1, the definition of acute alcoholism
Acute alcoholism refers to the disorder of the central nervous system caused by a large amount of alcohol or alcoholic beverages in a short period of time, which is often manifested as abnormal behavior and consciousness. In severe cases, organ function is damaged, leading to respiratory and circulatory failure and life-threatening. Also known as acute alcoholism.
2. Diagnosis of acute alcoholism
(1) The following two points can be used to diagnose acute alcoholism clinically.
I have an obvious history of excessive drinking or alcoholic beverages.
Two. Exhaled gas or vomit smells of alcohol and has one of the following characteristics: ① irritability, wordiness or silence, incoherent speech, emotional instability, rude or aggressive behavior, nausea, vomiting, etc. ② Sensation dullness, uncoordinated muscle movements, fidgeting, unsteady gait, obvious ataxia, nystagmus and diplopia; (3) There are deep consciousness disorders, such as drowsiness, shallow coma, deep coma, weakened nerve reflex, pale face, cold skin, hypothermia, increased or decreased blood pressure, abnormal breathing rhythm or frequency, accelerated or slowed heartbeat, incontinence, etc.
(2) Clinical diagnosis of acute alcoholism
On the basis of (1), the alcohol concentration of blood or exhaled gas is 1 1mmol/L(50mg/dL).
(3) Clinical classification of acute alcoholism
Mild (simple drunkenness):
There are only nervous system manifestations of emotional and linguistic excitement, such as incoherent speech but no aggressive behavior, walking, but mild motor incoordination, drowsiness can be awakened, simple answers are basically correct, and nerve reflexes are normal.
Moderate: One of the following conditions is moderate alcoholism.
(1) lethargy or coma or Glasgow coma score is greater than 5 and less than 8;
(2) Manic or aggressive behaviors that cannot be alleviated by language or psychological counseling;
(3) unconsciousness, weakened nerve reflex and severe ataxia;
(4) false hallucinations or seizures;
⑤ Blood biochemical examination shows one of the following metabolic disorders, such as acidosis, hypokalemia and hypoglycemia;
⑥ On the basis of mild poisoning, organ function is obviously damaged, such as arrhythmia (frequent premature beats, atrial fibrillation or atrial flutter) related to alcoholism. ), myocardial injury (ST-T abnormality, myocardial enzymology increased by more than 2 times) or upper gastrointestinal bleeding, pancreatitis, etc.
Severe: One of the following conditions is severe alcoholism.
(1) Glasgow score less than 5 in coma;
② The manifestations of insufficient microcirculation perfusion, such as pale face, cold skin, purple lips, increased heart rate, weak or inaccessible pulse, compensatory increase or decrease of blood pressure (less than 90/60mmHg or systolic blood pressure decreased by more than 30mmHg compared with the basic blood pressure, 1mmHg=0. 133kPa), and coma accompanied by shock and clinical manifestations in decompensated period is also called extremely severe.
③ Serious manifestations of metabolic disorder, such as acidosis (pH≤7.2), hypokalemia (serum potassium ≤2.5mmol/L) and hypoglycemia (blood sugar ≤ 2.5 mmol/L);
④ Acute dysfunction of heart, liver, kidney, lung and other important organs.
The classification of poisoning degree is mainly clinical manifestations, and the concentration of alcohol in blood can be used as a reference. The tolerance of different races and individuals varies greatly, and sometimes it is not completely consistent with clinical manifestations.
The lethal dose of ethanol to adults is 250~500g, and the tolerance of children is low. The lethal dose of ethanol is 6~ 10g for infants and 25g for children. The absorption rate and clearance rate of alcohol vary from person to person, depending on many factors, such as age, sex, weight, physique, nutritional status, smoking, diet, existing food in the stomach, gastric motility, ascites, liver cirrhosis and long-term alcoholism.
The clearance rate of alcohol in blood varies from person to person. The alcohol clearance rate of chronic drinkers is as high as 7.7 mmol/h [36 mg/(dl h)], while that of general emergency patients is only about 4.3 mmol/h [20 mg/(dl h)].
