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Clin Tox Exam 1 > Alcohol > Flashcards

Alcohol Flashcards

(69 cards)

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1
Q

Common products with alcohol content

A

Aftershave lotions - 15-80%
Mouthwash - 15-25%
Perfumes/colognes - 25-95%

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2
Q

Alcohol Proof =

A

2X the percentage of alcohol per the volume

I.E. Everclear 185 proof = 95% alcohol

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3
Q

Standard drink =

A
  1. 6 fluid ounces or 14 grams of pure ethanol

- 12 oz beer, 8-9 oz malt liquor, 5 oz wine, 1.5 oz brandy, 1.5 oz shot of 80 proof spirits

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4
Q

“At-risk” or “heavy” drinking

A

Men: >4 drinks on any day or 14 per week
Women: >3 drinks on any day or 7 per week

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5
Q

Adipose + Alcohol

A

More adipose tissues, the decrease the volume of distribution which increases the blood volume concentraiton

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6
Q

Age + Alcohol

A

Decreased renal function with increased age = reduced elimination
Children = higher metabolic rate

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7
Q

Chronic use + Alcohol

A

Rate of elimination increases

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8
Q

Food + Alcohol

A

Delays absorption of alcohol

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9
Q

Ethanol Absorption

A

80% small intestine, remainder in the stomach

ETOF: 20% optimal - champaign (get you drunk quick)

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10
Q

***Ethanol Distribution

A

Adults 0.6L/kg

Children 0.7L/kg

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11
Q

Ethanol Metabolism and Elimination

A

Alcohol → acetaldehyde → acetate → purine acid synthesis
Zero order elimination - no matter how much you intake, it will continue to eliminate at the same rate (chronic alcoholism lead to 2E1 kicking in taking ethanol to acetaldehyde)
Catalase takes peroxide to water to acid aldehyde

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12
Q

All the pathways of ethanol metabolism lead to

A

Accumulation of acetaldehyde which blocks the production of glutathione and 2E1 is waht take APAP to NAPQI (toxic metabolite
Acetaldehyde causes → NADH accumulation → energy pathway is saturated → energy is stored as fat (glycogen stores) → Excess fats cause TG synthesis increase → fatty liver → cirrhosis

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13
Q

***Ethanol Metabolism Rate

A

Adults: 20mg/dL/hr

Chronic alcoholics: 40 mg/dL/hr

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14
Q

***Ethanol Calculation

A

Serum Concentration = (mL of ethanol X % ethanol X 0.8)/ (Vd (L/kg) X kg)

Vd = 0.6 for adults and 0.7 for kids

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15
Q

Ethanol’s effects on the brain

A

Acute: Depress inhibitory neurons which makes you feel good
Chronic: Depletes glutamate too so that high feeling doesn’t happen

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16
Q

***Acute Ethanol Toxidrome

A

Stage 1: Talkative, noisy, morose - Feel Good
Stage 2: Mental impairment - Drunk
Stage 3: N/V - Sick
Stage 4: Hypothermia, amnesia, anesthesia - Passing Out
Stage 5: Coma, respiratory failure - Dead

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17
Q

Nontolerant Individual + Blood Alcohol Level

A 
Less than 50mg % - Stage 1
50-100 mg% - Stage 2
100-200: Dangerous to drive
200-300: Stage 3
300-400: Stage 4
400-700: Stage 5
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18
Q

Osmolality Formula

A

2X Na + (glucose/18) + (BUN/2.8)

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19
Q

Osmolal Gap Formula

A

Measured should be +/- 5 (>5 = unmeasured alcohol) mOsm/kg

Osmolality measured - calculated

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20
Q

Ethanol MW

A

46

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21
Q

Isopropanol MW

A

60

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22
Q

Methanol MW

A

32

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23
Q

Ethylene Glycol MW

A

62

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24
Q

CAGE Questions

A

Felt like you should CUT down on your drinking?
Have people ANNOYED you by criticizing you?
Have you every felt bad or GUILTY
EYE-opener: drink first thinking in the morning?

