Transcript Alcohol and Other Drug Emergencies

Alcohol and Other
Drug Emergencies
EMC SDMH 2015
Objectives
• Recognise and manage alcohol and opioid
overdose
• Recognise and manage stimulant toxicity
• Become familiar with dealing with severe alcohol
withdrawal and acute complications of alcohol
addiction
• Recognise and manage opioid withdrawal
• Develop an approach to ED assessment of less
acute alcohol related and appropriate referral
AOD and the ED
• Data lacking for amount of presentations to ED
• Point estimates 13.8% pt’s in ED relating to alcohol
during high demand times
• 8% average rate of alcohol related presentations
• Drug reporting absent – anecdotally increasing
• Frequent crisis presentations – interventions?
Alcohol overdose
• Occasionally seen
• Possible cardio-respiratory
depression with sudden elevations
to high levels
• BAL 0.4-0.5 in naïve individuals
• Risk of aspiration with drop in GCS
• Typically young males ‘sculling’
spirits
• Watch for hypoglycaemia
Opioid overdose
• Uncommon to get to ED – ASNSW
• Changing patterns of opioids
• Death from respiratory depression
• Resp. depression, miosis and hx of drug
exposure suggest diagnosis
• Naloxone 0.4 -2 mg IV/IM/IN reverses effects
for 20-90 mins.
• May provoke withdrawal !
• Larger doses may be required for SR
formulations, fentanyl and methadone
• May require infusion in above situation
Stimulant overdose
• Amphetamine, cocaine, MDMA,
methamphetamine
• Toxic usage - may only be 1-2 x
‘normal’ use
• Sympathomimetic toxidrome
• Methamphetamine – CNS excitation,
paranoia, psychosis common
• IV benzodiazepines to sedate +/fluids.
• Hyperthermia indicates severe toxicity
and requires aggressive management
• IM/IV droperidol for behavioural
disturbance may also be useful
Alcohol withdrawal
• Crisis presentations (unplanned
abstinence)
• Occurrence during intercurrent
illness/admission
• Request for ‘detox’ after bingeing
• Onset 6-24 from last drink.
• Withdrawal possible with positive
BAL
Symptoms/Signs of alcohol withdrawal
• Withdrawal seizure may be
presenting complaint
Severe withdrawal
• Seizures – 2-9%; occur within
first 48 hrs
Anticonvulsants ineffective for acute alcoholic seizures – use
benzodiazepines.
• Alcohol withdrawal delirium
(‘delirium tremens’) – 5%
• Hallucinations
• Requires inpatient
supervision and management
to prevent mortality
Management
• Benzodiazepines mainstay of
therapy
Diazepam standard agent
Oxazepam if concerns regarding age, hepatic function
• Dosing by differing approaches
‘Loading dose’ – 20mg q 2-4 hr until 80mg
reached, then cease and observe
‘Tapered’ 10-20mg qid, reducing on daily basis
‘Symptom triggered’ – PRN dosing basis upon an
AWS
NB – What does a febrile rigoring pneumonia pt
score on the AWS?
Wernickes encephalopathy
• Classic triad rarely present
• ~12.5% heavy drinkers (by autopsy studies)
• Nonspecific confusion and STM loss often
only signs.
• Confabulation = classic feature of Dx
• Failure to diagnose leads to irreversible
neurological changes (Korsakoff’s
syndrome)
• In malnourished/severe alcoholism
parenteral thiamine required (bioavailability
1.5%!)
• IMI Thiamine 300mg daily for 3-5 days, then
PO for further 1-2 weeks
Other problems
• Malnourishment
• Dehydration
• Electrolytes – K, Mg
• Hypoglycemia/Ketosis
• Arrhythmias' – AF
• Infection
• Trauma - falls
Opioid Withdrawal
• Uncommon (currently)
• May present with drug–seeking
behaviour
• ‘Acute abdomen’ – cramps,
pains, vomiting
• Loud !
• Presence track marks; yawning;
goosebumps typical features
• Pt may disclose hx of drug use
and request withdrawal
assistance
Opioid Withdrawal
• Onset time dependent upon drug of
abuse
• Aim to reduce symptoms whilst
attempting to engage in controlled
withdrawal
• Illegal to knowingly prescribe opioids
to known addicts for purposes of
withdrawal management without
specific authority
• Permitted to prescribe for pain for
medical illness
Opioid withdrawal
• Buprenorphine SL is
preferred agent of choice
4-8 mg SL daily
Binds m receptors, long acting, higher affinity
than other opioid
Partial agonist so lower risk overdose
• If unable to prescribe
buprenorphine, then
symptomatic management
undertaken 
Ongoing management
• Detailed assessment of drug
habit(s)
• Engagement with family and
social supports
• Counselling services
• AOD community services
Questions
Summary
• Patterns of opioid use changing dramatically; be aware of novel opioid
overdoses
• Stimulant overdose potentially fatal but uncommon. Psychosis common
• Alcohol withdrawal mortality virtually zero with early decisive care.
• Wernicke's encephalopathy under-recognized. Give all alcoholic pt.'s
parenteral thiamine
• Ensure other health issues have been attended to and that correct
diagnosis applied
• Acute opioid withdrawal less common than previously – can be
problematic to control in ED without authorized prescribers
• All AOD presentations will benefit from brief interventions to try and
engage with withdrawal management in community