Alcohol Poisoning


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Describes Abt. Hazardous effects of Drinking Alcohol

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Alcohol Poisoning

  1. 1. Free Powerpoint Templates INEBRIANTS ALCOHOL By - Rachit
  2. 2. DEFINITION <ul><ul><ul><ul><ul><li>INEBRIANT ALCOHOL </li></ul></ul></ul></ul></ul><ul><li>THE WORD ALCOHOL COMES FROM THE ARABIC ‘ALKOHL’ WHICH IS A FINE METALLIC POWDER USED IN THE EAST TO STAIN THE FACE AND EYELIDS. THE NAME WAS LATER EXTENDED TO MEAN ANY POWDER PRODUCED BY TITRATION AND SUBLIMATION, AND THEN TO A FLUID OBTAINED BY DISTILLATION . </li></ul><ul><li>Ethanol (ethyl alcohol) is a transparent, colorless, volatile liquid having a characteristic odor and a burning taste with a specific gravity of 0.79. </li></ul>
  3. 3. Introduction <ul><li>Ethanol is produced by the enzymatic action of yeasts on vegetable substrate containing sugars </li></ul><ul><li>At low doses, alcohol is said to have beneficial effects, such as decreased rates of myocardial infarction, diabetes, stroke, gallstones and possibly Alzheimer’s dementia, but consumption of two standard drinks per day increases the risk of health problems in many organ systems </li></ul><ul><li>. About 210 g of alcohol in men and 140 g of alcohol in women per week are considered as safe limits for drinking, if liver damage is to be avoided </li></ul><ul><li>.Different types of beverages with %age of alcohol are :- </li></ul>
  4. 4. BEVERAGES ALCOHOL { %V } PROOF RUM 42.8 75 WHISKY,BRANDY 42.8 75 GIN 42.8/40/37.2 75/70/65 WINES 8-15.5 14-27 BEERS 2-10 3.5-17.5 COUNTRY LIQUOR 11.4-45.7 20-80
  5. 5. <ul><li>Arrack (Arabic : araq – sweet or strong liquor usually made from raisins in those regions) is country liquor distilled from coco-palm, rice, sugar or jaggery and has strength of 40-50%. Country liquor is usually more intoxicating than either imported or Indian-made foreign liquor + </li></ul><ul><li>Denatured spirit (‘hooch tragedy’). </li></ul><ul><li>Action </li></ul><ul><li>Ethanol acts mainly on the CNS. </li></ul><ul><li>It acts as depressant of specialized </li></ul><ul><li>and sensitive cells of cerebral cortex </li></ul><ul><li>(centres regulating conduct, </li></ul><ul><li>judgement and self-criticism) </li></ul><ul><li>with release of inhibitory tone, leading to unrestrained behaviour. </li></ul><ul><li>This is followed by depression of vital centres of medulla producing coma and death.Alcohol also acts a hypnotic, diaphoretic and in small doses as an appetizer . </li></ul>
  6. 6. <ul><li>Metabolism </li></ul><ul><li>Following absorption, the concentration of alcohol in the blood reaches a maximum in about 45-90 minutes after ingestion. </li></ul><ul><li>With an empty stomach, there is a rapid rise and slow decline. With diluted drinks or a full stomach, the rise is slower and the maximum peak is lower, with a flatter BAC curve. If subsequent drinks are taken, the new alcohol is superadded to the existing curve . </li></ul><ul><li>Factors that interfere with absorption are: </li></ul><ul><li>Presence of food in stomach retards absorption. </li></ul><ul><li>Strength of alcoholic beverages taken – higher the strength more rapid will be the rate of absorption. </li></ul><ul><li>Diluted drinks, such as beer may take double the time to absorb, compared to stronger drinks. </li></ul><ul><li>Drugs, like insulin or prostigmine increase the absorption, while atropine delays absorption. </li></ul><ul><li>Chronic gastritis retards absorption . </li></ul>
  7. 7. <ul><li>Carbonated drinks hasten absorption, as the bubbles greatly increase the surface area carrying alcohol. </li></ul><ul><li>Warm alcoholic drinks which dilate gastric mucosal capillaries are more quickly absorbed than iced drinks of same strength . </li></ul><ul><li>Distribution </li></ul><ul><li>Ethanol is distributed evenly throughout the body, passing the blood-brain barrier easily to affect cerebral function. However, it is poorly soluble in body fat, which is why females of the same body size, will produce a higher BAC for the same amount of drink, as their aqueous compartment is smaller. </li></ul><ul><li>It attains equilibrium with a constant blood alcohol concentration and concentration of alcohol in other body fluids. </li></ul>
