Lecture 37/38 -- Alcohol/Tb/Illicit Substances Flashcards Preview

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Flashcards in Lecture 37/38 -- Alcohol/Tb/Illicit Substances Deck (36):
1

name some drug intoxications you can die from

Cocaine, amphetamines, benzodiazepines, alcohol, barbituates,
Opioids, PCP, steroids, inhalants,


NOT MARIJUANA

2

name some drug Withdrawals you can die from

Sedative -- alcohol, benzos, barbituates


very rarely: opioids, but only in infants

3

describe the metabolism of ETOH

enzmyes?
what is the rate limiting step?
elimination kinetics?

Alcohol DHG: ETOH --> Aldehyde

Aldehyde DHG: Aldehyde --> Acetic acid

(some metab through P450s)

RLH: Aldehyde DHG

Zero Order elimination

4

how do gender and ethnicity factor into metabolism of alcohol

Women -- less alcohol DHG; smaller volume of distribution

Asians -- less ADH and ALDH

5

Neuropharmacology of ETOH intoxication -- what NTs are involved and to what effect

Euphoria -- DA, Opioids

Sedation/anxiolytic -- GABA, decreased NMDA

Nausea -- 5HT

6

Treatment for ETOH intoxication

Supportive -- airway; correct fluid and electrolyte imbalances

Examine for other signs of trauma

7

two types of fatal ETOH withdrawal

DTs and Sz

usually mutually exclusive

8

Stages of ETOH DTs

95% are self limiting

Stage 1 withdrawal -- 24h after last drink.

Tremulous, HTN, tachy, sweating, nausea, anxiety, mild derealization


Stage 2 -- 48 hours after last drink. More severe symptoms than in stage I.
+ hallucinations (auditory) and patients are aware of reality

stage 3 = DTs
<1% of all cases
Marked disorientation
Hallucinations -- visual, tactile, auditory


9

ETOH withdrawal sz

12-48 hours after stopping drinking; usually earlier

Tonic Clonic

<5% of withdrawal cases

Usually self limited and no status epilepticus

10

treatment options for etoh withdrawal

Supportive --

BZDs -- longer acting ones give a smoother taper;

Barbituates --

Beta Blockers -- as an add on agent for tachy

Anti convulsant -- carvemezepine; gabapentin

Ethanol -- can be used, but rare; IV

Propofol -- generlized sedation; may specifically help with ETOH withdrawal, but respiratory depression does occur

11

effects on body systems with chronic etoh abuse?

B1 Deficinecy - -Wernickes and Korsakoffs

Brain, liver, pancreas, GI, Oro-esophageal cancers, Varicies, PNA,

Cardiomyopathies --> pulm congestion

Endocrine -- decreased testosterone and loss of secondary sex characterisitcs

12

Biomarkers for chronic heavy drinking

GGT (an liver enzyme) > 30

CDT (carbohydrate deficient transferrin) > 20

MCV > 90

13

three FDA approved drugs to help treat alcoholism ?

Mechanism
rationale for treatment
side effects/toxicity

Dilsulfram -- (antabuse) -- Aldehyde DHG inhibition; leading to aversive condition with consumption of ETOH.
SE: Liver toxicity; drowsiness, HTN


Naltrexone -- opiate blocker
Mu Antagonist
Decrease positive reinforcement of drinking
side effects: Minor liver tox; N/HA/Sedation

Acomprosate (Calcium acetyl homotuarinate) --
NMDA Glutamate R modulator

Helps control cravings, triggers

Side effects: Diarrhea
no liver toxicity

14

nicotine Pharmacology ---

assay to monitor nicotine consumpiton?

cotinine

15

nicotine intoxication --
can this be fatal?


symptoms

Can be fatal due to peripheral nicotinic receptor stimulation, but only in infants

Sx -- tachy, htn, n/v, diaphoresis, palpitations, sz, anxiety

16

Tx of nicotine intoxication

Primarily supportive
Gastric lavage
Activated charcoal

treat Bradycardia with atropine

17

Nicotine withdrawal --

decreased HR, Insomnia, dysphoria, irritability, poor concentration

18

FDA approved medications for smoking cessation

mechanism?

