Rosen & Barkin's 5-Minute Emergency Medicine Consult (218 page)

• ABCs, IV access
  
• Begin resuscitation with IVF if no signs or symptoms of pulmonary edema
  
• Rapid glucose determination (Accu-Chek)
  

• ABCs:
  
  • Airway protection if necessary
    
  • Supplemental oxygen
    
  • Mechanical ventilation as needed
    
  • Resuscitation with 0.9% NS IV for hypotension
    
• Pressor support with norepinephrine for refractory hypotension
  

• Management is primarily supportive with aggressive, appropriate care:
  
  • No specific antidote available
    
• GI decontamination:
  
  • Activated charcoal in cases of disulfiram overdose:
    
    • Caution if mental status depression
      
    • Caution if vomiting (potential for aspiration)
      
    • Do not intubate solely to give activated charcoal
      
  • Gastric lavage is unnecessary
    
  • Whole-bowel irrigation is not indicated
    
• Alleviation of flushing:
  
  • Antihistamines (H
    ₁
    and H
    ₂
    antagonists)
    
  • Prostaglandin inhibitors (indomethacin, ketorolac)
    
• Antiemetics for intractable vomiting (ondansetron, metoclopramide)
  
• Seizures:
  
  • Benzodiazepines (diazepam, lorazepam)
    
  • Pyridoxine (vitamin B
    ₆
    )
    
  • 4-methylpyrazole:
    
    • Inhibits ethanol metabolism at alcohol dehydrogenase enzyme
      
    • Not indicated for routine disulfiram–ethanol reactions or mild disulfiram overdose
      
    • May improve the hemodynamic profile in moderate to severe overdoses
      
• Hemodialysis:
  
  • Consider after massive ingestion of disulfiram and ethanol with refractory hypotension
    
  • No studies documenting beneficial effect
    

• Diazepam: 5–10 mg (peds: 0.2–0.5 mg/kg) IV
  
• Diphenhydramine: 25–50 mg (peds: 1–2 mg/kg) IV
  
• Indomethacin: 50 mg PO (peds: 0.6 mg/kg PO for age >14 yr)
  
• Lorazepam: 2–6 mg (peds: 0.03–0.05 mg/kg) IV
  
• Metoclopramide: 10 mg (peds: 1–2 mg/kg) IV
  
• Norepinephrine: 4 mL in 1,000 mL of D
  ₅
  W, infused at 0.1–0.2 μg/kg/min
  
• Ondansetron: 4 mg (peds: 0.1 mg/kg for >2 yr old) IV
  
• Pyridoxine: 1 g (peds: 500 mg) IV, repeat PRN
  

FOLLOW-UP

• ICU admission for mechanical ventilation, coma, refractory hypotension requiring pressors, cardiac ischemia, refractory seizures, and severe agitation
  
• Persistent vomiting, abdominal pain, or flushing
  
• Elderly patients or those who have pre-existing cardiac disease
  

• Mild reactions that resolve with supportive care after observation period of 8–12 hr:
  
  • Symptoms may recur on rechallenge with ethanol up to 7–10 days after last dose of disulfiram or agents that cause disulfiram-like reactions
    
  • Abstain from ethanol use until at least 2 wk after last dose of such agents
    
• Appropriate follow-up needed to assess development of hepatic or neurologic sequelae
  

• Psychiatry follow-up for intentional overdose with disulfiram
  
• Detox follow-up for patients with disulfiram–ethanol reactions
  

• Educate patients who are prescribed medications with potential for disulfiram-like reactions to avoid ALL alcohol
  
  • Includes: Mouthwash, alcohol-based hand gels, alcohol-based aftershaves, some cough syrups, and elixir-based liquid medications
    
• Recommend abstinence for 3 days longer than the course of treatment to ensure low likelihood of reaction
  

• Enghusen Poulsen H, Loft S, Andersen JR, et al. Disulfiram therapy–adverse drug reactions and interactions.
  Acta Psychiatr Scand Suppl
  . 1992;369:59–65.
  
• Kuffner EK. Chapter 79. Disulfiram and disulfiram-like reactions. In: Hoffman RS, Nelson LS, Goldfrank LR, Howland MA, Lewin NA, Flomenbaum NE, eds.
  Goldfrank’s Toxicologic Emergencies
  . 9th ed. New York, NY: McGraw-Hill; 2011.
  
• Leikin J, Paloucek F. Disulfiram.
  Poisoning and Toxicology Handbook
  . Hudson, OH: Lexi-Comp; 2002;502–503.
  
• Park CW, Riggio S. Disulfiram-ethanol induced delirium.
  Ann Pharmacother
  . 2001;35:32–35.
  
• Sande M, Thompson D, Monte AA. Fomepizole for severe disulfiram-ethanol reactions.
  Am J Emerg Med.
  2012;30(1):262.e3–e5.
  

See Also (Topic, Algorithm, Electronic Media Element)

Alcohol Poisoning

CODES

977.3 Poisoning by alcohol deterrents

BASICS

• Micro- or macroscopic perforation of diverticulum
  
  • Uncomplicated (75%) vs. complicated
    
• Incidence increasing
  
  • Obesity is a risk factor
    

• Fecal material in diverticulum hardens, forming fecalith, increasing intraluminal pressure
  
• Erosion of diverticular wall leads to inflammation
  
• Focal necrosis leads to perforation
  
• Microperforation: Uncomplicated diverticulitis:
  
  • Colonic wall thickening
    
  • Inflammatory changes (fat stranding on CT)
    
• Macroperforation: Complicated diverticulitis:
  
  • Abscess
    
  • Bowel obstruction
    
  • Fistulas after recurrent attacks
    
  • Colovesical fistula (most common) presents with dysuria, frequency, urgency, pneumaturia, and fecaluria.
    
  • Peritonitis
    

DIAGNOSIS

• Symptoms typically develop over days
  
  • Almost 50% have had prior episodes of pain
    
• Left lower quadrant pain in 70% of cases in Western countries
  
  • Initially vague, then localizes
    
  • RLQ in 75% of Asian patients
    
• Nausea/vomiting, constipation, diarrhea, urinary symptoms (in decreasing order)
  

• +/– low-grade fever
  
• Tenderness at left lower quadrant with occasional (20%) mass palpated (phlegmon):
  
  • Phlegmon
    —inflamed bowel loops or abscess
    
• Abdominal distension
  
• Bowel sounds variable
  
• Rectal tenderness with heme-positive stool:
  
  • Massive gross rectal bleeding (rare)
    
• Peritoneal signs if:
  
  • Perforation has occurred
    
• Unremarkable exam if:
  
  • Elderly
    
  • Immunocompromised
    
  • Taking corticosteroids
    

• CBC
  
• UA
  
• Blood cultures and lactate
  
  • If showing signs of sepsis
    
• CT of abdomen/pelvis
  
  • Preferred diagnostic modality
    
  • Ability to diagnose nondiverticular causes of abdominal pain
    
  • Accuracy enhanced with use of IV and PO/PR contrast
    
  • Gastrografin PO/PR (per rectum) contrast may be used; avoid barium, especially when perforation is suspected
    
• Plain radiographs: Chest/abdomen
  

• CBC
  
  • Leukocytosis common, but absence does not exclude diagnosis
    
• UA
  
  • Sterile pyuria is possible
    
  • Colonic flora (bacteria) suggests colovesical fistula