ALCOHOL INTOXICATION

Heny

TYPES OF ALCOHOL

Ethanol (ethyl alcohol, grain alcohol)

Methanol (methyl alcohol, wood alcohol)

Isopropanol (isopropyl alcohol, rubbing alcohol)

Ethylene glycol

ROUTES OF ADMINISTRATION

Topical

Inhalation

Intravenous injection

Oral ingestion

ABSORPTION

Absorption of ethanol is by simple diffusion

25% of an ingested dose of ethanol is absorbed from
the stomach
75% of an ingested dose of ethanol is absorbed from
the small intestine

FACTORS AFFECTING ABSORPTION

Alcohol concentration of the ingested beverage

Optimal absorption occurs for beverages

with alcohol concentrations between
10% alc. v/v and 30% alc. v/v

Beverages <10 % alc. v/v do not present as

large a concentration gradient
Beverages >30% alc. v/v will irritate the
gastric mucosa and increase mucous
production

FACTORS AFFECTING ABSORPTION

Physiology
Changes in blood supply to the GI tract
Changes in motility will affect the speed with
which ethanol enters the small intestine

FACTORS AFFECTING ABSORPTION

Presence of food in the stomach

Food in the stomach will prolong gastric

emptying time, resulting in a lower, delayed peak
blood alcohol concentration

EFFECT OF FOOD ON ABSORPTION

120
100
80

With food in stomach

60
40
20

Time

300

250

220

200

140

120

100

60

50

20

0
0

Blood Alcohol Concentration

Empty stomach

DISTRIBUTION

Alcohol is hydrophilic and will distribute into fluids

and tissues according to water content
Total body water (TBW) is dependent upon
Age
Sex

Body

weight

EXAMPLES
Effect of sex:
Man weighing 150 lbs
Woman weighing 150 lbs
Each consume 2 beer
BAC of the man will be 57
mg/100 mL
BAC of the woman will be
67 mg/100 mL

Effect of weight:

Man weighing 150 lbs

Man weighing 200 lbs

Each consume 2 beer

BAC of the lighter man will be 57 mg/100 mL

BAC of the heavier man will be 43 mg/100 mL

ALCOHOL METABOLISM

5-10% of ingested ethanol is excreted

Biotransformation occurs in the liver

Commences as soon as EtOH is absorbed

Alcohol dehydrogenase is primary enzyme

Ethan
ol
Alcohol dehydrogenase
Acetaldehyde
Aldehyde
dehydrogenase
Acetic Acid
CO2 + H2O

ELIMINATION

Elimination of alcohol from the blood:

Follows

zero-order kinetics
Ranges from 10-20 mg/100 mL/hour
Average rate of elimination is 15 mg/100 mL/hour
Is fixed and unaffected by:

coffee
sleep

exercise
eating showering
fresh air

FRUCTOSE

There is scientific agreement that fructose can

increase the elimination rate of alcohol
However the required intake of fructose is so
high that vomiting and abdominal pains result
from the ingestion

PATHOPHYSIOLOGY
GABA.

Glutamate.
NAD/NAD ratio.
ketogenesis.
gluconeogenesis
glycogenolysis
Fluid & electrolyte imbalance.

EFFECTS OF ALCOHOL ON THE BODY

Vasodilatation
Creates

a feeling of warmth when alcoholic beverages are

consumed
Contributes to paradoxical undressing in hypothermia
deaths

Disinhibition
Responsible

for the stimulant effects of alcohol

Euphoria, talkativeness, sociability

EFFECTS OF ALCOHOL ON THE BODY

Central nervous system depressant

Non-selective

depression of brain and spinal cord

Effects occur on a continuum - with increased BAC,
increased effects occur
Sedated Sleepy Stuporous Unconscious
Effects are additive with other CNS depressants

ASSCOCIATED ACUTE PROBLEMS.

Alcoholic ketoacidosis.
Alcoholic hypoglycemia.
Fluid & electrolyte imbalance.
Wernickes encephalopathy.

