“A Cup of Holiday Cheer?” Pre-hospital Alcohol Emergencies

Presence Regional EMS

December 2015

Objectives

Discuss the effects of ethyl alcohol on the human bodyDescribe delirium tremens, signs and symptoms,

complications and managementOutline physiological concerns specific to children

ingesting ethyl alcohol. List other emergency situations that might be masked by

alcohol intoxication Using a variety of scenarios discuss the assessment and

management of alcohol related emergencies

Alcohol and EMS Patients

The common alcohol encountered in patient interactions is Ethanol

Alcohol is the most common substance of abuse in the US and worldwide

75% of Americans have at least one alcoholic drink per year.

Between 15% and 40% of EMS patients have detectable levels of alcohol in their blood.

Alcohol and the Holiday Season

In American society, drinking alcohol is a tradition during the Holiday Season.

Actions of Alcohol on the Body

At low doses: excitatory and stimulating effects with depressing of inhibitionsAggressive behavior Inappropriate behavior

At higher doses: sedative effect, depresses the central nervous systemDulls sense of awarenessSlows reflexes, lack of coordinationReduces reaction timeStupor and coma

Physiology

Alcohol is completely absorbed from the GI tract in 30-120 minutes.Food in the GI tract slows absorption timeConcentrations in the brain rapidly approach

blood alcohol levelsAlcohol is broken down and eliminated

(metabolized) by the liverIntoxication occurs when alcohol enters the

bloodstream faster than the liver can break it down

Alcohol causes peripheral vasodilationFlushing of skinFeeling warmIncreased loss of body heat

Alcohol potentiates other drugs (prescription and non-prescription)

Physiology cont.

Alcohol inhibits the hormone responsible for conservation of water in the kidney (vasopressin)Increased urinationDehydration

Alcohol ingestion can cause vomitingDehydration Chance of aspiration

Blood Alcohol Concentrations

EMS providers have no way to determine blood alcohol levels in the pre-hospital setting.

Can sometimes estimate based on assessment and patient behavior

Patients with long term alcohol use will not have signs and symptoms until blood alcohol levels are much higher

Blood Alcohol Concentrations

0.02 – 0.05 gm/dl diminished fine motor coordination

0.05-- 0.10 gm/dl impaired judgment and coordination

0.08 gm/dl LEAGALLY INTOXICATED IN ILLINOIS

0.10 – 0.15 gm/dl difficulty with gait and balance

0.15 – 0.25 gm/dl lethargy, unable to sit upright without assistance

0.25 – 0.30 gm/dl coma in the non-habitual drinker

0.30 – 0.40 gm/dl respiratory depression

Scenarios

Alcohol (ethanol) ingestion can cause a variety of pre-hospital emergencies.

For each scenario, determine: what is important about the scene size up initial assessment (Mental status, Airway, Breathing,

Circulation)

SAMPLE history head to toe exam management of the patient (BLS & ALS)

Scenario 1

It is 2100 hours on New Year’s EveYou are called to a family home for an

unconscious male.

You are lead by an anxious middle aged woman to the basement family room.

You find 4 young men standing around Tony, an 18 year old male lying on the floor face down in vomit and blood.

The woman is Tony’s mother, she just got home from going out to dinner and found her son like this.

Initial Assessment

Level of Consciousness: Arouses to pain onlyAirway: occluded with vomit Breathing: labored and slowCirculation: pulse 90 at carotid strong, radial

pulse weaker, skin warm and sweatyChief Complaint: Altered level of consciousness

What do you do now??

What is Tony in immediate danger of?

SAMPLE

Allergies– noneMedications – none but vitaminsPast Medical History – none healthy young

senior in high schoolLast Meal – some chips and snacks since 7 pmEvents – to celebrate New Year’s Eve Tony had

a bottle of vodka. He has been drinking a shot with orange juice for each of his birthdays. He got to shot 10 and passed out flat on his face.

