Redwood Memorial Hospital Field Care Audit lecture on EtOH

1. Dying for a Drink:
Case Study
Veronica Bonales, M.D.
CEP America Emergency Physician

2. 1. Custom Search
2. Intoxicated Pa. woman bites EMT
3. Aug 9, 2010 ... By Valerie Waltz WPMT-TV HARRISBURG, Pa. A Harrisburg woman was arrested after biting an EMS worker. The incident happened early
Saturday ...
5. Intoxicated Kan. man steals ambulance
6. Oct 12, 2009 ... UPI LAWRENCE, Kan. Police in Kansas said they arrested an intoxicated 21-year- old man who attempted to drive home in an
ambulance left ...
8. Intoxicated driver blamed for Maine paramedic's death
9. Aug 31, 2007 ... TURNER, Maine — The driver that caused an ambulance crash that claimed the life of a Wilton paramedic last month was intoxicated, ...
11. Intoxicated man accused of assaulting Hawaii paramedic
12. Nov 2, 2007 ... Intoxicated man accused of assaulting Hawaii paramedic ... Mo'ili'ili while treating a "severely intoxicated" 19-year-old man, police said. ...
13. www.ems1.com/.../317502-Intoxicated-man-accused-of-assaulting-Hawaii- paramedic/
14. Labeled EMS Products All Content
16. Canadian medics told head trauma trumps intoxication
17. Aug 17, 2010 ... By Clare Ogilvie The Province VANCOUVER, Canada A B.C. Coroner's jury has recommended that more be done to look after people with
head ...
18. www.ems1.com/.../867643-Canadian-medics-told-head-trauma-trumps- intoxication/
19. Labeled All Content
21. Drunk NH woman allegedly attacks EMT
22. Oct 6, 2010 ... The Concord Monitor WEARE, nh An intoxicated woman assaulted two police officers and an emergency medical technician Sunday in
Weare, ...
23. www.ems1.com/ems.../889233-Drunk-NH-woman-allegedly-attacks-EMT/
24. Labeled All Content
26. NM woman allegedly bit EMT
27. Dec 18, 2010 ... LAS CRUCES, nm — Las Cruces police arrested a noticeably intoxicated woman who allegedly bit an emergency medical technician as
he attempted ...
28. www.ems1.com/ems-oddities/.../922675-NM-woman-allegedly-bit-EMT/
29. Labeled All Content
31. Pa. man charged for spitting blood on paramedic
32. Oct 7, 2010 ... Police reported that the intoxicated man gave paramedics a hard time ... An intoxicated Brisson, who had a bloody mouth and cuts on his
face ...
33. www.ems1.com/.../890334-Pa-man-charged-for-spitting-blood-on-paramedic /
34. Labeled All Content

3. EMS & EtOH Patients
2007 - NAEMT states 700,000 uncooperative patient
encounters
52% injuries %om assaults
Scene safety
AMA
The chronic alcoholic

4. Lecture Objectives
Case study
Metabolism of alcohol
Effects of alcohol on specific organ systems
Pediatric special considerations
CPI - History of alcohol
EMS and alcohol

5. JG
Case Study

6. JG
21 year old female
Chief complaint: Abdominal pain
HPI: Two days of abdominal pain that radiates to the
back. Taking Vicodin with no relief. Nausea and
vomiting.

7. JG
PMHx: chronic alcohol abuse, alcoholic hepatitis,
cholangitis secondary to cholelithiasis, pancreatitis, upper
GI bleed, depression, polysubstance abuse
Social Hx: smokes a pack a day, drinks up to a ga)on of
vodka a day, polysubstance abuse including: methadone,
methamphetamines, MJ
Meds: Vicodin - up to 4 a day

8. EtOH – Ethanol

9. Ethanol - EtOH
Very simple carbon molecule
Probably discovered by accident 10,000 BC
Product of fermented sugars

10. Beer
“bibere” (L) = to drink

11. Beer
Earliest records Middle East about 6,000 years ago
– Le- people feeling "exhilarated, wonderful and blissful."
Made out of berries and honey
“Cerveza” %om the Greek goddess of agriculture, Ceres