Acute

effects on heart.
Acute GI efects.
Acute alcoholic myopathy
Trauma
Associated other substance
poisoining.

ALCOHOLIC KETOACIDOSIS

High anion gap acidosis

Normal or low glucose level
Chronic alcoholics
Binge drinking wks before symptoms
Dehydration, starvation due to vomiting, gastritis

Alcohol

Acetaldehyde

poor food intake

glycogenolysis

Acetate

NADH/NAD
ratio

gluconeogenesis

ketogenesis

dehydration

counter
regulatory
hormones

glucagon
insulin

Altered mental status

Kussmaul breathing
Ketotic breath
Lab finding
high anion gap acidosis
beta hydroxybutyrate:acetoacetate
insulin level
Exclude other causes of A;G acidosis

ALCOHOLIC HYPOGLYCEMIA
Chronic

street alcoholic found unresponsive

Symptoms

neuroglycopenic confusion,fatigue,seizure,
loss of consciousness death
autonomic responses palpitation, tremor,
sweating
Signs
pallor, diaphoresis
tachycardia, raised systolic B.P
transient focal neurological signs

WATER AND ELECTROLYTES

DISORDERS
all

alcoholics are dehydrated is false.

Immediate in urine volume followed by
ADH.
Hydration also depends on
-diet,nonalcoholic fluids,type of drinks
-vomiting, diarrhea,infection
Water intoxication & hyponatremia in severe
chronic alcoholicsseizure& altered sensorium
Central pontine mylenolysis

OTHER ELECTROLYTES ABNORMALITIES

Hypomagnesemia

Hypophosphatemia
Hpokalemia

Hypocalcemia

WERNICKE-KORSAKOFFS
SYNDROME
As

high as 12.5% in alcoholics.

Major reversible cause of death.
If untreated 10-20% mortality rate.
Thiamine deficiency is the root cause.
Magnesium deficiency in thiamin resistant
cases.
Clinical features
global confusion
ocular abnormalities
ataxia

ACUTE EFFECT ON HEART

Direct negative inotropic effect & vasodilation.
PR & QT prolongation
Both supraventricular & venntricular arrythmia.
holiday heart syndrome
Various degree of heart block.
+ve correlation between and sudden cardiac
death.

ACUTE ALCOHOLIC MYOPATHY

Acute muscle necrosis mainly in binge drinkers
Alcoholism is the most common cause of
rhabdomyelisis
Raised CKMM, myoglobinuria
Acute tubular necrosisurea, creatinine
Conservative management

ACUTE GASTROINTESTINAL EFFECT

Acute

gastritis & esophagitis.

Epigastric distress and
gastrointesinal bleeding.
Mallory-weiss tear.
Acute hepatitis & pancreatitis.

STAGES OF ALCOHOL INTOXICATION

See also: Table 2, Chapter 10. Levine, 1999. p. 177

Slight intoxication
1050
mg/100 mL May be no observable signs of intoxication
Laboratory testing may reveal some effects
30-120 Mild euphoria, sociability, talkativeness
mg/100 mL Increased self confidence, inhibitions
Sensory perception (e.g. hearing)
Loss of fine motor skills
Slowed information processing

STAGES OF ALCOHOL INTOXICATION

90250 Emotional instability (dissatisfaction)
mg/100 mL Mental confusion
Memory impairment
Impaired balance and coordination
Sedation, drowsiness
180-300 Disoriented to time and place, confusion
mg/100 mL Exaggerated emotional state
Double-vision
Motor incoordination worsens, apathy
Anesthesia

STAGES OF ALCOHOL INTOXICATION

250-400 Loss of motor function
mg/100 mL Response to stimuli
Stupor, unconsciousness
Vomiting, incontinence
Hypothermia
350-500 Unconsciousness Coma
mg/100 mL Depression of reflexes
Impairment of respiration, circulation
Death

