Alcohol Intoxication And Withdrawal

Alcohol (ethanol) has a damping effect on the CNS. taken in large quantities, it can rapidly lead to respiratory depression, coma and death. ingested large amounts over a long time damage the liver and many other organs. Alcohol withdrawal manifests as a continuous series of specific events, from tremors to seizures, hallucinations, and life-threatening autonomic instability with severe withdrawal (delirium). The diagnosis is made clinically.

(See also alcohol diseases and rehabilitation.)

Alcohol (ethanol) has a damping effect on the CNS. taken in large quantities, it can rapidly lead to respiratory depression, coma and death. ingested large amounts over a long time damage the liver and many other organs. Alcohol withdrawal manifests as a continuous series of specific events, from tremors to seizures, hallucinations, and life-threatening autonomic instability with severe withdrawal (delirium). The diagnosis is made clinically. (See also alcohol diseases and rehabilitation.) More than half of US adults are currently drinkers, 20% were former drinkers, and 30-35% are lifetime abstainers. Alcohol consumption is also becoming an increasing problem in children of 9-12 and adolescents. For most drinkers, the frequency and quantity of alcohol use does not compromise the physical or mental health or the ability to safely carry out daily activities. However, acute alcohol poisoning is a major factor in injuries, particularly those caused by interpersonal violence, suicide and car accidents. Chronic alcohol abuse interferes with the ability to socialize and to go to work. About 7-10% of all adults meet each year the criteria for alcohol disorder (abuse or dependence). Binge drinking is defined by the consumption of ? 5 drinks per occasion for men and ? 4 drinks per occasion for women. Binge drinking is a particular problem in younger people. Pathophysiology unit drinking alcohol (a 12 oz [about 360 ml] can of beer, a 6 oz [about 180 ml] glass of wine or 1.5 oz [50 ml] distilled alcohol) contains 10-15 g of ethanol. Alcohol is absorbed primarily from the small intestine into the blood, even though a portion is also taken from the stomach. Alcohol accumulated in the blood because the absorption proceeds more rapidly than the metabolism and elimination. The concentration has its peak about 30-90 minutes after ingestion, when the stomach was empty before. About 5-10% of ingested alcohol is excreted unchanged in the urine, sweat and exhaled air, the rest is mainly metabolised in the liver, where alcohol dehydrogenase converts ethanol to acetaldehyde. Acetaldehyde is ultimately oxidized to CO2 and water in an amount of 5-10 ml / h (absolute alcohol); each ml yields about 7 kcal. Alcohol dehydrogenase in the gastric mucosa takes a small part of metabolism; in women much less gastric metabolism takes place than in men. Alcohol exerts its effect by several mechanisms. Alcohol binds directly to gamma-aminobutyric acid (GABA) receptors in the CNS, resulting in sedation. Alcohol also has a direct effect on the heart, liver and thyroid tissue. Chronic effects tolerance to alcohol develops rapidly; equal amounts cause less noise. The tolerance develops through adaptation processes in the cells of the CNS (cellular or pharmacodynamic tolerance) and by the induction of metabolic enzymes. In a surprisingly high alcohol tolerance blood alcohol concentration (BAC) is possible. However, the alcohol tolerance is incomplete; the dose is high enough, still shows a certain intoxication and impairment. Even drinkers with alcohol tolerance may die of respiratory depression due to an overdose of alcohol. When alcohol tolerance, the risk of alcoholic ketoacidosis is increased, particularly when binge drinking. In alcohol tolerance, there is also a cross-tolerance against many CNS-active substances (eg. B. barbiturates, nichtbarbiturathaltige hypnotics, benzodiazepines). The physical dependence that accompanies the tolerance is severe. An alcohol withdrawal leads to potentially fatal side effects. Chronic severe alcohol consumption typically results in liver diseases (for example, fatty liver, alcoholic hepatitis, cirrhosis.); The required amount and duration is different (alcoholic liver disease). Patients with severe liver disease often have a clotting disorder by decreased hepatic synthesis of clotting factors, thereby reducing the risk of serious bleeding due to trauma (eg. As by falls or traffic accidents) and gastrointestinal bleeding (eg. As a result of gastritis, from esophageal varices rises due to portal hypertension); Alcoholics are at particular risk of gastrointestinal bleeding. Chronic severe abuse causes often include gastritis pancreatitis cardiomyopathy, often accompanied by cardiac arrhythmias and hypertension Peripheral neuropathy brain damage, including Wernicke encephalopathy, Korsakoff’s psychosis, Marchiafava-Bignami disease and alcoholic dementia, certain cancers (eg, head and neck, esophagus.) , especially if drinking is associated with smoking indirect long-term effects are malnutrition, especially vitamin deficiency. On the other hand (? 