  8. 8. <ul><li>Detoxification </li></ul><ul><li>Ninety percent of ethanol is metabolized in the liver, while the kidneys and lungs help to excrete about 10% only. In the liver, alcohol is oxidized by alcohol dehydrogenase . Some of the alcohol is converted to other substances (such as fat, as in beer belly. </li></ul><ul><li>Non-habituated persons metabolize ethanol at 13-25 mg/dl/h. </li></ul><ul><li>In alcoholics, this rate increases to 30-50 mg/dl/h. because of tolerance, BACs must be interpreted in conjunction with history and clinical presentation. </li></ul><ul><li>Excretion of alcohol is mainly by the kidneys, lungs and skin through urine, breath and sweat respectively. It is also secreted in saliva and milk . </li></ul>
  9. 9. <ul><li>Acute alcohol poisoning </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Stage of Excitement (Blood level: 50-150 mg%) </li></ul><ul><li>Person will be euphoric (sense of well-being). Actions, speech and emotions are less restrained. </li></ul><ul><li>He may perform dancing, thrilling shows, carelessly and fearlessly. </li></ul><ul><li>He might disclose secrets. </li></ul><ul><li>Person might show increase in confidence, but lack of self-control. </li></ul><ul><li>Nystagmus present. </li></ul><ul><li>Mental concentration is poor and judgment impaired. </li></ul><ul><li>Faculty of attention deteriorates. </li></ul><ul><li>Recall memory is disturbed, person cannot accurately recall certain situations, or names . </li></ul><ul><li>It increases the desire for sex, but markedly impairs performance. </li></ul>
  10. 10. <ul><li>ii. Stage of In-coordination (Blood level: 150-250 mg%). </li></ul><ul><li>Due to further depression of higher centres, the person may be morose/cheerful/irritable/ill-tempered/excitable/sleepy. </li></ul><ul><li>Centres of perception and skilled movements are involved-there is clumsiness and in-coordination of fine and skilled movements and alterations in speech and fine finger movements. </li></ul><ul><li>Nausea and vomiting. </li></ul><ul><li>Sense of touch, taste, smell and hearing are diminished. </li></ul><ul><li>Hypothermia. </li></ul><ul><li>Breath smells of alcohol. </li></ul><ul><li>Pupils are dilated and react sluggishly to light. </li></ul>
  11. 11. <ul><li>iii. Stage of Coma (Blood level > 250 mg%). </li></ul><ul><li>Thick, slurred speech. </li></ul><ul><li>Coordination is markedly </li></ul><ul><li>affected </li></ul><ul><li>Pulse is rapid. </li></ul><ul><li>Hypothermia. </li></ul><ul><li>Pupils are contracted, </li></ul><ul><li>but on stimulation of the person, </li></ul><ul><li>e.g. by pinching or slapping, </li></ul><ul><li>Causes them to dilate with slow return (McEwan’s sign). </li></ul><ul><li>Patient passes into coma with steatorous breathing . </li></ul><ul><li>Recovery: About 35% of drinkers may experience a blackout, an episode of temporary anterograde amnesia, in which the person forgets all or part of what occurred during a drinking session. </li></ul><ul><li>With recovery, coma gradually lightens into deep sleep. Person will wake up in 8-10 hours with acute depression of mood, nausea and headache aka alcohol hangover . </li></ul>
  12. 12. <ul><li>Death: If the victim does not recover from coma within 5 hours, prognosis is bad and may result in death due to shock, depression of respiratory center or aspiration of vomit. </li></ul><ul><li>Fatal dose (non-addict) </li></ul><ul><li>150-250 ml of absolute alcohol consumed in 1hour. </li></ul><ul><li>Risk of death is increased if BAC > 200 mg/dl and death is typical if the BAC is between 300-400 mg/dl. </li></ul><ul><li>Fatal period: 12-24 hours. </li></ul><ul><li>Diagnosis : The distinctive aroma of </li></ul><ul><li>alcohol may assist in diagnosis. </li></ul><ul><li>Confirmation is done by analysis </li></ul><ul><li>of blood. Possibility of </li></ul><ul><li>intoxication with other drugs </li></ul><ul><li>should be considered and </li></ul><ul><li>or urine sample is indicated to screen. </li></ul>