Head to Toe

Vomit on face and mouth, continues to vomit frequently requiring suction

Approximately 1 inch gash over right eyebrow that is bleeding

Pupils equal and slow to reactChest sounds are congested on right sideAbdomen soft but Tony groans to palpation.No injuries noted on arms and legs.Tony has been incontinent of urine.

Vital Signs

BP 100/70 Pulse 90 Respirations 6Oxygen saturation 90% on room airBlood Glucose 80

How do you manage Tony? What are your concerns?

Management??

BLSKeep airway open with suctioningAssist ventilations with BVM and high flow

oxygenControl bleeding of lacerationMonitor level of consciousness for potential

head injuryDetermine how to extricate from basementConsider spinal motion restrictionTransport/ call for intercept

ALSContinue BLSMonitor airway and breathing – lung congestion could

mean aspiration

Begin IV fluids for rehydrationMonitor blood glucose -- acute intoxication can cause

blood sugar to drop

Consider Zofran 4 mg for vomiting controlContinue to monitor neurological status for

head injury

Rule Out:

Other reasons Tony may have an altered level of consciousnessHead injurySeizureSepsisDrug overdoseHypoglycemiaStrokeHypoxiaHypothermiaHyperthermia

Binge Drinking

National Institute on Alcohol Abuse and Alcoholism: consuming alcohol to reach a blood alcohol level of 0.08 gm/dl in < 2 hours

One in six adults binge drinks 4 times a month with an average of 8 drinks

Although binge drinking is more common among young adults (18-24 years) drinkers 65 years and older binge more often (5-6 times a month)

Binge drinking is more common in high income households

In addition to acute alcohol poisoning, binge drinking is associated with: unintentional injuries

Motor vehicle crashesDrowningBurnsFalls

intentional injuriesDomestic violenceSexual assaultFirearms injures

medical emergenciesPoor control of diabetesLiver diseaseHypertension– cardiovascular disease and stroke

Scenario 2

You respond to a residence where a 3-year-old girl has been found unconscious.

The parents tell you that the child, Ellie was fine when put to bed at eight the night before. They awoke this morning to find Ellie “asleep” on the living room floor, they are unable to arouse her.

You note partially filled cocktail glasses on the coffee table and an open bottle of bourbon on its side on the floor. Some of the glasses have cherries in them. The parents admit that they were too tired to clean up after a party last night.

What could be going on? What happened to this Ellie? How sick is she?

General Assessment: PAT

Appearance Unresponsive, lying

sprawled in a pool of red vomit with cherry

stems

Work of Breathing Normal

Circulation to Skin

Normal

What is your general impression?

General Impression and Management Priorities

General impression: Ellie is SickBrain dysfunction; likely a

metabolic/toxic causeWhat else could cause this?

SeizureInfectionHead traumaOther toxic ingestion

What do you need to know to manage Ellie?

Initial Assessment: ABCDEsAirway — open, vomit in mouth – lips and tongue are

red and vomit contains bits of cherry and cherry stemsBreathing — RR 16; symmetric chest rise; clear lungs;

SaO2 94% Circulation — HR 90; skin moist; capillary refill 2

seconds; BP 80/60Disability — AVPU = P; pupils sluggish but equal;

decreased toneExposure — breath and clothes smell of alcohol; no

signs of traumaChief complaint – Altered level of consciousness

What is the most likely toxin?Sedative

SleepyCentral nervous system depressionDecreased respirations, heart rate and BPSuggested by open containers of alcohol and smell

of alcohol on child’s breath and clothingEating the sweet cherries out of the leftover drinks

could contain enough alcohol to incapacitate a small child

Management PrioritiesThe patient is in impending respiratory failure

because of alcohol ingestion.BLS:

Consider airway adjunct. (OPA)Prepare for bag-mask ventilation. Arrange for transport.

ALS:Check blood glucoseTreat documented hypoglycemia.Establish IV access.

