Author: Kohylah Piper, Antigua & Barbuda

Physician, medical educator, and health writer; FOAMed, Emergency Medicine, and MedEd enthusiast who hopes to encourage and motivate aspiring physicians in the Caribbean, and worldwide to continue humbly exploring, discovering, and studying what this art continuously teaches, while contributing to medical education development.

Alcohol Poisoning

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What We Know From Current Statistics

Alcohol (ethyl alcohol), also known as ethanol, is one of the most abused substances worldwide, and alcohol poisoning is one of its varying manifestations. Furthermore, alcohol is psychoactive and is known for its ability to induce dependence. Therefore, misuse of alcohol has detrimental effects neurologically and systemically on an individual’s body, and it impacts their sphere of life psycho-socially and economically, the effects of which are generally negative within households and countries on a wider scale.

The National Health Institute mentions that 5.3 percent of deaths globally are related to alcohol consumption, with men being more at risk. The World Health Organization informs that this percentage approximates to around 3 million lives lost around the world.

In the United States particularly, Levine (2021) explains that “more than half of all trauma patients are intoxicated with ethanol” upon accessing the trauma center. It is also a frequent substance ingested along with other substances in suicide attempts.

As a result, it is crucial to be able to identify the presentation of alcohol poisoning or ethanol poisoning in the acute setting.

Risk Factors

Increased risk for alcohol poisoning is related to factors linked to the individual and how alcohol is consumed.

Risks Related To The Individual:

  • Body mass index
  • General health
  • Recent food ingestion
  • Alcohol tolerance level

Risks Related To Alcohol:

  • Amount of alcohol ingested
  • Co-ingestion of other drugs
  • Rate of alcohol consumption

Risk factors may also include a history of alcoholism, binge drinking, as well as mental health issues, including depression associated with suicidal ideation.

Etiology

The general cause of alcohol poisoning results from drinking too much alcohol in a short period; more specifically, binge drinking is considered the main factor, where large quantities of alcoholic beverages are consumed rapidly in less than three hours.

Clinical Presentation

Levine (2021) clarifies that identifying recent changes in the circumstances of the patient may reveal the reason for the presentation.

It is important to note that the serum concentration of ethanol along with the frequency at which the patient may ingest alcohol can influence presentation as patients with antecedents of chronic drinking may not manifest cerebellar dysfunction in comparison to new drinkers. Signs and symptoms will encompass slurred speech, disinhibition in behavior as well lack of coordination. Posteriorly, the patient may show signs of central nervous system depression. Thus, causes that may also present with depression of the central nervous system (CNS) must also be considered. Hidden injuries must be evaluated in the physical examination.

Especially in children and adolescents, the physician must also consider the hypoglycaemic effects of alcohol in the clinical presentation due to the risk of experiencing it after single use in comparison to adults.

Signs and Symptoms of Alcohol Intoxication:

  • Slurred speech
  • Behavioural disinhibition
  • Dizziness
  • Ataxia
  • Drowsiness
  • Coma

 

Differential Considerations

The following are a few causes that also present similarly to alcohol poisoning:

  • Acute hypoglycemia
  • Diabetic ketoacidosis
  • Meningitis
  • Other drug toxicities
    • Benzodiazepine
    • Barbiturates
    • Lithium
    • Opioids
    • Sedatives
  • Stroke

 

Investigations

As previously mentioned, other causes related to depression of the CNS must be considered in such a presentation. (See a list of differentials above)

However, despite various tests that correspond to alternative causes, an investigation that must be evaluated quickly is the serum glucose level. Other tests include and are not limited to:

  • Serum ethanol level. Levine (2021) notes the toxic dose of ethanol is 5 mg/dl and in children 3mg/dl.
  • Toxicology Screen
  • Routine Complete Blood Count and Chemistry to include Bicarbonate, bearing in mind that as the patient progresses, values will also change as related to the anion gap calculation.
  • Liver Function Tests
  • Arterial Blood Gas
  • Electrocardiogram
  • Imaging studies are dependent on suspicion or discovery of traumatic injuries, for example, head trauma.

Management

Treating or managing alcohol poisoning is founded on supportive care, bearing in mind the risk of respiratory depression; the patient’s airway must be protected.