  13. 13. <ul><li>Treatment </li></ul><ul><li>Patient must be kept </li></ul><ul><li>warm and placed in a </li></ul><ul><li>quiet environment. </li></ul><ul><li>ii.Gastric lavage with </li></ul><ul><li>alkaline solution </li></ul><ul><li>within 2 hours of ingestion. </li></ul><ul><li>iii. infusion of 1 litre </li></ul><ul><li>of normal saline with 10% glucose and 15 units of insulin or 50% dextrose (50 in 100 ml) is given i.v. </li></ul><ul><li>iv.Thiamine 100 mg in 500 ml glucose solution i.v. </li></ul><ul><li>v.Hemodialysis and peritoneal dialysis may be used. </li></ul><ul><li>vi.In case of aggressive behavior, non-threatening force by intervention team or short acting benzodiazepine, such as lorazepam 1 mg orally may be used. </li></ul>
  14. 14. <ul><li>Postmortem Findings </li></ul><ul><li>Odour of alcohol around the mouth and nose. </li></ul><ul><li>Congestion of conjunctiva. </li></ul><ul><li>Rigor mortis is prolonged and decomposition is retarded. </li></ul><ul><li>Acute inflammation of the stomach with coating of mucus. </li></ul><ul><li>All viscera are congested and smells of alcohol. </li></ul><ul><li>Blood is fluid and dark . </li></ul><ul><li>Alcoholic gaze nystagmus </li></ul><ul><li>it can be: </li></ul><ul><li>Positional nystagmus: </li></ul><ul><li>Horizontal nystagmus : </li></ul>
  15. 15. <ul><li>Chronic Alcoholism (Systemic Effects) </li></ul><ul><li>It is characterized by a gradual physical, mental and moral deterioration . </li></ul><ul><li>Physical : There is lack of personal hygiene loss of appetite, chronic gastroenteritis, wasting, peripheral neuropathies, impotence, sterility, fatty changes in liver and heart, cirrhosis, tremors. Insomnia, red eyes and intermittent infections. </li></ul><ul><li>Mental: There is loss of memory, impaired power of judgement and dementia . </li></ul><ul><li>Common clinical syndromes </li></ul><ul><li>associated with chronic </li></ul><ul><li>alcoholism : </li></ul><ul><li>Delirium tremens </li></ul><ul><li>Acute alcoholic hallucinosis </li></ul><ul><li>Korsakoffs psychosis </li></ul><ul><li>Werrnicke’s psychosis </li></ul><ul><li>Marchiafava-Bignami syndrome </li></ul><ul><li>Alcoholic paranoia </li></ul>
  16. 16. <ul><li>Moral: It manifests as crimes which the addict commits to get his drink. He becomes morbidly jealous and suspicious of his wife’s fidelity and may assault her. </li></ul><ul><ul><li>Treatment :- </li></ul></ul><ul><li>i. Sudden withdrawal of alcoholic drinks. </li></ul><ul><li>ii.Antabuse (disulfiram) is given as an aversion technique etc. </li></ul>
  17. 17. <ul><li>Withdrawal Symptoms :- </li></ul><ul><li>Tremulousness or shake or jitter (most common sign) weakness, pain in muscle, cold sweat, insomnia, loss of appetite, vomiting, diarrhea, restlessness, exaggerated reflexes, raised temperature, fluctuating BP, hallucinations, loss of memory and delirium tremens </li></ul><ul><li>The Tremors may be accompanied by tachycardia, diaphoresis, anorexia, and insomnia. After 24-72 hours, the alcoholic may have rum fits (i.e. generalized seizures). </li></ul>
  18. 18. <ul><li>Cage questionnaire: Developed by Dr. John Ewing , CAGE is an internationally used assessment instrument for identifying alcoholics. </li></ul><ul><li>Have you ever felt you should Cut down on your drinking? </li></ul><ul><li>Have people Annoyed you, by criticizing your drinking? </li></ul><ul><li>Have you ever felt bad or Guilty about your drinking? </li></ul><ul><li>Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? </li></ul><ul><li>Scoring: Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. </li></ul><ul><li>Delirium Tremens </li></ul><ul><li>acute organic brain syndrome, usually seen within 2-4 days of complete absence from heavy alcohol drinking. </li></ul>