1-2 drinks a day) can low to moderate alcohol consumption may reduce the risk of death from cardiovascular disease. Numerous explanations, including increased high density lipoprotein (HDL) levels and a direct antithrombotic effect were used. Nevertheless, alcohol should not be recommended for this purpose, mainly because there are better and more effective approaches to reducing cardiovascular risk gibt.Besondere groups Young children who drink alcohol are exposed to a significant risk of developing hypoglycemia because alcohol gluconeogenesis impaired and their smaller glycogen stores are depleted quickly. Women may be more sensitive than men, even when the weight is included because their stomachs metabolize alcohol less. Drinking during pregnancy increases the risk of fetal alcohol syndrome. Symptoms and signs Acute episodes Symptoms stride ahead proportional to the blood alcohol concentration (BAC). In fact, the alcohol level that it needs to cause certain symptoms depend on the tolerance. 20-50 mg / dl: relaxation, light sedation, a certain decrease in fine motor 50-100 mg / dl: impaired judgment and a further decrease of coordination 100-150 mg / dl: Unsteady gait, nystagmus, speech disorder, uninhibited behavior, memory problems 150-300 mg / dl: delirium and lethargy (probably) vomiting is common in moderate to severe poisoning. Because vomiting usually occurs with disorders of consciousness, Aspiration is a significant risk. In most states is the legal definition of intoxication a BAC of ? 0.08-0.10% (? 80 to 100 mg / dl), 0.08% is the most common Wert.Toxizität or overdose In humans, the no Alkhohol are accustomed to from 300 to 400 mg / dl causes BAK often unconsciousness and a BAC ? 400 mg / dl can be lethal. Large quantities quickly consumed, can cause sudden death by respiratory depression or arrhythmias. This problem occurs now also to US colleges on, but in other countries where the disease is more common, has long been known (n. D. Talk .: called. Binge drinking, s. U.). Other common side effects include hypotension and hypoglycemia. The impact of a particular BAK are very different; some chronic drinkers appear to be working, while non-drinkers and social drinkers with a BAC that has no effect in chronic drinkers, severely impaired sind.Chronische consequences for all chronic alcoholic liver disease with a BAC of 300-400 mg / dl to a Dupuytren- Kontrakturder palmar fascia, spider nevi, peripheral neuropathy, Wernicke encephalopathy, Korsakoff’s syndrome (n. d. Ed .: due to the continuous transition in German-speaking called Wernicke-Korsakoff encephalopathy) and in men signs of hypogonadism and feminization (e.g. available. B. smooth skin, gynecomastia and testicular atrophy). Malnutrition can lead to enlargement of the salivary glands führen.Entzug a set of symptoms and signs of (including autonomous) CNS hyperactivity may accompany alcohol withdrawal. With a slight alcohol withdrawal syndrome tremor, muscle weakness, headache, sweating, hyperreflexia, and gastrointestinal symptoms are observed. Symptoms usually begin within about 6 hours after the last alcohol consumption. Some patients have generalized tonic-clonic seizures (epilepsy called alcohol), but usually not> 2 in quick succession. The alcoholic hallucinosis (hallucinations without further impairment of consciousness) followed by abrupt cessation after prolonged, excessive alcohol consumption, hours usually within 12-24. Hallucinations are visually generally. One of the main symptoms include auditory hallucinations, esp. Abusive or threatening voices. The patient is anxious and can be displaced from the hallucinations and vivid, frightening nightmares literally in fear and panic. An alcoholic hallucinosis may be similar to schizophrenia; However, the thinking is usually ordered and the history atypical for schizophrenia. The symptoms are similar to the delirious