FSM Impotant topics

      ACUTE ALCOHOL INTOXICATION  

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Consider acute alcohol intoxication in any patient presenting with:

-coma

-syncope

-any inappropriate behavior

-any neurological abnormality

-trauma

-traffic accident

-hypothermia

Inappropriate Behavior; in coordination, confusion, slurred speech, aggressive, inappropriately sensitive behavior etc

Neurological Abnormality; e.g. ataxia, nystagmus, divergent bulbae etc.

Reliable history gives more helpful information in contrast to physical examination which is less sensitive and specific.

MANAGEMENT

               Assess vital functions

                                -Airway

                                -Breathing

                                -Circulation

                Assess level of consciousness

                Assess and treat for complications of alcohol

CIRCULATION

·         Palpate carotid artery pulsations

·         Absent pulse

                    Observe ECG rhythm

                    Prepare for cardiopulmonary resuscitation

·         Weak pulse

                     Measure blood pressure

                      If systolic <90mmHg

                       - Give saline 0.9% 500ml by rapid I/V infusion; repeat as needed

                       - If refractory to saline give nor epinephrine continuous I/V infusion, start with 0.5-1 µg/min

·         Evaluate for bleeding; aspirate stomach fluid via nasogastric cannula and consider endoscopy

               (Chronic alcoholics may have esophageal varices, peptic ulcer or congestive gastropathy. Also,                           

                Mucosal tears may occur after bouts of vomiting in alcohol overdose-Mallory Weiss Syndrome.)

ASSESS LEVEL OF CONSCIOUSNESS

·         Speak to the patient in a loud voice

·         If no adequate response, apply a painful stimulus

·         Put the patient in lateral decubitus position while not intubated

·         Intubate trachea if tracheal reflexes are not adequate to prevent aspiration

·         Give Oxygen, initially @2-4L/min

·         Thiamine 100mg I/V

·         Measure blood glucose level by bedside test

·         I/V glucose 500ml of 10% or 100ml of 30%

·         Search for head trauma

·         Frequently assess pupils

·         Consider additional toxin ingestion

·         Consider cerebral computed tomography

COMPLICATIONS AND PROBLEMS OF ACUTE ALCOHOL INTOXICATION

·        AVOID BENZODIAZEPINES as they are potent respiratory depressants in combination with alcohol

·         Aggressive patients

                  -try to listen, talk

                  -Haloperidol 10mg PO,I/V,I/M,S/C

                  -physical restraints are only a last resort

·         Co ingested poisons esp. cocaine, benzodiazepines and antidepressants

·         Hypoglycemia

·         Hypothermia

·         Rhabdomyolysis

·         Occult head injury

·         Wernicke’s encephalopathy

·         Hyponatremia

LABORATORY INVESTIGATIONS

BLOOD TESTS

       Peripheral Blood Cell Count      

                             -initially concentration of Hemoglobin and RBC’s will be unchanged

                             -with bleeding, plasma and blood cells are lost

                             -ultimately leads to decrease in Hemoglobin and RBC concentration

       Blood Ethanol levels

                             -poorly correlate with intoxication due to tolerance

       Osmolal Gap

       Anion Gap

       Potassium levels

       Arterial Blood Gas Analysis

BREATH TESTS

   Roadside breath test

    Calibrated breathalyzer

URINE

VITREOUS HUMOUR

    Only taken postmortem and is most useful when blood not available or unsuitable for analysis

AUTOPSY FINDINGS IN CHRONIC ALCOHOLISM

     Chronic alcoholism refers to a steady, regular abuse of a drink.

     On autopsy,

       GENERAL FEATURES

                -Signs of general neglect and malnutrition or obese and even edematous due to chronic heart failure

       INTERNAL FEATURES

             -LIVER DAMAGE

                   In early stages, there will be fatty change and enlargement with increase in weight up to 2000g.

                                               Surface will be pale and greasy.

                                               Patchy yellowish area may be visible within normal hepatic parenchyma.

                  If abuse continues, fatty change may give way to fibrosis.

                               Cirrhosis of liver with nodules of 5-10 cm in diameter.

                  In late stage, liver becomes smaller and contracts to a hard, grayish –yellow block of only 800-1200g.

         -CARDIAC DAMAGE

                   Heart is enlarged and shows patchy fibrosis with mixed cellular infiltrate, hypertrophy of muscle fibers, patchy necrosis, hyalinization, edema and vacuolization, nuclear enlargement and polymorphism.

                 Specific myocardium damage cause by cobalt added to commercial beers.

            -SPLEEN

                  May be enlarged and firm, portal varices may be present at the gastro-esophageal junction

            -OTHER FINDINGS

                 Systemic fat embolism

                 Micro infarcts in brain and myocardium

 AUTOPSY INSTRUMENTS

1. Forceps (serrated):     To hold soft tissue and organs
2. Large artery forceps with bent tip
3. Blunt tip straight scissors      opening coronay arteries, bile duct and pancreatic duct
4. Pointed tip scissors
5. Cartilage knife                  To cut costochondraljunctions to open thracic cage
6. Scalpel with fixed blade
7. Scalped with disposable blade
8. Chisel and hammer

                        Used to separate skull cap and spinal laminaeand expose pituitary gland

• Hooks : To hook and separate organs
• Probe : To explore the coronaryarteries, bile ducts, urethera, oviductetc
• Axe
• Bone saw  :To cut skull cap and spinal laminae