  19. 19. <ul><li>Signs and Symptoms :- </li></ul><ul><li>There is an acute attack of insanity in which there is: </li></ul><ul><li>Clouding of consciousness with disorientation in time and space. </li></ul><ul><li>Coarse muscular tremors of face, tongue and hands. </li></ul><ul><li>Insomnia with reversal of sleep-wake cycle and loss of memory. </li></ul><ul><li>Psychomotor agitation, ataxia, uncontrollable fear and tendency to commit suicide/homicide/violent assault or cause damage to property. </li></ul><ul><li>Peculiar type of delirium of horrors due to hallucinations of sight and hearing. Tactile hallucinations of insects and ants crawling under the skin or on the beds may occur. </li></ul>
  20. 20. <ul><li>Treatment :- </li></ul><ul><li>(for both withdrawal symptoms and delirium tremens) </li></ul><ul><li>Diazepam (40-80 mg/day in divided doses) is used. </li></ul><ul><li>Oral multi-B vitamins, including thiamine </li></ul><ul><li>Chlordiazepoxide </li></ul><ul><li>Intravenous fluids are avoided </li></ul><ul><li>Symptomatic treatment. </li></ul>
  21. 21. <ul><li>Medico-legal Aspects :- </li></ul><ul><li>It is medical emergency and should be treated on an inpatient basis. </li></ul><ul><li>When a person in delirium tremens commits any illegal act, he is not held responsible by the reason that he/she is considered to be mentally unsound during this state. </li></ul><ul><li>Alcoholic hallucinosis </li></ul><ul><li>It is a state of hallucination mainly auditory with systematized delusions of persecution lasting from weeks to months. </li></ul><ul><li>Occurs during abstinence, in 2% of patients </li></ul><ul><li>It is a psychiatric emergency, requiring hospitalization, sedation and close monitoring. </li></ul><ul><li>Patient may become homicidal or suicidal in response to his hallucination. </li></ul><ul><li>: Treatment :- Same as delirium tremens. </li></ul>
  22. 22. <ul><li>Korsakoff’s Psychosis </li></ul><ul><li>Korsakoff first identified this condition in 1887. korsakoff’s psychosis often follows Wernicks’s encephalopthy so they are referred to as Wernicke-Korsakoff syndrome . </li></ul><ul><li>Cause: Severe, untreated thiamine deficiency, secondary to chronic alcohol abuse. </li></ul><ul><li>Signs and Symptoms :- </li></ul><ul><li>It presents as an amnestic syndrome, characterized by inability to learn new information </li></ul><ul><li>Insight is often impaired. </li></ul>
  23. 23. <ul><li>Wernicke’s Encephalopathy </li></ul><ul><li>This is an acute reaction due to severe thiamine deficiency, the commonest cause being chronic alcohol abuse. Characteristically the onset occurs after a period of persistent vomiting . </li></ul><ul><li>Signs and symptoms :- </li></ul><ul><li>Ocular : Coarse nystagmus and opthalmo-paresis (usually the 6 th cranial nerve is involved). Pupillary irregularity, retinal hemorrhages. </li></ul><ul><li>CNS : Disorientation, confusion, recent memory disturbances, poor attention span and distractibility. Apathy and ataxia are early symptoms. </li></ul><ul><li>Peripheral neuropathy and serious malnutrition are often coexistent . </li></ul>
  24. 24. <ul><li>Treatment:- </li></ul><ul><li>( For wernicke-korsakoff syndrome) </li></ul><ul><li>Intravenous thiamine initially, followed by oral (100 mg 8 hourly). </li></ul><ul><li>Supplementation of electrolytes, particularly magnesium and potassium. </li></ul><ul><li>Alcoholic paranoia :- In this, there is a fixed delusion, but no hallucinations. Patient becomes suspicious of the motives and actions of those he meets and of his family members. </li></ul><ul><li>Merchiafava-Bignami syndrome :- rare disorder characterized by disorientation, epilepsy, ataxia, dysarthria, hallucinations, spastic limb paralysis, and personality and intellectual deterioration. There is widespread demyelination of corpus callosum, optic tracts and cerebellar peduncles. The cause is probably some alcohol-related nutritional deficiency. </li></ul>