Fluid bolus of 20 ml/kg or 10 ml/pound for dehydration Perform electronic monitoring.Consider intubation for airway protection if ALOC and

absent gag reflex.

Blood glucose is 30 mg/%.IV started on scene.10% Dextrose 1-2 ml/pound (2-4 ml/kg) IV

administered.Patient becomes somewhat more

responsive, but she remains sleepy.If problem was hypoglycemia alone she

should wake up quickly. She is depressed because of the sedative effects of alcohol. There is no antidote for alcohol

Case Progression

Key Concept: Hypoglycemia

Hypoglycemia is common complication of alcohol ingestion in young children.

If the patient is awake, ask the caregiver to give oral glucose (soda or juice).

If patient is not alert or the gag reflex is depressed, give 10% Dextrose IV.

Key Concept: Risk Assessment of Poisoning

Determine: The substance ingested. ToxicityDose ingested: mg toxin ingested per/kg

body weight. Time since exposure.

Call:Poison center (1-800-222-1222) or medical

oversight to help with risk assessment.

Key Concept: Ingestions by Toddlers

Toddlers frequently ingest household products: solvents, cosmetics, plants, and cleaning liquids.

Most ingestions in this age group involve single toxins.

Few ingestions require charcoal or any specific treatment.

Case Progression

En route: patient remains stable, with progressive improvement in the level of consciousness.

ED Course

In the ED: repeat blood glucose 58. IV glucose infusion started, electrolytes, blood gas, and blood alcohol level sent. Social work consult obtained to evaluate home safety.

Diagnosis: alcohol ingestion; hypoglycemiaOutcome: social work call to children’s

protective services (CPS) reveals an open case, with a past report of child neglect. Child is discharged the following day in the care of the maternal grandmother, pending CPS investigation.

Toddlers are highly susceptible to the metabolic effects of alcohol, particularly hypoglycemia.

Accidental ingestions peak in the 2- to 3-year age group.

Prevention of poisoning in the home requires constant vigilance by caregivers and multiple rounds of “childproofing!”

Scenario 3

You are dispatched at 2230 hours to a local tavern for an altercation

On arrival you find 32 year old Dale sitting at the bar with a bloody towel to his face.

What issues do you need to consider in this scene as you are approaching Dale?

Dale states he got “sucker punched” in the nose.

Police are on the way.The person who hit Dale has left the bar.

Initial Assessment

Mental Status: Dale is awake with slow measured speech

Airway: mouth is clear, but nose is grossly deformed and swollen with blood coming from both nostrils

Breathing: Unlabored at about 20/minuteCirculation: Face flushed, skin warm and sweaty.

Radial pulse strong and regular at 92/minuteChief Complaint: “I think that #&^* broke my nose”

SAMPLE

Signs/Symptoms: pain and swelling of the noseAllergies: noneMedications: nonePast Medical History: noneLast Meal: supper at about 6:30 p.m. and has been at

the tavern since about 8 p.m. He says he has had about 4 beers and 1 “Jack and coke”. (confirmed by bartender)

Events: Dale got into an argument with another patron and Dale got punched in the face. Bystanders state he did not lose consciousness

Head to Toe

Pupils equal and reactAlert to person, place, time and eventsNose is swollen and deformed with

bleeding from both nostrilsNo other injuries found: chest, abdomen,

arms, legs

BP 150/96Pulse 92/minuteRespirations 20/minuteOxygen saturation 94% room air

Refusal??

Dale says he doesn’t want to go to the hospital. He just wants to get in his truck and go home?

Can he do that?

Autonomy

All patients have the right of autonomy or the right to make decisions about their care.

A patient does not lose their right to autonomy simply because they have been drinking alcohol.

The challenge is to determine if the patient is competent to make these decisions.

EMS providers are familiar with the signs of alcohol intoxication:Diminished fine motor coordinationDecreased social inhibitions

As alcohol intoxication increasesImpaired judgementImpaired coordination, difficulty walkingAgitation and combativenessAltered mental stateSlurred speechWarm flushed skin

Quick Confusion Scale

A tool will soon be available to help providers determine how confused someone is due to alcohol.