Nicotine replacement
Patch/gum/nasal spray/inhaler/oral spray/lozenge

Bupropion (Zyban/wellbutrin)

Varenicline(Chantix) -- nicotine partial agonist

19

rationale for nicotine replacement therapy


contraindications

Nicotine absorption is worse than cigarettes
Lower does is delivered
First pass metabolism can inactivate
Less rewarding --

Contraindications -- Recent MI, smoke less than 10 cigs per day; use with caution in breast feeding/pregnant patients

20

Contraindications for Buproprion

Mechanism Verenicline (chantix)
side effects

Bup: Contraidncated -- SZ or Eating D/o


Varenicline (Chantix)
Mechansims -- Nicotinic partial agonist; some effect on 5HT
Taken BID
Side effects -- N/V/HA/ Insomnia/abnormal dreams
Increased risk of suicide

21

cocaine intoxication --

Phsyical effects?
behavioral/psychiatric effects?

what are a lot of the severe effects due to?

vasconstriction in the setting of cocaine use

tachy, midriasis, HTN, N/V, CP, SZ, HA, bruxisms


manic: Grandiosity, hyperactivity, delusions, paranoia, hallucinations (formication)

Cardiac arrythmia, MI, Stroke, Rhabdo, Death

22

cocaine withdrawal

sx?

tx?

opposite of intoxication: fatigue, hypersomnia, lethargy, irritability, dysphoria, SI

Tx -- supportive; unless there is underlying depression

23

hallucinogen intoxication

fatal?
sx?

not life threatening expcept for impaired judgement which can lead to fatal decisions

Tachy, diaphoresis, palpitations, tremulous, disoriented, intesnified perceptions, illusions, visual distortions, hallucinations, delusions, distorted sense of time

24

tx of hallucinogen intoxication

Largely supportive
Provide a quiet,stimulus-free environment
Agitation
benzodiazepine
high-potency neuroleptic

25

hallucinogen withdrawal?

what is a manifestation than occur long after using hallucinogens?

No real withdrawal syndrome

HALLUCINOGEN PERSISTING PERCEPTION DISORDER (flashbacks)
Often triggered by stress, fatigue, anxiety, entry into a dark environment, drug use

26

classic finding for PCP

vertical nystagmus

27

Benzo intoxication:

symptoms
worse with?
treatment of benzo over-dose
(what drug)

Sx: same as alcohol; sedatiave;
Worse with Alcohol, opioids, barbituates




Flumezanil

28


benzo withdrawal

similar to alcohol
including seizures

29

main concern for fatality with opioids


Intoxication sx

Respiratory depression



Pinpoint pupils; resp depresion, drowsiness,
Pruritiis (histamines), euphoria, sedative

30

Opioid intoxication treatment:


difference if its a methadone overdose

Airway, oxygenation

Naloxone -- short acting mu opioid antagonist; response within 1-2 minutes;


Methadone overdose -- long half life; have to adminster multiple doses;

31

Opioid withdrawal

sx
peak if untreated
duration

Sx -- Pupilary dilation, piloerection, diaphoresis, lacrimation, rhinorrhea, N/V/D
Involuntary muscle jerks

Dysphoria, irritable, hyperalgesia, craving


Peak -- 1-3 days
Sub acute symptoms --can last for months;

Not life threatening

32

Treating opioid withdrawal



Clonidine
Opioids -- methadone
Buprenorphine

symptomatic

33

(rationale for treating opioid withdrawal with clonidine)

opioid use can destroy LC, therefore decreasing NE

Rebound effect of NE when in withdrawal

Teat with A2 agonist to decrease NE release

34

Inhalants -- 3 kinds


general mechanism

Volatile Compounds

Nitrites

Nitrous Oxide


mechanism -- CNS depression and hypoxemia

35

Steroids

intoxication symptom

HA, diaphoresis, tachy,
anxiety, irritability
aggressive, combative, some psychosis, paranoid, depression
"roid rage"




36

Treatment of steroid intoxication

taking patients off steroids?

supportive

Psychosis -- neuroleptics;

Agitated --Benzos


need to taper pts off steroids