Alcohol Misuse

Introduction

Alcohol is the most frequently used/abused drug. It is a CNS depressant which inhibits neuronal activity. It is predominantly metabolised in the liver via alcohol dehydrogenase and acetyldehyde dehydrogenase. It metabolises at approx. 30mg/dL/hour but tolerant drinkers metabolise it at higher rates. Blood alcohol levels are a highly unreliable measure of a person’s level of intoxication because of this. People who drink large amounts regularly may have minimal symptoms with high blood alcohol levels and another person who doesn’t drink regularly would be extremely symptomatic at the same blood alcohol level.

Notably only 1 in 10 Irish adults are able to correctly define the standard drink values of common drinks, please find a link to some here

Risk Factors

It is important to remember that alcohol is an independent risk factor for trauma. Patients who have had an unwitnessed collapse should be carefully assessed for signs of injuries, the symptoms of which may be masked by intoxication, most especially head injury.

Risk factors for alcohol abuse include;

Male gender
Young age
Adverse socioeconomic factors

Clinical Features

Neurologic

Slurred speech
Dis-inhibition
Decreased coordination
Altered consciousness
Respiratory depression (severe cases)

Cardiovascular

Tachycardia
Hypotension
Arrhythmias

Gastrointestinal

Gastritis
Oesophagitis
GI bleeding
Pancreatitis

Wernicke’s Syndrome can develop with chronic alcohol use as a result of prolonged Thiamine (Vit B1) deficiency. This is a triad of;

Ataxia
Opthalmoplegia
Encephalopathy

Korsakoff’s Syndrome is also related to severe prolonged Thiamine (Vit B1) deficiency. Features include;

Amnesia: anterograde > retrograde
Confabulation
Lack of insight
Apathy
Fixation amnesia (loss of immediate memory)

Symptoms of alcohol withdrawal include;

Agitation
Nausea and vomiting
Tachycardia
Pyrexia
Tremulousness
Hallucinations
Seizures

Differential Diagnosis

There is a wide range of differentials that should be considered in patients presenting to the emergency department who appear to be intoxicated including but not limited to;

Trauma, particularly head injury
Infection - meningitis / encephalitis
Hypoglycaemia
Other substance misuse

Acute psychosis
Pancreatitis
Diabetic ketoacidosis
Seizure disoder - post ictal

Clinical Investigations

Bedside

The most important part of your investigation is a detailed clinical exam, looking for signs of head injury or any other injuries

Temperature; patients often present hypothermic when collapsed outdoors
Blood glucose; impaired gluconeogenesis leads to hypoglycaemia
ECG; assessing for arrhythmias

Laboratory

FBC - to assess for possible infection, platlets and Hb may be reduced in chronic alcohol use and MCV may be raised
Coag - A measure of the livers synthetic function, its useful in patients with hepatic failure.A high INR is a poor prognostic indicator
U&E - Abnormalities are common, including low Na, Mg, Ca, phos and K
LFT’s - May be deranged, however if significantly changed from baseline consider other potential causes
Alcohol levels - are available however should rarely be used as they are not a reliable indicator of intoxication and patients who are intoxicated can still have a significant head injury etc. They should only be sent in the case of ethylene glycol poisoning as the osmolar gap calculation needs to be adjusted for alcohol.

Radiology

Further investigations if any will depend on your clinical exam

FAST could be indicated in haemodynamically unstable patients with suspected injuries to the chest or abdomen

Top TIP: Examine your patients fully; a small stab wound is easy to miss if patient is not fully stripped and examined

CT Brain - indicated in patients with reduced GCS if head injury is suspected or in those with abnormal neuro exam: unequal pupils, hemotympanum, racoon eyes or Battle’s sign (signs of intracranial bleed and base of skull fracture)
CT C-spine - if there is a suspicion that a patient has neck trauma

Also remember to re-examine your patient once they are clinically sober as less severe injuries (rib fractures, hand injuries or clavicular fractures could be missed on initial exam)

Management & Disposition

Initial Resuscitation

Approach every patient with assessment of their:
Airway - vomit is commonly found, in rare cases where the airway is threatened, endotracheal intubation might be required.
Breathing - rarely alcohol causes respiratory depression; patients more commonly aspirate.
Circulation – hypotension and tachycardia are common and usually respond to IV fluids.
Disability- GCS is commonly low, it will require serial assessment to ensure that it is improving. Do not assume that a low GCS is due to alcohol intoxication alone, and assess your patient from the point of view of injury.
Exposure - check temperature as patients who have collapsed outside may be profoundly hypothermic and require rewarming measures. Full screen for injuries.
Glucose – should always be checked in patient with reduced GCS.

Symptomatic Treatment

Symptomatic treatment will depend on your primary assessment:
Hypotension and tachycardia – NaCl 0.9%
Hypothermia – warming blanket, assess for cardiac arrythmias
Nausea and vomiting – antiemetics
Administer high dose thiamine – in Ireland most commonly used agent is Pabrinex I&II
Treat hypoglycaemia with IV dextrose
If aspiration is suspected, treat with antibiotics

Specefic Treatment

Alcohol withdrawal syndrome requires close monitoring of the patient as well as treatment with high doses of benzodiazepines. The most commonly used agent in Ireland is chlordiazepoxide (Librium). There are many clinical decision tools to aid your exam. One such tool is the CIWA score.

Disposition

Patients need to be observed until clinically sober. Once clinically sober and able to care for themselves patients may be discharged home. However, they require secondary survey prior to discharge to assess for other injuries that were not apparent on initial exam.

Patients who present with features of delirium tremens or alcohol withdrawal seizures require medical admission as untreated DT’s carry 20% risk of mortality.