12. EtOH Metabolism
Up to 10% excreted in urine, sweat, breath
90+% metabolized to acetaldehyde (toxic) by alcohol
dehydrogenase
Acetaldehyde dehydrogenase in liver & GI tract breaks
down to acetic acid (non-toxic)

13. EtOH Metabolism
Women have less ALDH in their stomachs than men
Older men have less ALDH than younger men
Some people of Asian decent have a mutation of ALDH
Quickly leads to acetaldehyde poisoning
Develop a characteristic flushing of the skin and increased
heart and respiratory rate
*Mechanism behind Disulfuram

14. EtOH Metabolism
Average = 13ml of EtOH per hour

15. EtOH Intoxication
State legal limit = 0.08 mg/dl
Occasional drinker wi) be inebriated w/a level = 0.2,
Coma/death/resp. arrest at levels of 0.3 – 0.4 mg/dl
Alcoholics can reach levels of 0.7 mg/dl & be functional

16. EtOH Intoxication
Physical and Emotional Effect
BAC
0.02 %
You may feel relaxed and might experience slow reaction time.
0.04 %
Your vision is affected.
0.08 %
Your coordination decreases and your driving ski)s are impaired.
This is the legal drinking limit. You are lega)y intoxicated and it's i)egal to drive in the U.S.
0.10 %
Your speech may become slurred. Lost of coordination and judgment.
0.15 %
You may stumble when walking and may have trouble standing up.
0.30 %
You might vomit and probably pass out.
0.40 %
You may pass out (unconscious) and may go into a coma.
Over 0.40 %
Alcohol poisoning and death can occur. Your breathing might stop. This is the lethal blood alcohol level.

17. Your Brain on EtOH
• Glutamate • Dopamine
◦ Alcohol inhibits glutamate receptor function ◦ Alcohol raises dopamine levels
◦ This causes muscular relaxation, dis- ◦ This leads to excitement and stimulation
coordination, slurred speech, sta0ering, ◦ Cocaine and amphetamine have similar effects
memory disruption, and blackouts on the dopamine system
◦ Ether and chloroform have similar effects on
the glutamate system
• Endorphins
• GABA (gamma-aminobutyric acid) ◦ Alcohol raises endorphin levels
◦ Alcohol enhances GABA receptor function ◦ This ki)s pain and leads to an endorphin
◦ This causes feelings of calm, anxiety- "high"
reduction and sleep ◦ Morphine and heroin have similar effects on
◦ Valium has a similar effect on the GABA the endorphin system
system

18. Acetaldehyde
Similar to formaldehyde
Excess spi)s over into bloodstream
Inhibits mitochondrial functions
Dec. metabolism of acetaldehyde to acetic acid, more
acetaldehyde accumulates, & causes further liver damage
Dec. oxidation of fatty acids leads to build-up
Interferes with activation of vitamins (esp. Vitamin B1)

19. EtOH Metabolism

20. EtOH Metabolism

21. EtOH Metabolism

22. EtOH Metabolism

23. EtOH Metabolism
Problems w/excess
NADH
Overweight
Fat breakdown
(ETC)
Lactic acidosis
Takes pyruvate %om
glucose cycle
Hypoglycemia

24. EtOH Metabolism
Problems w/excess
NADH
Overweight
Fat breakdown
(ETC)
Lactic acidosis
Takes pyruvate %om
glucose cycle
Hypoglycemia

25. EtOH Metabolism
Problems w/excess
NADH
Overweight
Fat breakdown
(ETC)
Lactic acidosis
Takes pyruvate %om
glucose cycle
Hypoglycemia

26. EtOH Metabolism
Problems w/excess
NADH
Overweight
Fat breakdown
(ETC)
Lactic acidosis
Takes pyruvate %om
glucose cycle
Hypoglycemia

27. EtOH Metabolism
Problems w/excess
NADH
Overweight
Fat breakdown
(ETC)
Lactic acidosis
Takes pyruvate %om
glucose cycle
Hypoglycemia

28. Wine
Oenology - study of wine and wine-making

29. Wine
2700 BC wine symbols found in Egyptian drawings
No vineyards, but traded with other cultures for grapes
Soon developed their own lines of grapes
Wine-making quickly spread