Adapted from: Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: Comparison with the mini-mental state examination. Am J Emerg Med 2001;19:461-464

The Quick Confusion Scale

Item Scoring System

  # Correct X weight = Total

What year is it now? 0 or 1 (score 1 if correct and 0 if incorrect)

2 =  

What month is it? 0 or 1 2 =  

Present memory phrase: “Repeat this phrase after me and remember it: John Brown 42 Market Street, New York.”

About what time is it? 0 or 1 2 =  

Count backward from 20 to 1. 0, 1, or 2 1 =  

Say the months in reverse. 0, 1, or 2 1 =  

Repeat the memory phrase.(each underlined portion correct is worth 1 point)

0, 1, 2, 3, 4 or 5 1 =  

Final score is the sum of the totals: 

=  

Explanation of Scoring for Quick Confusion Scale

The highest number in category indicates correct response; decreased scoring indicates increased number of errors

What year is it now? Score 1 if answered correctly, 0 if incorrect.

What month is it? Score 1 if answered correctly, 0 if incorrect.

About what time is it? Answer considered correct if within one hour: score 1 if correct, 0 if incorrect

Count backward from 20 to 1. Score 2 if correctly performed; score 1 if one error, score 0 if two or more errors

Say the months in reverse. Score 2 if correctly performed; score 1 if one error, score 0 if two or more errors

Repeat the memory phrase: John Brown 42 Market Street, New York.”

Each underlined portion correctly recalled is worth 1 point in scoring; score 5 if correctly performed; each error drops score by one.

Final Score is sum of the weighted totals; items one, two, and three are multiplied by 2 and summed with the other item scores to yield the final score.

Max score = 15. Score 11 likely cognitive impairment; score 7 = substantial impairment.

Irons MJ, Farace E, Brady WJ, Huff JS: Mental status screening of emergency department patients: Normative study of the Quick Confusion Scale. Acad Emerg Med 2002; 9:989-994.

What About Refusal?

Complete the refusal form.Explain the benefits of medical treatment and

the risk of refusing treatmentStrongly encourage Dale to seek treatmentIf he continues to refuse, contact Medical

Control.Involve local law enforcement to insure Dale is

safe.

Dale scores 12 on the confusion scale (he cannot repeat all of the memory phrase)

Dale’s speech is progressively more slurredHe was drinking when you arrived at the tavern

Local law enforcement help you encourage Dale to seek treatment.

Scenario 4

It is December 26 at 1330 hours.Bill has just arrived to visit his 88 year old

mother Emma. Bill is from out of town and has not seen his mother since August.

When she answered the door her gait was not steady. Bill helped her to her recliner and thought her speech was slurred and she was “dopey” so he called 911 thinking she has had a stroke.

Scene Size Up

Emma lives in a well kept house in an older neighborhood.

The house is clean and tidy but full of “collectables” and books.

Emma is sitting in a recliner in the living room. The table next to her has an empty glass and a wastebasket full of papers and other trash is next to the chair.

Initial Assessment

Mental Status: Emma is awake but slow to respond, with slightly slurred speech

Airway: Open and clearBreathing: Respirations easy and deep at

16/minute. Breath smells of peppermintOxygen saturation 93% room airCirculation: pulse is irregular at 88/minute, skin is

warm and dryChief Complaint: “I’m fine Sweetie, just a little

tired.”

SAMPLE

Signs/symptoms: unsteady gait and slurred speech

Allergies: morphineMedications: Vasotec 5 mg twice a day,

potassium 20 meq daily, Lipitor 30 mg daily, Micronase 5 mg daily, Aspirin 81 mg daily

Past Medical History: hypertension, high cholesterol and Type II diabetes

Last meal: Unknown for sure. Emma said she had lunch at 11:00 am

Events: Unknown

Head to Toe Exam

Pupils hard to evaluate due to cataracts.Mouth has green/blue discoloration of the

tongue, lips and tongue are dry.Chest has some congestionAbdomen softMultiple bruises on bilateral lower arms and

shinsAnkles have bilateral edemaBlood Sugar 280

FAST Assessment

Face – both sides move equallyArms – both arms raise equallySpeech – slurred, Emma giggles when

she has trouble speakingTime – Bill has not seen his mother since

August and has not talked to her on the phone for 2 days.