Glucose must be checked frequently when the clinical presentation is severe. It should be monitored ideally every two hours in such cases. The presence of hypoglycemia must be corrected using intravenous dextrose solution. Intravenous fluids may also serve a dual effect to correct dehydration caused by the diuretic effect of alcohol on the body. Any associated traumatic injuries must also be managed. It is important to note that 100 mg of thiamine may be intravenously or intramuscularly administrated if Wernicke’s encephalopathy is suspected.

Key Points

  1. Three million deaths globally are linked to alcohol use.
  2. Alcohol poisoning is related to drinking large quantities of alcohol over a short period of time. Binge drinking is a major cause of alcohol poisoning.
  3. The clinical presentation ranges from slurred speech to coma in severe presentation.
  4. Patients’ blood glucose must be monitored, and another diagnosis that may present with signs of central nervous system depression must be ruled out.
  5. Investigations related to evaluating for hypoglycemia, verifying ethanol toxicity, organ damage, assessing suspected or apparent trauma, and ruling out other possible causes of the clinical presentation.
  6. Treatment is generally supportive and includes correction of hypoglycemia, dehydration, and management of any traumatic injuries.

References and Further Reading

Cite this article as: Kohylah Piper, Antigua & Barbuda, "Alcohol Poisoning," in International Emergency Medicine Education Project, September 27, 2021, https://iem-student.org/2021/09/27/alcohol-poisoning/, date accessed: April 2, 2023

Sepsis – An Overview and Update

An Overview and Update
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What is Sepsis?

Sepsis is a composite of symptoms and clinical signs that correspond to infection within a patient. This clinically heterogeneous syndrome may be fatal due to the extensive inflammatory processes and organ dysfunction it can provoke.

The New Definition of Sepsis

In 2016, after a revision by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, sepsis was redefined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection.”

This new definition of sepsis means that the patient’s body, in response to infection, reacts by causing damage to its own organ structures, and this process can progress to the point where death can be an unfortunate end result.

Along with this up-to-date definition of sepsis, up-to-date criteria for evaluating sepsis were also provided; however, let’s first consider the causes of sepsis.

What is the Aetiology of Sepsis?

Sepsis can be caused by various organisms ranging from viruses to fungi to protozoans; however, bacterial infections are the main offenders. Vincent et al. (2009) concluded in the international EPIC II study that gram-negative bacteria were the principal perpetrators, accounting for 62%, while the gram-positives followed with a frequency of 47%. Of these groups, the principle organisms include:

  • Staphylococcus aureus and Pseudomonas at 20%
  • Escherichia coli at 16%

Different risk factors may predispose persons to become infected by these organisms.

Risk Factors

  • Non-Communicable diseases (Diabetes Mellitus, Chronic Kidney Disease)
  • Hemodialysis
  • Liver disease
  • Immunodeficient conditions
  • Trauma
  • The elderly, children, infants
  • Burns
  • Corticosteroid Use
  • Cancer
  • Prolonged Hospital Stay
  • Indwelling catheters

What is the Clinical Presentation of Sepsis?

The presentation of sepsis ranges from acute to insidious. There are cases where the patient may indicate a site of infection to cases where there is none apparent. Symptoms and signs of this syndrome generally include the following:

Another early sign of sepsis includes the presence of leukopenia or leukocytosis.
Along with these parameters, there are also specific signs within each organ system that must also be taken into account when investigating the source of primary infection or exploring the secondary effects of the same.

For example, when examining the respiratory system, listen for adventitious sounds or decreased breath sounds that may point to pneumonia and other chest infections. Respiratory causes of sepsis account for 42% of cases, according to the EPIC II study.

Patients who present with abdominal pain should be evaluated to rule out infection sources in abdominal structures such as the appendix, colon, pancreas, gallbladder. Other sources of infection may include the urinary tract and the prostate gland.

Patients with a history of trauma, wounds, and recent surgeries should be evaluated for any signs of wound infection (e.g., pain, erythema, purulent discharge, weeping wound, abscess formation)

In patients who are already admitted to the hospital and have been given invasive adjuncts, such as a central line, urinary catheters, and hemodialysis access sites, evaluate for inflammatory signs around the insertion site.