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25
Ethanol Withdrawal Syndromes
Sharply decreased consumption or intercurrent illness - mild tremor and anxiety to hallucination/convulsions Common in regular heavy drinkers Abstinence syndrome (shake, tremors, HTN) Alcoholic hallucinosis - tactile and visual not auditory Seizures or delirium tremens
26
Intoxication Vital Signs
Normal or decreased temperature Elevated pulse Normal BP Decreased RR!!!
27
Withdrawal Vital Signs
Normal or elevated temperature Elevated pulse Normal or elevated early and then orthostasis Elevated RR!!!
28
Ethanol OD Treatment
Emergency Stabilization Emesis up to 1 hour after ingestion Hemodialysis (blood alcohol level > 500, hypotension) Supporitve Care (ventilation, Mg, thiamine)
29
Ethanol Withdrawal Treatment
Benzo- lorazepam (ONLY IF THEY HAVENT HAD ALCOHOL RECENTLY) | Haldol for hallucinaitons
30
Isopropyl Alcohol main ingredient =
Rubbing alcohol and twice as potent as ehtanol
31
Lethal dose of Isopropyl Alcohol
240 mL
32
Isopropryl Alcohol Kinetics
Re-secreted in the saliva and stomach Main toxin is the alcohol itself not the metabolites Eliminated in the kidney and lungs (fruity breath)
33
Isopropryl Alcohol TOxidrome
1. GI effects (gastritis, vomiting) 2. CNS Depression (dizziness), HYPOTENSION, respiratory depression 3. Coma 4. Toxic symptoms at level of 50 mg/100 mL and coma at 120 mg/100 mL 5. Cross reacts with analytical methods to detect levels
34
Treatment of Isopropyl ALcohol
Emergency Stabilization (ABCDEF) GASTRIC LAVAGE!!!! Hemodialysis ( Level >400 or hypotensive) Supportive care = ventilation
35
Methanol Produced and From
Distillation of wood | From contaminated moonshine in old radiators or windshield washer fluid
36
Methanol Kinetics
Methanol --> Formaldehyde through alcohol dehydrogenase --> formic acid through aldehyde dehydrogenase --> metabolic acidosis or formate and broken down by folate
37
Methanol Toxic Dose
15 mL of 40% solution but 30 mL is lethal | 10 mL can cause blindness!!!
38
Early Stages of Methanol Poisoning
Methanol to formaldehyde to formic acid to metabolic acidosis (fire ants use this)
39
Formaldehyde causes what toxicity?
Pickles your brain and eyes
40
Define circulus hypoxicus
Tissue hypoxemia from formaldehyde
41
Methanol Toxidrome
1. CNS: headache, coma convulsions 2. GI: N/V, pancreatitis 3. Ocular Toxicity: blurred vision, constricted visual fields, DILATED pupils (formaldehyde) 4. Metabolic acidosis secondary to formic and lactic acids (formate > 20 mg/dL)
42
ALL ALCOHOLS HAVE WHAT SYMPTOMS?
CNS depression and N/V
43
Methanol and Formate concentrations
Methanol falls and formate increases over time
44
Methanol: anion gap and osmolal gap?
Early: anion gap is low, osmolal gap is high Later: switches
45
Treatment of Methanol OD
Emergency Stabilizaiton | Emesis or lavage within 2 hours of ingestion and up to 4 hours if coma or co-ingestion
46
Fomepizole (Antizol) MOA
Affinity for alcohol dehydrogenase that is 8000 times greater than ethanol - Competitive inhibitor of alcohol dehydrogenase and CYP P450
47
Fomepizole Distribution, Metabolism, Excretion
Low protein binding and Vd 0.6-1.2 L/kg MM kinetics - induces its own metabolism Extensively cleared by hemodialysis (increase dose)