Your partner looks in the waste basket and finds 2 large bottles of blue mouthwash that are empty.

Emma tells you that she will admit she has been drinking more since her friend Betty died this fall because it makes her feel “happy”. She ran out of Tequila and the weather was bad, so she has been drinking mouthwash because it was in the house and it tastes better.

Mouthwash???

Ethanol is not only found in alcoholic beverages but is a main ingredient in mouthwash, over the counter cold medications (Nyquil™) and perfume.

Individuals who want to hide their ethanol intake or who are unable to obtain alcohol may drink other forms of ethanol.

Household ethanol is also a danger for accidental pediatric overdose.

Medical Side Effects of Ethanol

Poor control of diabetesHypertensionLiver diseaseStrokeCardiovascular disease

What are your concerns about Emma?How do you want to manage her care?

Management

BLS careMonitor airway and breathingOxygen by cannula to an O2 Saturation of 94%

ALS care IV access and fluid bolus (monitor lungs)EKG monitoring for dysrhythmias

Her monitor shows

What is this?What else does Bill need to consider

regarding his mother?

Bill needs to seek help to find other ways for his mother to deal with the loss of her friend other than drinking.

Scenario 5

Dispatched at 0730 hours For a middle aged woman who is “out of

her mind”

Scene Size Up

Upscale neighborhoodWell kept houseSmall barking dog is held by husband who

answers the door.

General Impression

Disheveled middle aged woman, Edie, sitting on kitchen floor

Hitting the floor with her slipperAppears very anxious and frightened

Initial Assessment

Mental Status: awake but is distracted and does not follow commands

Airway: open with very dry mucus membranes

Breathing: 28, deep and rapidCirculation: skin pale, cool and moist

Radial pulse fast, weak and threadyChief Complaint: “There are too many bugs”

Focused History

Allergies: codeineMedications:

Alprazolam 1 mg BIDInderal for blood pressureSynthroid 150 mg Ambien at nighttime for sleep

Past HistoryHypothyroidism“bad nerves”Social drinker (averages 2 bottles of

Chardonnay or other wine every evening)

Last Meal 24 hours ago

Events: Edie wanted to surprise her son for Christmas, so she quit drinking 2 days ago. She started feeling ill yesterday with feeling weak and no appetite. This morning Edie is shaky and confused. She says she sees black bugs all over the kitchen (no one else can see them). She feels them crawling all over her skin and she is trying to rub them off.

Focused Physical

VS: BP 100/60, P 120, R 28Pulse Ox: 94% on room air EtCO2 34Blood Sugar: 70Has trembling of armsRubs on arms and legs trying to brush off bugsRed raw abrasions on both armsPoor skin turgor, and dry mucus membranesVery poor attention span. Does not listen to you. Edie’s husband says “she’s lost it and has gone

crazy”

Cardiac Rhythm What is this?

Long Term Alcohol Abuse

General Alcoholic ProfileDrinks early in the day, alone, or secretly.Binges, blackouts, GI problems, chronic

flushing of face and palms.Cigarette burns, tremulousness, and odor of

alcohol.

Alcohol Abuse

Consequences of Chronic Alcohol Ingestion Poor nutrition Alcohol hepatitis Liver cirrhosis, pancreatitis Sensory loss in hands/feet Loss of balance and

coordination Upper GI hemorrhage Hypoglycemia Falls (fractures and

subdural hematoma)

Alcohol Withdrawal Syndrome

Alcohol (ethanol) withdrawal syndrome can begin as early as 6 hours after the fall of blood alcohol levels and usually peaks between 24 and 36 hours. It can take up to 5 days after the termination of drinking to resolve.