stage of acute organic brain syndrome far less than a delirium tremens or other pathological reactions in the context of a withdrawal. Awareness remains clear; usually no signs of autonomic instability as in delirium tremens are available. An alcoholic hallucinosis usually occurs before a delirium tremens, and is temporary. The delirium tremens or Alkoholentzugsdelir usually begins 48-72 hours after alcohol withdrawal and manifests itself in anxiety attacks, enhancing confusion, poor sleep (with nightmares or night illusionary cognitions), heavy sweating and a deep depression. Volatile hallucinations to agitation, fear, even lead horror are common. It is typical of the first delirious, confused and disoriented state that usual activities are resumed. So often the patient believes to be back at work, and tried to carry out appropriate activities. A vegetative lability accompanies the delirium and amplifies it. It manifests itself in sweating, increased pulse rate and temperature. In light delirium normally show profuse sweating, a pulse of 100-120 beats / min and a temperature 37.2 to 37.8 ° C. A heavy delirium with severe disorientation and cognitive impairment is a psychomotor restlessness, a pulse on accompanied 120 beats / min and a temperature> 37.8 ° C. The risk of dying is high there. During a delirium tremens, the patient is highly suggestible. He can be influenced by many sensory stimuli, esp. Objects that are seen in diffuse light. Balance disorders can cause the patient believes, the floor is moving, the walls would come up or the space revolves. With progression of delirium, a resting tremor of the hands, sometimes expands on the head and trunk development. Due to a significantly pronounced ataxia precautions must be taken to protect the patient from self-injury. The symptoms vary from patient to patient; However, the individual shows the same symptoms usually with each new delirium. Diagnosis usually clinically acute: BAK, investigation to rule out hypoglycemia and occult trauma and possible coinfection Chronic: blood count, magnesium, liver function tests and PT / PTT withdrawal: exclude clarification to CNS injury and infection, acute intoxication: Laboratory tests are not useful except glucose finger test to exclude hypoglycaemia. The diagnosis is made clinically in general. A confirmation by respiratory or BAC testing is useful only for legal purposes (eg. As for the documentation of intoxication for drivers or employees that appear functionally impaired). However, the finding of a low BAC in patients who have an altered mental status and alcohol breath is helpful because it speeds up the search for an alternative cause. Doctors should not assume that a high BAC is the cause of their consciousness disorders in patients with apparently minor trauma automatically that possibly may be due to intracranial injuries or other abnormalities. In these patients, toxicological tests should be carried out for the detection of toxicity with other substances. Chronic alcohol abuse and dependence are chronic clinical diagnostics; experimental marker of long-term use have not been successful as a sufficiently sensitive or specific for general use so far. Screening tests such as AUDIT (identification test for disorders due to alcohol consumption) or the CAGE questionnaire can be used. However, heavy drinkers may have a range of metabolic disorders that may require screening such. For example, a blood count, electrolytes (including magnesium), liver function tests including coagulation profile (PT / PTT), and serum albumin. Clinical Calculator: AUDIT questionnaire for screening alcohol consumption In severe withdrawal symptoms and toxicity can resemble those of CNS injury or infection symptoms so that if necessary a medical evaluation with CT and lumbar puncture may be required. Patients with mild symptoms do not require routine testing, unless it occurs after 2 to 3 days there is no improvement. A clinical tool for assessing the severity of alcohol withdrawal is available. Clinical Calculator: alcohol withdrawal scale according CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) Treatment Supportive care once withdrawn: Benzodiazepine and sometimes phenobarbital or propofol toxicity or overdose Treatment of alcoholic toxicity could include: airway management Sometimes infusions of thiamine, magnesium and vitamins the first priority is to ensure an adequate respiratory function; Intubation and ventilation for apnea or inadequate respiration may be