  25. 25. <ul><li>Drunkenness </li></ul><ul><li>Definition : It is a condition which results from excessive intake of alcohol. The person under its influence shows the following: </li></ul><ul><li>Loss of control over his mental faculties. </li></ul><ul><li>Inability to perform the duties in which he is engaged. </li></ul><ul><li>Dangerous to himself or to others. </li></ul><ul><li>Consent for Examination </li></ul><ul><li>The detained persons should not be examined and blood, urine or breath should not be collected without his written consent. </li></ul><ul><li>If the person becomes unconscious or incapable of giving consent, examination and treatment can be carried out, but the doctor should not disclose any information obtained during examination and wait for his consent, till he regains consciousness. </li></ul><ul><li>Under Sec 53 (1) CrPC , examination of an accused can be carried out by a doctor at the request of the police, even without his consent and by use of force, if necessary. Such examination may include taking of body fluids in cases of suspected intoxication. </li></ul>
  26. 26. Diagnosing a Case of Drunkenness Preliminary data such as name, age, sex etc. History: should be obtained from the accused person while observing him. Note, if he admits having taken alcoholic drinks. If so, the nature, quantity and time of consumption should be recorded. Exclusion of injuries n Pathological conditions:
  27. 27. <ul><li>Clinical Examination </li></ul><ul><li>General appearance </li></ul><ul><li>Manner of dressing-properly dressed or not and soiling of clothes. </li></ul><ul><li>Posture-whether over-erect and over smart, can stand can stand without support or not. </li></ul><ul><li>General behavior and attitude-sober, abusive, drowsy, alert, cooperative and self-controlling capacity . </li></ul><ul><li>General examination </li></ul><ul><li>The scalp should inspected and palpated for evidence of any head injury . </li></ul>
  28. 28. <ul><li>Specific physical examination </li></ul><ul><li>Gait </li></ul><ul><li>Stance </li></ul><ul><li>Smell </li></ul><ul><li>Handwriting </li></ul><ul><li>Speech </li></ul><ul><li>Memory </li></ul><ul><li>Muscle coordination : The person can be asked to perform a few tests:- </li></ul><ul><li>Finger nose test: Ask the patient to touch the tip of nose by an outstretched hand closing the eyes. Inability to perform suggests impaired coordination. </li></ul><ul><li>Test of dexterity , such as picking up small objects from the floor are preferable to walking on a straight be able to perform well. </li></ul><ul><li>When undressing for examination, the ability to undo buttons or any fumbling with zip should be noted. </li></ul>
  29. 29. <ul><li>Eyes : Drooping and swollen eyelids and congestion of conjunctiva may be seen. </li></ul><ul><li>State of visual acuity </li></ul><ul><li>Pupil-dilated, constricted or normal, and reaction of pupil to light. </li></ul><ul><li>Convergence test-negative in drunkenness </li></ul><ul><li>Strabismus-positive in drunken person. </li></ul><ul><li>Nystagmus-positive in drunken person . </li></ul><ul><li>Skin : . It is warm, dry and flushed in drunkenness . </li></ul><ul><li>Mouth : General state of mouth, teeth and tongue .. </li></ul><ul><li>Pulse : . Pulse is rapid, full and bounding in a drunk . </li></ul><ul><li>Blood pressure : . Slight rise in BP may occur . </li></ul><ul><li>Respiration : Hurried, slow, shallow, deep, sterto rous, sighing,or gasping . </li></ul><ul><li>Reflex : . All reflexes are sluggish . </li></ul><ul><li>Any tremor of fingers . </li></ul>