Warning Signs of Severe Sepsis

Sepsis progresses through a continuum that begins with a systemic inflammatory response syndrome (SIRS) and ends with multi-organ dysfunction syndrome (MODS), where mortality is almost inevitable. Its severest form is known as Septic Shock, a subcategory of sepsis where there is a great probability of mortality due to severe metabolic and circulatory irregularities.

The New Criteria for Evaluating Sepsis

The Sequential Organ Failure Assessment score, otherwise known as the SOFA score, is the new criteria used to evaluate sepsis. It replaces the SIRS Criteria.

SOFA takes into consideration six parameters that relate to specific organ systems. These systems are aligned with clinical signs and laboratory values, which fit into a numerical score ranging from 0 to 4, where 0 corresponds to normal values, and 4 corresponds to a high level of organ failure. See the image below, adapted from Vincent et al. (1996).

Since this criteria at its base enable physicians to assess the level of dysfunction occurring in the patient’s organ systems, the higher the score given, the more probable there will be an increase in mortality.

Using the SOFA criteria,  a score equal to and greater than 2 in the presence of confirmed or suspected infection corresponds to organ dysfunction. It indicates a mortality risk of around 10%.

The abbreviated version of the SOFA score, known as quick SOFA or qSOFA, is helpful for screening patients suspected to have sepsis by quickly evaluating three parameters, mental status, systolic blood pressure, and the respiratory rate.

REBELEM Blog (2016) qSOFA Score

Laboratory and Imaging

The general laboratory, imaging, and special studies for sepsis can include various tests depending on the suspected source of the infection, for example:

  • A Chest X-ray may show signs of pneumonia or any other lung infection.
  • CT imaging may reveal abdominal abscesses, perforation of the bowels.
  • An ultrasound can rule out pelvic sources of infection, as well as in organs such as the gall bladder.
  • Cardiac tests (electrocardiogram and troponins) may reveal suspected causes such as Myocardial Infarction.
  • Routine tests such as Complete Blood Count and Chemistry studies provide a baseline analysis for infection screening and organ dysfunction (kidney and liver).
  • Procalcitonin is a sepsis biomarker and increases in the presence of systemic bacterial infection.
  • Blood, urine, and source cultures should be taken for organism identification and antibiotic sensitivities.
  • Certain clinical presentations may necessitate abscess aspiration, lumbar puncture, or paracentesis.
  • Arterial blood gas is also a beneficial test for analyzing how septic a patient may be.

It is also important to note that serum lactate has become an important test in diagnosing sepsis, especially in relation to septic shock. (Lee and An, 2016)

The image below provides a summary of test results related to sepsis, as adapted from Mahapatra and Heffner (2020):

Treatment of Sepsis

The foundational aspects of treating sepsis rest upon rapid recognition and rapid remedy.

Schmidt and Mandel (2021) explain that resuscitation must be aggressively instituted in order to reperfuse the organs; just like antibiotic therapy, fluid resuscitation should be implemented within the first hour. It is given at 30 mL/kg and should be finalized by the third hour.

Initial antibiotic therapy should aim to cover both gram-positive and gram-negative organisms, any other considerations must be fully in line with the information found in the patient’s history, and physical examination. Where the source of infection necessitates surgical intervention, this must be pursued additionally.

The patient’s response to the treatments should be continuously monitored for improvements or worsening condition, and appropriate transfers should be pre-empted, for example, if the patient needs to be transferred to the Intensive Care Unit.

Key Points

  1. Sepsis is a clinically heterogeneous syndrome, which has a progression that can lead to severe cellular, metabolic, and overall hemodynamic dysfunction.
  2. If left un-recognized or, if it is not treated aggressively, the patient outcomes may be dim.
  3. The SOFA score is a criteria that is used in-depth and in a quick overview to assess the level of organ dysfunction in suspected or confirmed sepsis.
  4. Patients should be consistently monitored while exploring for the possible primary source.
  5. Sepsis is treated with rapid infusion of intravenous fluids and by using broad-spectrum antibiotics.
Cite this article as: Kohylah Piper, Antigua & Barbuda, "Sepsis – An Overview and Update," in International Emergency Medicine Education Project, June 28, 2021, https://iem-student.org/2021/06/28/sepsis-an-overview-and-update/, date accessed: April 2, 2023

References and Further Reading