Question Of The Day #78

question of the day
Which of the following is the most likely cause for this patient’s condition?

This patient presents to the Emergency department from a party with slurred speech and somnolence after drinking homemade alcohol.  On exam, his vital signs and glucose are normal, he is nonresponsive to pain, and he has a GCS of 3 (normal GCS is 15).  He is intubated due to his inability to protect his airway and risk for aspiration.  Intubation is an important first step in managing this patient.

Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions.  The immediate evaluation and treatment of this patient should focus on the ‘ABCs’, or any abnormality in the airway, breathing, and circulation.  Any rapidly correctable causes of altered mental status, like hypoxia, hypoglycemia, or hyperthermia, should be addressed appropriately at this stage (i.e., supplemental oxygen, intubation, IV dextrose, body cooling). 

Paracetamol (APAP) overdose (Choice A) is often accompanied with little to no symptoms in the first 24hours.  Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given.  The symptoms exhibited by the patient do not correlate with APAP overdose.  Opioid overdose (Choice D) can cause severely depressed mental status as seen in this patient.  However, opioid overdose also has decreased respiratory rate, pinpoint pupils, and sometimes associated bradycardia or hypotension.  This patient has normal vital signs and normal pupil size.  This patient ingested some type of alcohol at the party, but it is unclear if it is ethanol or a toxic alcohol (i.e., methanol, ethylene glycol).  Both ethanol and methanol ingestion (Choice B) can cause similar exam findings of depressed mental status as in this patient.  Other features of toxic alcohol ingestion include vision changes (methanol), hemorrhagic gastritis (isopropyl alcohol), coma, seizures, and hyperventilation (respiratory compensation for severe acidosis).  Ethanol and many of the toxic alcohols will cause an increased anion gap metabolic acidosis with an increased osmolar gap.  Helpful tests to differentiate ethanol from a toxic alcohol are serum levels of ethanol and serum toxic alcohol levels (if available).  A somnolent, intoxicated-appearing patient with a negative ethanol level should raise suspicion for toxic alcohol poisoning.  Urine studies may also show oxalate crystals in ethylene glycol ingestion. 

Since ethanol is not a listed choice and laboratory studies are not provided, methanol ingestion (Choice B) is the most likely cause of this patient’s symptoms.  Fomepizole (Choice C) is an intravenous medication that inhibits the alcohol dehydrogenase enzyme.  Fomepizole is the antidote to toxic alcohols by slowing the production of dangerous toxic alcohol metabolites.  The correct answer is Choice B.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #78," in International Emergency Medicine Education Project, February 25, 2022, https://iem-student.org/2022/02/25/question-of-the-day-78/, date accessed: July 3, 2022

Alcohol Poisoning

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: July 3, 2022