaluation Other med/psych illness Toxicological screen Other intox/withdrawal Smell of alcohol AAI signs & symptoms Laboratory tests © AMSP 2012 21
Check BAC & use of other drugs Toxicological Screen BAC > 300 mg% → potential death How to do Draw ~ 50 cc blood sample Collect ~ 50 ml urine sample Opioids or other depressants ↑ risk BAC ↓ by ~15mg%/h © AMSP 2012 22
Bleeding Shock Electrolyte disturbances Cardiac disorders Infections Consequences of brain trauma Rule Out Other Problems © AMSP 2012 23
Use a fingerstick If ↓ administer 50 cc of 50% glucose IV & 100 mg vit. B1 (IV or IM) if needed Test for blood sugar © AMSP 2012 24
Medical Treatment If↓vital signs = EMERGENGY PROBLEM © AMSP 2012 25
NO MEDS until are sure they are needed Airway Breathing Circulation © AMSP 2012 26 ABCs Of Emergency Care Support Vital Signs Measure vital signs frequently Address life-threatening problems =
Assure adequate ventilation Airway & Breathing Remove obstructions in mouth Straighten head (if no neck injury) If needed intubate Use respirator (~12 breaths/min) © AMSP 2012 27
Maintain adequate blood pressure Circulation Start IV line Use large-gauge needle Use a slow drip until know if need fluids © AMSP 2012 28
Other Drugs: ↓ Absorption Patient awake & stable pulse Gastric lavage Inducing vomiting (oral ipecac syrup) Patient not awake Took drugs within 12 h Not corrosive, kerosene, strychnine, oils If comatose, only after intubation © AMSP 2012 29
Gastric Lavage: How to do Sample of washings for drug analysis Nasogastric tube Patient on his/her left side Head slightly over the edge of the table Evacuate stomach Isotonic saline lavage until fluid clear Repeat up to 10-12 times © AMSP 2012 30
BDZ → flumazenil Specific Drugs: Antidotes Opioids → naloxone Monitor possible opioid abstinence syndrome Monitor possible seizures & ↑ intracran press Atropine-like drugs→ physostigmine Barbiturates → No antidote Forced diuresis & alkalinization of urine © AMSP 2012 31
Should improve < 1 month AAI Psychiatric Symptoms Medical Treatment Meds should be avoided Protect & reassure Consider inpatient Observe & provide general support BDZ or antipsyc meds for sedation No antidepressants © AMSP 2012 32
AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 33
Unhealthy Drinking Consider this in all patients 1) Alcohol Abuse and Dependence k 2) At-risk Drinking © AMSP 2012 34
Abuse 1+ Role failure Risk of harm Run-ins with law Dependence 3+ In same 12 months Relationship trouble Tolerance Withdrawal Unable to limit Unable to cut down ↑ Time with alcohol ↓ Time elsewhere Use in spite of problems © AMSP 2012 35
At-Risk Drinking > 7 drinks per week ≥ 4 drinks per occasion > 14 drinks per week ≥ 5 drinks per occasion © AMSP 2012 36
ID Unhealthy Drinking 1) Ask How many drinks per occasion? How many drinks per week? 2) Blood markers* MCV> 90 µ3 GGT> 35 U/l CDT> 2.0 U/l ALT> 35 U/l AST> 33 U/l © AMSP 2012 37
Questionnaires CAGE AUDIT (Alcohol Use Disorders Identification Test) Cut down Annoyed Guilty Eye-opener 10 items about Alcohol consumption Drinking behavior Alcohol-related problems © AMSP 2012 38
1 st step: Intervention 2 nd step: Detoxification 3 rd step: Rehabilitation Rx Abuse/Dependence Rx At-Risk Drinkers Help patients ↓ drinking Brief Intervention © AMSP 2012 39
1 st Step: Intervention Help patients to Recognize problems ↑ Motivation to change ↓ Future difficulties Motivational interview Brief intervention © AMSP 2012 40
Motivational Interview Feedback Responsibility Advice Menu Empathy Self-efficacy Brief Intervention Education Dangers Suggest ↓ alcohol use Avoid risky situations © AMSP 2012 41
~ ½ Patients need it Reassurance temporary nature Meds Oral multivitamins Benzodiazepines for ~1 week 2 nd Step: Detoxification © AMSP 2012 42
Help patients to Keep motivation high A lifestyle free of alcohol ↓ Risk of relapse 3 rd Step: Rehabilitation Counseling Self-help groups (AA) Meds © AMSP 2012 43
Rehabilitation Meds 1. Disulfiram 2. Oral naltrexone 3. Slow release naltrexone 4. Acamprosate © AMSP 2012 44
AAI: Lecture Focus 1) Alcohol’s drug class 2) Alcohol's brain effects 3) AAI signs and symptoms 4) Evaluation and treatment of AAI 5) Unhealthy alcohol consumption © AMSP 2012 45
Conclusions on AAI 2) Other depressants ↑ risk of death 1) May be a life-threatening 5) Evaluate unhealthy alcohol use 3) May → temporary psych symptoms 4) Rx: support vital signs until Alcohol has been metabolized Psych symptoms disappear © AMSP 2012 46
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