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  • Alcohol abuse can cause the small pancreatic ducts to become clogged. It's also unclear how alcohol damages the pancreas. One theory is that excessive alcohol leads to protein plugs - precursors to small stones - that form in the pancreas and block parts of the pancreatic duct. Another theory is that alcohol directly injures pancreatic tissues
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    • 1. ALCOHOL – EFFECTS, DEPENDENCE, WITHDRAWAL & TREATMENT St Vincent’s Hospital D&A Service Lisa Jayne Ferguson and Jeku Jacob
    • 2. Alcohol  CNS depressant: acting at several sites in brain Enhances GABA activity Stimulates serotonin receptor = pleasure & nausea Stimulates dopamine and opioid receptors = euphoria & reinforcement  Provides kilojoules or energy but NO nutritional value  Is a toxin to multiple organs
    • 3. Alcohol 1 standard drink (10 gm) raises the BAL by approximately 0.02 The body/liver processes 1 standard drink (10 gm) per hour BAL continues to rise for 30 – 90 minutes after the last drink
    • 4. The National Health & Medical Research Council 2009 Recommended maximum: (1/100 lifetime chance of death)  Women: 2 standard drinks/day  Men: 2 standard drinks/day (was 4) Risky: ie increasing life time risk of death  Women: 3 standard drinks/day  Men: 5 standard drinks/day Known to cause harm: - chronic organ damage  Women: Over 4 standard drinks/day  Men: Over 6 standard drinks/day  Pregnant women recommends 0 drinks – data still sparse  Health benefits of Alcohol greatly exaggerated
    • 5. Alcohol Dependence  More common than dependence on all other drugs combined in Australia  About 5% of Australians are dependent  17 times as common as opioid dependence  10% receive some form of treatment  Only 1% are prescribed anti-craving drugs ...this is compared to -30% opioid dependent people in treatment  Alcohol contributes to over 3,000 deaths per year and 50,000 hospitalisations
    • 6. Alcohol Intoxication 0.01-0.02 Sense of well being 0.02-0.05 Slightly dizzy, talkative, over-confident, euphoria, clumsy 0.06-0.1 Decrease inhibitions & motor co-ordination. Increase pulse, ataxia, talkative 0.2-0.3 Poor judgement, nausea, vomiting 0.3-0.4 Blackout, memory loss, emotionally labile 0.4+ Stupor, breathing reflex threatened, deep anaesthesia, death (in non tolerant people)
    • 7. High Alcohol Consumption – Long Term Effects  GIT/Hepatic     Alcoholic Hepatitis Cirrhosis Pancreatitis Colitis  Nervous System  Endocrine  Hypgoglycemia (don’t give thiamine until you replace sugar)  Hypogonadism  Oncology  Increased risk of mouth, colon, breast and larynx  Wernicke/Korsakoff’s  Alcoholic Dementia  Myopathy  Obstetric  Neuropathy  Hematologic  Cardiac  AF  Hypertension  Cardiomyopathy  Foetal Alcohol Syndrom  Bone marrow suppression leads to macrocytic anemia  Cirrhosis can lead to thrombocytopenia
    • 8. Alcohol Related Presentations to ED
    • 9. Common Presentations  Pt can usually come in complaining of withdrawal symptoms.  Hallucinations  Tremors  Sweats  Anxiety  Perceptual disturbances  Seizures  Hemetemesis  Abdominal Pain  Falls  Palpitations  Productive Cough  Jaundice  Feeling unwell  Intoxication  Trauma/ Violence
    • 10. History taking  Please take a good history  Try to quantify alcohol use to grams/SD  How often they drink (try to take a day history)  Last drink?  Age of starting drinking  Reasons why drinking was exacerbated  ?Depression/Suicidality  Social Situation  Any other substances of misuse  Please exclude other causes of presentation
    • 11. Physical Findings  Signs of Chronic Liver Disease  In withdrawal Anxious Sweaty Tachycardic and Hypertensive Tremulous  Wernicke’s: confused, ataxic and opthalmoplegic  Malnourished  Encephalopathic if CLD
    • 12. Investigations          UDS BAC BSL FBC – may show macrocytic Anemia UEC, LFTS, CMP B12 + folate – usually deficient INR - caogulopathy CT brain if history of fall/seizures or ataxic U/S abdomen if you suspect CLD
    • 13. Management Hydrate Thiamine (BEFORE GLUCOSE) – youll never go wrong with giving more 300 mg tds iv please to start on all intoxicated pts 500 mg tds iv if you suspect wernicke’s Glucose in thiamine deficiency precipitates wernicke’s Replace Sugar please if glycopenic Replace Electrolytes