  30. 30. <ul><li>Opinion </li></ul><ul><li>The report should be written at that time and at the end the police informed about the doctor’s opinion (based on examination and laboratory findings). The opinion can be drafted with any one of the following statements: </li></ul><ul><li>He/she has not consumed alcohol. </li></ul><ul><li>He/she has consumed alcohol, but not under the influence of it. </li></ul><ul><li>He/she has consumed alcohol and is under its influence </li></ul><ul><li>Medico-legal Aspects </li></ul><ul><li>. sec. 85 IPC : Nothing is an offence which is done by a person who at the time of doing it, by reason of intoxication, is incapable of knowing the nature of the act , or that he is doing what is either wrong or contrary to law; provided that thing which intoxicated him was administered to him without his knowledge or against his will. </li></ul><ul><li>Voluntary drunkenness is not an excuse for commission of crime. </li></ul><ul><li>Sec. 510 IPC: Misconduct by a drunken person in public is punishable with imprisonment upto 24 hours. </li></ul>
  31. 32. <ul><li>Driving under the influence of alcohol or drunk driving : Operating a motor vehicle after having consumed alcohol or other drugs, to the degree that mental and motor skills are impaired. </li></ul><ul><li>Authorities around the world have laid down their own standards for permissible maximum BAC. </li></ul><ul><li>In India, according to Motor Vehicles Act 1998, for the first offence, punishment is imprisonment of 6 months and/or fine of Rs 2000. If a second offence is committed within 3 years, the punishment is 2 years and/or fine of Rs 3000. Under this Act, there can be arrest without warrant, a breath test and a laboratory test can also be carried out. </li></ul><ul><li>The age for possession and consumption of alcoholic beverages in Australia and Canada is 18 years, in European countries, it is between 16-18 years, in US, it is ≥21 years and India, it is between 18-25 (varies between states). </li></ul>
  32. 33. <ul><li>Laboratory Investigations :- </li></ul><ul><li>The common laboratory tests include estimation of alcohol from: </li></ul><ul><li>Blood </li></ul><ul><li>Urine </li></ul><ul><li>Breath </li></ul><ul><li>Vitreous fluid, bile and </li></ul><ul><li>other tissues (during autopsy). </li></ul>
  33. 34. <ul><li>Measurement of Alcohol </li></ul><ul><li>The BAC is the most useful measure, because there is rapid equilibration across the blood-brain barrier, therefore BAC reflects the concentration of alcohol currently affecting the brain. </li></ul><ul><li>The urine alcohol is more concentrated than blood level, due to tubular resorption of water in the ratio of 1.3: 1. However, it is less useful, as the ureteric urine concentration varies with rising or falling BAC </li></ul><ul><li>Breath alcohol, unlike urine, is in equilibrium with blood, even though in a very small concentration of about 1: 2300. The exact ratio of blood/breath alcohol is temperature dependent and varies slightly with other factors, such as the depth of respiration and concentration of alcohol. </li></ul>
  34. 35. a=cpr
  35. 36. a = ¾ qpr
  36. 37. <ul><li>Breathalyzer (or breath analyzer is a device for estimating BAC from a breath sample. In 1954, Dr. Robert Borkenstein invented the breathalyzer, which used chemical oxidation and photometry to determine alcohol concentration. The invention of the breathalyzer provided law enforcement with a non-invasive test with immediate results to determine an individual’s BAC at the time of testing. </li></ul><ul><ul><li>Other methods: </li></ul></ul><ul><li>Gas liquid chromatography (GLC): Most reliable method. It is extremely sensitive and produces accurate quantitative results. In high performance liquid chromatography (HPLC), the sample is in liquid state at the time or analysis, rather than in volatile state as in GLC* </li></ul><ul><li>2. Alcohol dehydrogenase (ADH) method : It is highly specific and accurate </li></ul>
  37. 38. <ul><li>Erroneous BAC results can be obtained due to: </li></ul><ul><li>Postmortem diffusion from other body fluids and tissues </li></ul><ul><li>Samples stored at room temperature for more than a week </li></ul><ul><li>Improperly preserved sample </li></ul><ul><li>Hemolysis </li></ul><ul><li>Clot formation </li></ul><ul><li>Putrefaction. </li></ul>