needed. An intravenous hydration is necessary for hypotension or existence of volume depletion, but the alcohol precipitation can not significantly improve. If i.v. Liquids are used, a single dose of 100 mg thiamine is i.v. given to treat Wernicke encephalopathy or prevent. Many doctors also add multivitamins and Mg added to the infusions. The disposition of the acutely intoxicated patient depends on clinical response, not on a particular BAK.Entzug patients with severe alcohol withdrawal or delirium tremens should be treated in an intensive care unit until these symptoms subside. Treatment may include the following measures include, to prevent Wernicke-Korsakoff syndrome and other complications: thiamine i.v. Benzodiazepines thiamine 100 mg i.v. given is used to prevent the Wernicke-Korsakoff syndrome. Alcohol tolerant people often have a cross-tolerance to some drugs that are commonly used to accompany a withdrawal (z. B. benzodiazepines). Benzodiazepinesind the cornerstone of therapy. Dosage and procedure depend on the degree of excitement, from the vital signs and mental status. Diazepam, i.v. in a dose of 5-10 mg or p.o. occurs every hour until sedation is a common first intervention measure; Lorazepam 1-2 mg p.o. or iv is an alternative. Chlordiazepoxide 50-100 mg p.o. every 4-6 hours, then reduced, is an older acceptable alternative for less severe withdrawal cases. Phenobarbital can help if benzodiazepines are ineffective, but respiratory depression is a risk when co-administered. Phenothiazine and haloperidol are not recommended as a first measure, because they can lower the seizure threshold. In patients with severe liver disease a short-acting benzodiazepine (lorazepam) or metabolized via glucuronidation benzodiazepine is preferable. (Note: Benzodiazepines may intoxication, physical dependence and withdrawal symptoms in alcoholics cause and should therefore be discontinued after detoxification An alternative is carbamazepine 200 mg PO four times a day, which is then withdrawn gradually..) Unlike in the US, in Germany clomethiazole the benzodiazepines usually preferred. I.v. Administration of clomethiazole should only be done under intensive care conditions. Because of the specific side-effect profile (respiratory depression, bronchial hypersecretion) may clomethiazole not be used in patients with pulmonary predamages. to lower in severe hyperadrenerger activity or to the required amount of benzodiazepine, a short-term therapy (12-48 h) with a beta-blocker can be titrated (z. B. metoprolol 25-50 mg po or iv 5 mg every 4-6 h) and clonidine 0.1-0.2 mg iv every 2-4 h are used. A seizure does not need specific therapy when it occurs briefly and isolated, but some doctors administered routinely a single dose of lorazepam 1-2 mg iv as prophylaxis for another attack. Repeated or prolonged (> 2-3 min) seizures should however be treated. Lorazepam is often i.v. in a dose of 1-3 mg effective. Routine use of phenytoin is unnecessary and ineffective. Outpatient therapy with phenytoin is almost always time and medication waste since the seizures occur only during alcohol withdrawal and patients in the withdrawal or heavy drinkers do not take their anticonvulsant drugs. Delirium tremens can be fatal and must get back to a high i.v. Dose of benzodiazepines to be treated, preferably in an intensive care unit. The dosage is higher and more frequently than with less severe withdrawal. Very high doses of benzodiazepines may be required, and there is no maximum dose or defined treatment plans. Diazepam 5-10 mg i.v. or 1-2 mg Lorazepam i.v. every 10 min as needed given to control the delirium; some patients need several hundred milligrams in the first few hours. Patients who do not respond to high doses of benzodiazepines, phenobarbital 120-240 mg iv obtained every 20 min, as required. can tremens heavy and drug resistant Delirium with a continuous infusion of lorazepam, diazepam, midazolam or propofol, are usually treated with simultaneous mechanical ventilation. Fixations, should be avoided if possible, to minimize additional excitement, but patients should not be able to escape to remove infusions or putting themselves in danger in other ways. Intravascular volume must be balanced with intravenous fluids. There are immediately high doses of Vitamin C and vitamin B complex, esp. To administer thiamine. A sudden increase in temperature at a delirium tremens indicates a poor prognosis.

Health Life Media Team

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