The seminar by Dr. Nathan Muluberhan covers alcohol poisoning, diagnostic criteria, and the effects of various alcohols including ethanol, isopropanol, methanol, and ethylene glycol. It highlights the physiological impacts, symptoms of toxicity, and the importance of identifying withdrawal symptoms, particularly in severe cases. Notably, it emphasizes the diagnostic criteria for alcohol withdrawal delirium tremens and the need for clinical attention in cases of alcohol consumption and poisoning.

1. ALCOHOL POISONING
(seminar)
Dr. Nathan Muluberhan(E M
r e s i d e n t )
Emergency And Critical Care
Medicine
JULY 2017

2. OUTLINE
 Intr oduc tion
 Diagnos tic c riteria
 Ethanol
 Is opr opanol
 Methanol
 Ethylene glyc ol
 Alc ohol w ithdr aw al

3. INTRODUCTION
 Globally, alcohol consumption results in 3.3
million deaths/year

5. DIAGNOSTIC CRITERIA(DSM V)
A. Recent ingestion of alcohol.
B. Clinically significant problematic behavioral or
psychological changes that developed during, or
shortly after, alcohol ingestion.

6. C. One (or more) of the following signs or symptoms developing
during, or shortly after, alcohol use:
1. Slurred speech
2. Incoordination
3. Unsteady gait
4. Nystagmus
5. Impairment in attention or memory
6. Stupor or coma
D. The signs or symptoms are not attributable to another
medical condition and are not better explained by another
mental disorder
DIAGNOSTIC CRITERIA CONT…

7.  All alcohols cause clinical inebriation
strength of the inebriating effects directly
proportional to the alcohol’s molecular weight
 Ethanol and isopropanol are the most
common alcohols ingested.
 Methanol and ethylene glycol are toxic
alcohols with serious physiologic morbidity.

8. ETHANOL
 is a colorless, volatile liquid
 most frequently used and abused drug
 Toxicity most commonly occurs from ingestion,
 Also absorbed via inhalation or percutaneous
exposure.

9. METABOLISM
 Rapidly absorbed after oral administration.
 Peak blood levels about 30 to 60 minutes.
 The volume of distribution of
 0.6 L/kg in men
 0.7 L/kg in women

11. CINICAL FEATURES
CNS effect of ethanol as compared to blood alcohol
concentration

12. CINICAL FEATURES CONT…
 CARDIOVASCULAR
 Alcoholic cardiomyopathy
 peripheral vasodilation, tachycardia.
 “holiday heart syndrome”

13.  RESPIRATORY SYSTEM
 respiratory depression
 decreased airway sensitivity to foreign bodies
 decreased ciliary clearance and aspiration
 increased risk of bacterial infection
CINICAL FEATURES CONT…

14.  HYPOGLYCEMIA
 usually in children and malnourished individuals
 Increases NADH/NAD+ ratio, which then promotes
the conversion of pyruvate to lactate, diverting
pyruvate away from the gluconeogenesis pathway
CINICAL FEATURES CONT…

15. Alcoholic Ketoacidosis
 Nausea, vomiting, and abdominal pain are
common
presenting complaints.
 ketonuria, and little or no glucosuria.
 Serum glucose levels are usually less than 200
mg/dL.

16. Wernicke-Korsakoff Syndrome
 Although they are similar pathologically and
caused by thiamine deficiency.
 Wernicke’s encephalopathy,
 a medical emergency
 mortality rate of 10 to 20%,

17.  dietary deficiencies
 oculomotor abnormalities
 cerebellar dysfunction
 either an altered mental state or mild memory
impairment
Wernicke-Korsakoff CONT…

18.  Korsakoff ’s psychosis or amnesic state
 is a disorder with recent memory impairment
 inability to learn new information , recall
previously learned information
 apathy
Wernicke-Korsakoff CONT…

19.  RBS level.
 Ethanol blood levels are not necessarily
required in cases of mild or moderate
intoxication
 Can cause of an osmolar gap and may be
associated with a mild metabolic acidosis

20. ISOPROPANOL
 is a colorless, volatile liquid with a bitter,
burning taste and an aromatic odor.
 found in many household products, such as
rubbing alcohol (usually 70% isopropanol).
 a component of a variety of skin and hair
products, jewelry cleaners, detergents, paint
thinners.

