Rosen & Barkin's 5-Minute Emergency Medicine Consult (40 page)

• Often provided by EMS, family, or friends
  
• Beware the “frequent flyer” in the ED:
  
  • Can sometimes have other causes of AMS:
    
    • Hepatic disease/encephalopathy
      
    • Seizures (postictal)
      
    • Hypoglycemia
      
    • Head injury or intracranial bleeding
      

• Vital signs:
  
  • Acute intoxication: Normal or depressed
    
  • Withdrawal: Usually elevated
    
• Mental status:
  
  • Acute intoxication: Somnolent, obtunded, or comatose
    
  • Withdrawal: Hyperalert, agitated
    
• Signs of hepatic injury:
  
  • Jaundice
    
  • Icterus
    
  • Spider angiomata
    
  • Asterixis
    
  • Hepatomegaly
    
• Signs of malnutrition:
  
  • Alopecia
    
  • Poor dentition
    
  • Poor muscle mass
    
  • Abdominal wasting
    
  • Temporal wasting
    

• Obtain accurate alcohol ingestion and abstinence history
  
• Investigate for life-threatening causes of seizures:
  
  • Hypoglycemia (get rapid bedside glucose)
    
  • Intracranial hemorrhage
    
  • CNS infection
    
  • Electrolyte abnormalities
    
• Evaluate for occult trauma
  
• Monitor all vital signs frequently:
  
  • Hyperthermia predicts poorer outcomes
    

• Alcohol level if abnormal mental status
  
• Urine toxicology panel to screen for coingestants
  
• Electrolytes, BUN, creatinine, and glucose
  
• CBC
  
• Magnesium, calcium, and phosphate
  
• PTT, PT/INR if coagulopathy suspected
  
• LFTs if liver disease suspected
  
• Ammonia level if hepatic encephalopathy suspected
  
• Urinary ketones or serum acetone if alcoholic ketoacidosis suspected
  

• CT of head if:
  
  • Alteration in mental status is out of proportion to expected AMS based on serum alcohol level
    
  • Suspected head trauma
    
  • Signs of increased intracranial pressure or focal findings on neurologic exams
    
  • New-onset seizure
    
  • Unimproved or deteriorating level of consciousness
    
• EEG differentiates alcohol withdrawal seizures from idiopathic epilepsy
  
• Chest radiograph if suspected aspiration or pneumonia
  

• Acute alcohol intoxication:
  
  • Hypoglycemia
    
  • Carbon dioxide narcosis
    
  • Mixed-drug overdose
    
  • Ethylene glycol, methanol, or isopropanol poisoning
    
  • Hepatic encephalopathy
    
  • Psychosis
    
  • Severe vertigo
    
  • Psychomotor seizure
    
• Alcohol withdrawal and seizures:
  
  • Sedative–hypnotic withdrawal
    
  • Acute intoxication or poisoning:
    
    • Carbon monoxide
      
    • Isoniazid (especially if prolonged seizures not responding to standard therapy)
      
    • Amphetamine
      
    • Anticholinergic
      
    • Cocaine
      
  • Secondary seizure disorders:
    
    • Infection
      
    • Meningitis
      
    • Encephalitis
      
    • Brain abscess
      
  • Trauma
    
  • Intracranial hemorrhage
    
  • CVA
    
  • Tumor
    
  • Anticonvulsant noncompliance
    
  • Thyroid disorder
    

TREATMENT

• Administer benzodiazepines for seizures
  
• Give naloxone, oxygen, and dextrose for comatose individuals
  
• Intubate as necessary for airway protection to prevent aspiration
  
• C-spine immobilization if suspected trauma
  

• Airway, breathing, circulation (ABCs)
  
• Evaluate C-spine if suspected trauma
  
• Initial IV rehydration with 0.9 NS, then D5 0.45 NS
  
• Administer naloxone, thiamine, and glucose (or Accu-Chek) if altered mental status
  
• Benzodiazepines if seizing (may require large doses)
  

• Young children have decreased hepatic glycogen reserves
  
• Cannot mount an appropriate response to increased glucose needs
  
• Rapid bedside glucose (Accu-Chek) is ESSENTIAL:
  
  • Administer dextrose if indicated with D5 (10 mL/kg), D10 (5 mL/kg), or D25 (2 mL/kg) depending on age and size
    

• Alcohol intoxication:
  
  • Rehydrate with IV fluids
    
  • Correct electrolyte abnormalities:
    
    • Magnesium
      
    • Potassium
      
    • Folate
      
    • Thiamine
      
    • Multivitamins
      
• Alcoholic ketoacidosis:
  