Delirium Tremens (DTs) is a life threatening manifestation of ethanol withdrawal characterized by tremors, hallucinations and hypovolemic shock. DTs appear in 48-96 hours and can persist up to 7 days.

Withdrawal Syndrome DTs

Signs & SymptomsCoarse tremor of hands, tongue, eyelidsNausea, vomiting, general weakness, anxietyTachycardia, sweating, Hallucinations – frightening or threatening visual

(seen) auditory (heard) and/or tactile (felt)

Signs and Symptoms cont.

Increased sympathetic tone -- seizures Orthostatic hypotension (BP drops when patient

stands up)OR hypertension Dehydration – hypovolemic shock Irritability or depressed mood, poor sleep

DTs are a serious medical

emergency!!

Alcohol Abuse

BLS TreatmentEstablish and maintain the airway.Determine if other drugs are involved.Prevent self harm. Be alert for seizuresDo not “buy into” the hallucinations

• Do not say that you see the hallucinations too• Do not tell Edie that there are no bugs there• Acknowledge that Edie is afraid and that she sees

bugs but that you can’t see them.

Treatment cont. ALSEstablish IV access.

• Replace fluids at 20 ml/kg for dehydration • 25g D50W if hypoglycemic or • 1-2 ml/pound (in 50 ml boluses) of D10W if hypoglycemic• Versed 0.1 mg/kg for shaking or seizures

Transport, maintaining a sympathetic attitude, and reassure the patient.

ReviewAnswer the following questions as a group.If doing this CE individually, please e-mail your

answers to:

shelley.peelman@presencehealth.orgUse “December 2015 CE” in subject box.You will receive an e-mail confirmation. Print

this confirmation for your records, and document the CE in your PREMSS CE record book.

IDPH site code # 067100E1215

1. How does alcohol (ethanol) effect the body?

a. Hallucinogen

b. Stimulant

c. Sedative

d. Opiate

2. How does a person usually respond to low doses of alcohol?

a.

b.

3. How does a person usually respond to higher doses of alcohol?

a.

b.

c.

4. Why do people get warm when they drink?

5. Why do people wake up very thirsty after drinking alcohol?

6. Name some other emergency conditions that might be masked by alcohol intoxication?

a.

b.

c.

7. What specific medical problem occurs when children drink alcohol?

8. True/False Patients with alcohol on their breath lose all their ability to make decisions and must be transported to the hospital.

9. If a person has no access to alcohol, what other household items contain ethanol and can be used to get intoxicated?

10.Why are DTs dangerous?

Answers

1. How does alcohol (ethanol) effect the body?

a. Hallucinogen

b. Stimulant

c. Sedative

d. Opiate

2. How does a person usually respond to low doses of alcohol?

a. depression of inhibitions

b. aggressive or inappropriate behavior

3. How does a person usually respond to higher doses of alcohol?

a. dulled sense of awareness

b. decreased coordination

c. decreased reaction time

stupor and coma

4. Why do people get warm when they drink?

Alcohol ingestion causes peripheral vasodilation which increases sense of being warm and loss of body heat

5. Why do people wake up very thirsty after drinking alcohol?

Alcohol is dehydrating and increases removal of water through urination.

6. Name some other emergency conditions that might be masked by alcohol intoxication?

a. head injury

b. low blood sugar

c. infection

seizures/ post ictal state

hypoxia

7. What specific medical problem occurs when children drink alcohol?

hypoglycemia (low blood sugar)

8. True/False Patients with alcohol on their breath lose all their ability to make decisions and must be transported to the hospital. False

9. If a person has no access to alcohol, what other household items contain ethanol and can be used to get intoxicated?

mouthwash, perfume, liquid cold medicine

10. Why are DTs dangerous?

DTs can lead to seizures, hypotension and hypovolemic shock.