ALCOHOL AND DEATH

Primary mechanism for death due to acute alcohol

intoxication is respiratory depression
Average BAC at which respiratory paralysis occurs is
350 mg/100 mL
Death can occur at much lower BAC where aspiration
of vomit occurs

POSITIONAL ASPHYXIA

Alcohol intoxication is the major risk factor for

positional asphyxiation. Central nervous system
depression causes relaxation of the muscles that keep
the airway open during sleep
Average BAC in 23 cases of positional asphyxiation was
reported to be 240 mg/100 mL (Bell et al. 1992)

MANAGEMENT
Airway
Breathing
Circulation
Intubate if poor gag reflex
Fingerstick glucose, iv dextrose
Thiamin 100 mg im/ iv stat.
Magnesium

2 mg naloxone
Exclude other causes of intoxication
ABG
Osmolar gap.
Serum electrolytes
Anion gap.
Correct other electrolyte abnormalities
Dilantin
CT scan.

Blood alcohol conc (BAC)

Enhanced elimination
evacuation after 1 hr little benefit
activated charcoal.
fructose
haemodialysis
metadoxine (300-900mg iv)

Alcohol's Brain Effects

1. Homeostasis

2. Acute use
ALCOHOL

Inhibitio
n

Excitatio
n

3. Chronic use
(tolerance)
OPPOSITE

ALCOHOL

Inhibitio
n

CHANGES

Excitatio
n

t io
i
b
i
Inh n

ati
t
i
c
Ex n

4. Withdrawal
Inh

ibit
io
n

AMSP 2012
10

OPPOSITE
CHANGES

Exc
i ta
ti o
n

TOLERANCE

Chronic use of alcohol will result in a decreased

susceptibility to the effects of alcohol
Visible

signs of intoxication are decreased

Increased survivability even after consumption of large
amounts of alcohol

Tolerance to alcohol may be either functional and/or

metabolic in nature

FUNCTIONAL TOLERANCE

Decreased sensitivity to the CNS depressant effects of

EtOH
e.g.

Integrity of phospholipid bilayer

e.g. Up-regulation of excitatory receptors

Requires higher BAC and higher doses of EtOH to

produce the same effect
Learning by the chronic alcohol user

METABOLIC TOLERANCE
Induction of enzymes in chronic, heavy users of
alcohol can result in an enhanced metabolic rate
Elimination rate in alcoholics has been measured at
40 mg/100 mL/hour and up
Result is a comparatively lower BAC after equivalent
doses of alcohol are ingested

ALCOHOL IN BLOOD, BREATH AND

URINE

ALCOHOL IN BLOOD

Plasma and serum are the watery components of whole

blood
Plasma and serum therefore have a higher alcohol
content than whole blood
Plasma:whole blood ratio ranges from approximately 1.0
to 1.3. Average plasma:whole blood ratio is 1.14

CASE EXAMPLE
An individual suspected of driving while impaired is
brought to the hospital for medical treatment following a
car accident in which his 2 passengers were badly
injured
Blood is drawn at the hospital for medical purposes and
hospital laboratory results reveal a serum alcohol
concentration of 17 mmol/L
Police would like to know if they can charge this
individual with driving over the legal limit

OVER 80?
17.5 mmol/L 80 mg/100 mL
Serum:blood =1.14
Therefore, a serum alcohol concentration of 80
mg/100 mL indicates a whole blood alcohol
concentration of 70 mg/100 mL
This individual is not over 80 at the time the
blood sample is drawn

ALCOHOL IN URINE

Alcohol will pass from the blood into the urine as

the blood is filtered in the kidneys
Urine contains approximately 1.3x as much water
as blood, therefore the UAC will be 1.3 times that
of the BAC.

ALCOHOL IN BREATH

Alcohol is volatile - at physiological temperatures

alcohol will diffuse from the blood into the
alveolar air of the lung and into the breath
Breath analysis is rapid, non-invasive, and does
not require specialized medical personnel for
sampling