30. Liver

31. Liver

32. Fatty Liver
Weekend fatty liver
Bingers
Acute, reversible fatty changes

33. Fatty Liver
Weekend fatty liver
Bingers
Acute, reversible fatty changes

34. Hepatitis
Acute alcoholic hepatitis
Due to mitochondrial damage, toxic effects of
acetaldehyde (reduced antioxidants)
Necrotic areas form, hypoxia-induced
Fever, liver tenderness, jaundice
Initia)y reversible

37. Cirrhosis
Irreversible liver damage
Hard, shrunken liver
Fibrosis %om chronic damage
Weakness, muscle wasting, ascites, GI
hemorrhage, coma

42. Liver Functions
Over 500 different functions!
contro)ing levels of fats, amino acids and glucose (via glycogen) in the blood
combating infections in the body
clearing the blood of particles and infections including bacteria
neutralizing and destroying drugs and toxins
storing iron, vitamins and other essential chemicals
breaking down food and turning it into energy
manufacturing, breaking down and regulating numerous hormones including sex hormones
making enzymes and proteins which are responsible for most chemical reactions in the body, for
example those involved in blood clotting and repair of damaged tissues

43. JG
Physical Exam
Vitals: Temp 36.8, HR 104, RR 16, b/p 74/55, 98% on
RA, wt 54 kg
A&O x 2 (person, place), skin jaundiced, sclera icteric,
heart tachy, abdomen firm w/dec. bowel sounds &
tender in epigastrum

44. Labs
WBC 7.8 Glucose 69
Hb/Hct 10.3/30.3 Ca 7.2
Platelets 90K Bili 21.3
Na 126 AlkPhos 172
K 3.2 AST/ALT 659/91
Cr 3.2 Lipase 20

45. Labs
EtOH 79
U/A
INR 2.4
+ bili
NH3 39
+ nitrites
UTox
+ ketones
+acetaminophen
+ protein
+methadone

46. Shubat = fermented camel milk
Kumis = fermented mare’s milk

47. Heart effects
Cardio-protective in sma) amounts
Increases HDL & decreases platelet a0regation
Alcoholic cardiomyopathy due to acetaldehyde and
EtOH’s direct effects on heart ce)s

48. Holiday Heart
Atrial fibri)ation most common arrhythmia
Thought to be due to acetaldehyde and increase in fatty
acids
Prolongs PR, QRS, and QT intervals
Most common in young people a-er a weekend or
“holiday” binge, but may occur a-er casual drinking

49. Other effects
Wernicke’s encephalopathy GI effects
Thiamine deficiency – poor Gastritis
nutrition
Pancreatitis
Ataxia, nystagmus
Reproductive effects
Korsakoff syndrome
Testicular atrophy
Mammilary bodies
Spontaneous abortion risk
Confabulation increases

50. Tequila
Tequila %om Nahuatl word “place of harvesting plants”

51. Tequila
Mezcal wine made in 1521 %om agave plant
Origina)y for bandits & rancheros
Tequila vi)age founded 1656, export grew in 1700’s along trade route to ocean
1758 – Jose Cuervo granted royal license to cultivate in region, 1880 se)ing
10,000 barrels/year to local market alone
1944 Mexican government began regulating
– Only beverages brewed in region could be ca)ed tequila
– Had to have at least 51% blue agave
– Top brands are 100% blue agave

52. FAS
Fetal alcohol syndrome
Acetaldehyde crosses the placenta
Most damaging in first trimester
Even one drink per day can cause
Growth & developmental defects, facial dysmorphology
(FAS facies), malformations of brain, CV system &
reproductive organs

53. FAS

54. FAS

55. Pedis and EtOH
Hypoglycemia and hypoglycemic seizures
Loss of gluconeogenesis and sma)er glycogen stores
Classic triad: coma, hypoglycemia, hypothermia
Trauma leading cause of death
EtOH increases risk 3 - 7 times higher
Increases risk-taking behavior in a patient with slowed reflexes

56. JG
To be continued.....

57. ? Questions ?