48
Fomepizole Efficacy
Essentially replaced ethanol but NEED HIGHER DOSE in HD
49
Fomepizole Indication
Methanol > 20 mg/dL History of methanol ingestion and OG > 10 mOsm/kg History of strong clinical suspicion and 2 of the following: arterial pH less than 7.3, bicarbonate less than 20, OG > 10, visual changes
50
***Fomepizole Dosing
LD = 15 mg/kg MD: 10 mg/kg Q12H X 4 doses then 15 mg/kg Q12H until the methanol concentration is less than 20 and patient is asymptomatic with a normal pH - HD: increase MD to Q4H during HD or continuous infusion of 1-1.5 mg/kg/hr
51
Ethanol MOA
Alcohol dehydrogenase attaches to ethanol with 20 X more affinity than methanol (ethanol levels maintained at above 100 mg/dL)
52
Indication for Ethanol over Fomepizole?
Unavailable or hypersensitive to fomepizole
53
Leucovorin and Folic Acid Dosing
Symptomatic: 1 mg/kg (up to 50 mg X 1) then folic acid 1 mg /kg (up to 50mg) Q4H X 6 doses Asymptomatic: 1 mg/kg folic acid Q4H X 6 doses - Increase during HD or chronic alcoholics
54
When to use leucovorin?
ALWAYS FIRST LINE IF SYMPTOMATIC
55
Hemodialysis Indications
Methanol > 50 mg/dL (continue until less than 25) Metabolic acidosis not immediately correctable with bicarb Visual Impairments Deteriorating vital signs Renal failure Electrolyte imbalance
56
Supportive Care
Correct metabolic acidosis with sodium bicarbonate (correct up to 15) Monitor for sever hypoglycemia, hypocalcemia, myogloinuria (pancreatitis) Phenytoin for seizures
57
Ethylene Glycol From and Letahl Dose
Antifreeze/Coolant Dose: 1-1.5 mL/kg As much as one swallow can kill a small child
58
Ethylene Glycol Kinetics
EG --> glycoaldehyde via alcohol dehydrogenase --> glycolic acid via aldehyde dehydrogenase --> glyoxylic acid via lactate dehydrogenase --> oxalic acid or alpha/beta ketoadipic acid through thiamine or glycine through pyridoxine Mg
59
Primary metabolite for ethylene glycol
Glycolic acid
60
Cystals from ethylene glycol?
Oxalic acid + Calcium form crystals that can deposit in the cardiopulmonary tree
61
Ethylene Glycol Toxidrome
1. CNS depression (N/V, coma) 2. Tachycardia, HTM, edema (crystals) 3. Kidney stones due to crystals, acute renal failure 4. Metabolic acidosis
62
Ethylene Glycol Labs
Hypocalcemia --> tetany and ST prolongation Sever metabolic acidosis Eleavted osmolal gap
63
****What labs do you always get for EG?
Ca, EKG, chesty X-ray
64
EG Treatment
Emergency Stabilization Supportive care (correct acidosis-bicarb) Antidote (thiamine, pyridoxine, fomepizole, ethanol) Hemodialysis
65
EG Antidote Need when:
Conc > 20 Recent history of ingesting toxic amounts of EG and OG > 10 History of strong suspicion of EG poisoning and at least 2 of the following: arterial pH less than 7.3, bicarb less than 20, osmolal gap . 10, crystal spresent
66
Thiamine Dose
100 mg IV daily
67
Pyridoxine Dose
100 mg IV daily
68
Hemodialysis in EG OD
Mainstay - dramatically increases the clearance of EG
69
Hemodialyis in EG Indication
Deteriorating vital signs Metabolic acidosis 7.25-7.3 Renal failure or electrolyte imbalance Continue fomepizole until concentration less than 20 and the patient is asymptomatic with normal pH

Clin Tox Exam 1 (5 decks)

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