  • Aggressive rehydration with D5 0.9 NS
    
  • Exclude other causes of wide anion-gap metabolic acidosis
    
• Alcohol withdrawal syndrome:
  
  • CIWA-Ar
    
    • Validated scale for assessing withdrawal severity
      
    • Guides initial pharmacotherapy
      
    • Gauges response to therapy and needs for repeat dosing (“symptom-triggered” therapy)
      
  • Benzodiazepines are the agent of choice:
    
    • Cross-tolerant with alcohol
      
    • Increases GABA
      _A
      -mediated transmission
      
    • Anticonvulsant effect
      
    • Large, frequent doses required with significant withdrawal
      
    • May halt progression to DTs
      
  • Barbiturates (phenobarbital):
    
    • Useful if severe withdrawal or DTs refractory to large doses of benzodiazepines
      
  • Propofol:
    
    • Agent of choice for intubated patients
      
    • Completely suppresses seizure activity
      
    • Requires intubation/ventilation
      
    • Caution if hypotensive
      
  • β-blocker (labetalol, esmolol, or metoprolol):
    
    • Normalizes vital sign abnormalities
      
    • Does
      not
      treat CNS complications of alcohol use or withdrawal
      
  • α-agonist (clonidine):
    
    • Centrally acting α
      ₂
      -adrenergic agonists
      
    • Normalizes vital sign abnormalities
      
    • Do
      not
      treat CNS complications of alcohol use or withdrawal
      
  • Phenytoin:
    
    • Not indicated in seizures primarily due to alcohol withdrawal
      
    • Indicated if seizures secondary to idiopathic epilepsy, posttraumatic, or status epilepticus
      

• Dextrose: D
  ₅₀
  W 1 amp (50 mL or 25 g; peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Diazepam (Valium): 5–10 mg IV q5–10min until patient calm
  
• Lorazepam (Ativan): 0.5–4 mg IV/IM q5–10min until patient calm
  
• Naloxone (Narcan): 0.4–2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Phenobarbital: 10–20 mg/kg IV (loading dose) monitor for respiratory depression
  
• Phenytoin: 15–18 mg/kg not to exceed 25 mg/min:
  
  • May give Fosphenytoin at 15–20 mgPE/kg at a maximum rate of 150 mgPE/min
    
• Propofol: 25-75 μ/kg/min IV (loading dose) then 5–50 μg/kg/min (maintenance dose)
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• Inability to control seizures or withdrawal symptoms with oral medications
  
• Hepatic failure, infection, dehydration, malnutrition, cardiovascular collapse, cardiac dysrhythmia, or trauma
  
• Hallucinations, abnormal vital signs, severe tremors, or extreme agitation
  
• Wernicke encephalopathy
  
• Confusion or delirium
  

• Clinically sober
  
• Seizure free for 6 hr (with negative workup if 1st seizure)
  

Discuss with social worker and/or police and/or department of family services for pediatric patients.

Substance abuse referral for patients with recurrent alcohol intoxication/use

• Failure to appreciate AMS due to nonalcoholic causes in chronic alcoholics:
  
  • Serum levels should drop by 15–40 mg/dL/hr
    
  • If mental status not improving (or worsening) need to investigate further
    
• Failure to adequately treat with benzodiazepines:
  
  • May require massive doses (e.g., 200–300 mg of diazepam) to control
    
  • If unable to control, consider other GABAergic agents (phenobarbital, propofol)
    
• Failure to appreciate hypoglycemia as a common entity in these patients:
  
  • Can masquerade as “intoxication”
    
  • Can result in poor outcomes
    
  • Frequently occurs in chronic alcoholics and children
    

• D’Onofrio G, Degutis LC. Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review.
  Acad Emerg Med
  . 2002;9:627–638.
  
• Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of Alcohol Withdrawal Delirium: An Evidence-based Practice Guideline.
  Arch Int Med
  . 2004;164:1405–1412.
  
• McKeon A, Frye MA, Delanty N. The Alcohol Withdrawal Syndrome.
  J Neurol Neurosurg Psychiatry.
  2008;79(8):854–862.
  
• Nelson LS, Gold JA. Chapter 78. Ethanol Withdrawal. In: Hoffman RS, Nelson LS, Goldfrank LR, et al., eds.
  Goldfrank’s Toxicologic Emergencies
  . 9th ed. New York, NY: McGraw-Hill; 2011.
  
• Pitzele HZ, Tolia VM. Twenty per hour: Altered mental state due to ethanol abuse and withdrawal.
  Emerg Med Clin N Am
  . 2010;28:683–705.
  

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