21.  Poisoning usually results from ingestion
 Toxic dose of 70% isopropanol is about
1mL/kg
 The minimum lethal dose for an adult is
approximately 2 to 4 mL/kg

22.  80% of a dose is absorbed within 30 minutes
of ingestion.
 Its peak blood levels occur 30 to 120 minutes
after ingestion

24.  CNS
 headache, dizziness, neuromuscular
incoordination, confusion, and nystagmus.
 Pupillary size varies, but miosis is most common
 Severe ingestions may result in CNS depression,
deep coma.
CINICAL FEATURES

25.  GASTRIC IRRITATION
 nausea, vomiting, abdominal pain, acute
pancreatitis, hemorrhagic gastritis and upper
GI bleeding
CINICAL FEATURES CONT…

26.  Rhabdomyolysis and renal failure
 hypotension secondary to peripheral
vasodilation.
 Hypoglycemia
 the increased NADH/NAD+ ratio
CINICAL FEATURES CONT…

27.  primarily are used to exclude other ingestions
 ketosis with little or no acidosis
 “pseudo–renal failure”
labaratory

28. METHANOL
 the simplest alcohol
 colorless, volatile liquid
 found in automotive windshield cleaning
solution, solid fuel for stoves and chafing
dishes, model airplane fuel, carburetor
cleaner, gas line antifreeze, photocopying
fluid, and solvents.

29.  Peak blood levels achieved within 30 to 60
minutes,
 volume of distribution of 0.6 to 0.77 L/kg.
 minimum lethal dose is thought to be
approximately 1 gram/kg or 1.25 mL/kg.

31.  Formic acid’s main mechanism of
toxicity
 binding to cytochrome oxidase
 This leads to anaerobic metabolism and
development of lactic acidosis.
CINICAL FEATURES CONT…

32.  less inebriating than ethanol,
 Early symptoms of methanol poisoning include
depressed mental status, confusion, and
ataxia.
 in severe cases, coma and seizures may be
seen

33. Optic neuropathy
 The primary sites of ocular injury are the
retrolaminar optic nerve and retina
 may present as photophobia or blurred or “snow
field” vision,
 clinical findings: papilledema, nystagmus (rare),
and nonreactive mydriasis.

34. putaminal necrosis
 Acute signs and symptoms may take several days
to develop despite the presence of these
radiographic findings
 occurring in 13.5% of patients

36.  Cardiovascular toxicity
 tachycardia and hypotension, which may
progress to shock.
 Tachypnea and shortness of breath
 while attempting to compensate for the metabolic
acidosis, and progress to respiratory failure.

37.  Elevated osmolar gap
 A severe anion gap metabolic acidosis
 onset of acidosis may be delayed 12 to 24
hours

38. ETHYLENE GLYCOL
 is a colorless, odorless, sweet-tasting liquid
 has many contemporary uses as a glycerin
substitute, preservative, component of
hydraulic brake fluid, foam stabilizer,
component for chemical synthesis, and most
commonly an automotive coolant (antifreeze)

40.  End-organ damage from ethylene glycol
poisoning
 due direct cytotoxicity of glycolic acid
 tissue damage from precipitation of calcium
oxalate crystals.

41.  The first (neurologic) stage
 typically begins 30 minutes to 12 hours after
ingestion
 may range from mild depression to seizure and
coma.
 Metabolites effect include
 cerebral edema,
 basal ganglia hemorrhagic infarction
 meningoencephalitis.

42.  The second (cardiopulmonary) stage
 begins 12 to 24 hours after ingestion
 characterized by tachycardia and possibly
hypertension.
 Glycolate and oxalate crystal deposition in
tissues leads to multiorgan system failure

43.  The third (renal) stage
 is often delayed 24 to 72 hours after ingestion
and
 is characterized by renal failure due to calcium
oxalate
crystal deposition in the proximal tubules,

44. DIAGNOSIS
 Laboratory tests include: serum e-; ca+2; BUN;
cr; RBS; serum osm; ABG; ethylene glycol
level; ECG.
 Urine analysis
 calcium oxalate monohydrate/dihydrate crystals
 specific gravity, proteinuria, microscopic
hematuria, pyuria.

45. ALCOHOL WITHDRAWAL
Diagnostic Criteria
1. Cessation or reduction in alcohol use that has been heavy and prolonged
2. Two (or more) of the following,
I. Autonomic hyperactivity
II. Increased hand tremor.
III. Insomnia.
IV. Nausea or vomiting.
V. Transient visual, tactile, or auditory hallucinations or illusions.
VI. Psychomotor agitation.
VII. Anxiety.
VIII. Generalized tonic-clonic seizures.

46. 3. The signs or symptoms in Criterion B cause clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.
4. The signs or symptoms are not attributable to another
medical condition and are not better explained by
another mental disorder
ALCOHOL WITHDRAWAL

48. DELIRIUM TREMENS
 affects 5% to 10% of patients
 result of modulation of 2 primary sites
 the γ-aminobutyric acid type A (GABAA)
 N-methyl-D-aspartate (NMDA) receptors

49.  Tintinalli’s Emergency Medicine 8th edition
 Rosen's Emergency Medicine - Concepts and
Clinical Practice 8th edition
 Global status report on alcohol and health
2014
 Up to date 21.6
REFERRENCE