    • 14. Alcohol Withdrawal Is a syndrome of central nervous system hyperactivity Onset  Usually between 6-24 hours after last regular dose of alcohol (symptoms occur as blood alcohol concentration decreases) Duration  Between 2-7 days (most commonly 4-5 days)  Residual symptoms will last longer when brain injury is involved
    • 15. Rationale  Withdrawal symptoms can range from mildly uncomfortable to life threatening  Symptoms can be prevented or alleviated  Early intervention can reduce or prevent progression to severe withdrawal, injury, dehydration or seizures
    • 16. Severe Alcohol Withdrawal Symptoms CAN BE FATAL (RARELY) Seizures - 6-48 hours Mod-Severe Hypertension - 6-48 hours+ (Diastolic above 110) Disorientation - 48 hrs+ Confusion - 48 hrs+ Hallucinations - 48 hrs+ Delirium Tremens- 48 hrs+
    • 17. Alcohol Withdrawal Scales  The most systematic & useful way to measure the severity of withdrawal is to use a withdrawal scale  These provide a baseline against which changes in withdrawal severity may be measured over time  Research shows that the use of scales minimises both under-dosing & overdosing with benzodiazepines for alcohol withdrawal syndromes
    • 18. AWS  Please do not start AWS prematurely  Calculate when BAC will return to normal, then start  (Pt’s may go into withdrawal prior to this – clinical perogative necessary)  AWS not diagnostic...make diagnosis of withdrawal first before instituting  5 – 10 mg every 4 hours with a cap of 80 mg in the first 24 hours  Can get 120 mg in first 24 hours if appropriate
    • 19. Perceptual disturbances/ Hallucinations in withdrawal Curtains/floor/furniture moving ‘Insects over skin’ Hallucinations rarer and signify severity of withdrawal colour changes Animal forms Scary These require antipsychotics Olanzapine
    • 20. Special Considerations Use Oxazepam (7.5-45mg) if: Cirrhosis Be careful with doses of BZD Elderly Head injury Stay away from BZD if delerious, use antipsychotics instead Difficulty in encepholapathy  use lactulose!
    • 21. Gorman House  Pts in ED who don’t require admission can be rehydrated, given thiamine and discharged  Gorman House is appropriate for detoxification  Gorman House – 5/7 program  Pts need to be discharged on weaning diazepam  Day 1 – 10mg qid  Day 2 – 10 mg tds  Day 3 – 10 mg bd  Day 4 – 10 mg daily
    • 22. Wernicke-Korsakoff Syndrome  Form of brain injury resulting from thiamine deficiency  If not treated early it can lead to permanent brain damage & memory loss  Signs & symptoms of Wernicke’s encephalopathy (usually the first stage of the syndrome) = 1. Ophthalmoplegia (reduced eye movements) or Nystagmus (dancing eyes) 2. Ataxia 3. Confusion
    • 23. Wernicke-Korsakoff Syndrome  This condition is reversible if recognised and treated with parenteral vitamin B1  Parenteral thiamine should be administered before any form of glucose  Glucose in the presence of thiamine deficiency risks precipitating Wernicke’s encephalopathy  Korsakoff’s by itself : confabulation, amnesia and apathy  (ask: ‘do you remember me?’ Or ‘where did we meet before’
    • 24. Wernicke-Korsakoff Syndrome  NB: Studies have shown that the absorption of PO thiamine in alcohol dependent patients is minimal to none!!!  Example of dosing regime:  Thiamine 300mg tds IVI / IMI for 3/7’s , then PO  If WE established: Thiamine dose should be increased
    • 25. Potential Problems  High doses of Diazepam should not be used to treat alcohol related delirium  Diazepam can precipitate and cause delirium  Olanzapine/Haloperidol can lower seizure threshold  AWS should only be used for Alcohol, not opioid or benzodiazepine withdrawal
    • 26. Treatment Options for Patients  Follow up with outpatient services / Tx – - 1:1 counselling (public & private), - Groups (SMART Recovery, AA’s) - Residential Rehab, - Pharmacotherapy‘s * Impaired Cognition (Moderate-Severe) 1. Cognistat /Neuropsych Assessment 2. Guardianship /Inebriates Act 3. Placement?????
    • 27. Take Home Messages Take a good alcohol history Don’t start the AWS too early Please replace thiamine iv before glucose (at least one dose)  AWS not diagnostic – pt not improving, consider alternative diagnosis
    • 28. SVH A&D Service THANK YOU 

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