At the time of first diagnosis in emergency, the blood alcohol concentration of mild poisoning is usually16 ~ 33 mmol/L (75 ~150 mg/DL), and that of severe poisoning is above 43mmol/L (200mg/dL). Due to individual differences, a small number of patients show pathological drunkenness, that is, after drinking a certain amount of alcohol, serious psychopathological abnormalities will occur.
It mostly happens to people who have no habitual drinking. After drinking a small amount, they show anxiety and rage, causing paranoid or aggressive behavior, often with hallucinations and delusions, which are extremely out of harmony with the environment and objective reality at that time. They usually end in a few hours, often ending in deep sleep, and are classified as moderate poisoning after the attack.
3. Diagnostic considerations
(1) Diagnostic principles and differential diagnosis
Acute alcoholism is the only diagnosis. Before the diagnosis of alcoholism, hypoglycemia, hypoxemia, hepatic encephalopathy and mixed alcohol overdose should be considered. The possibility of occult head trauma and metabolic disorder should be considered after diagnosis. Doctors can get a complete medical history from the accompanying family members, and make repeated physical examinations and auxiliary examinations to confirm the diagnosis.
(2) compound poisoning
It is not uncommon for alcoholics to take other drugs and poisons again after losing control of their emotions. Alcohol aggravates the toxicity of sedative and hypnotic drugs and organophosphorus pesticides, and reduces the toxicity of methanol, ethylene glycol and fluoroacetamide. The toxicity of paraquat after drinking remains to be discussed.
(3) Inducing pathological changes or complications
Trauma after acute alcoholism is common, and it is easy to miss diagnosis because patients and caregivers can't clearly describe the medical history. Acute alcoholism can aggravate the existing basic diseases, such as inducing acute coronary syndrome, hemorrhage or ischemic stroke, complicated with gastric mucosa tearing, upper gastrointestinal bleeding, arrhythmia, pancreatitis, rhabdomyolysis syndrome and so on. , but also complicated with digestive tract perforation. Obtaining detailed medical history as much as possible, systematic and meticulous examination and necessary auxiliary examination are conducive to reducing missed diagnosis and misdiagnosis.
(4) Disulfide-like awakening reaction
Patients who drink alcohol during the application of certain drugs or after drinking certain drugs have similar reactions to those after taking Disulfiram (also known as Disulfiram), and most of them develop symptoms within 0.5h after drinking, mainly manifested as facial flushing, headache, chest tightness, shortness of breath, increased heart rate, limb fatigue, sweating, insomnia, nausea, vomiting, blurred vision, decreased blood pressure, and severe dyspnea.
It may be related to the inhibition of acetaldehyde dehydrogenase and the increase of acetaldehyde concentration in the body, which leads to vasodilation. The clinical manifestations of disulfiram-like reaction vary greatly among individuals, and the symptoms usually last for 2 ~ 6 hours without drug treatment. Disulfide-like arousal reaction is similar to many diseases, which is easy to cause misdiagnosis, so we should pay attention to differential diagnosis.
4. Treatment of acute alcoholism
(1) Simple acute mild alcoholism needs no treatment.
Home observation, obesity, poor ventilation and other basic diseases should be told to keep warm, lie on your side, prevent complications such as vomiting and aspiration, and those with severe Disulfiram-like awakening reaction should be treated as soon as possible.
(2) Measures to promote alcohol excretion in digestive tract
Because of the rapid absorption of alcohol, vomiting, gastric lavage and activated carbon are not suitable for patients with simple alcoholism. Gastric lavage should evaluate the condition and weigh the advantages and disadvantages. Suggestions are limited to one of the following situations: ① There is no vomiting within 2 hours after drinking, and the coma patients whose condition may deteriorate are evaluated; (2) coexistence with other drugs or poisons or high suspicion of poisoning; ③ The gastric tube has been indwelling, especially in patients with coma and shock. The gastric tube can be used for artificial gastric lavage.
(3) drug therapy
Metadoxine is a drug to promote alcohol metabolism and an activator of acetaldehyde dehydrogenase, which can antagonize the decrease of alcohol dehydrogenase (ADH) activity caused by acute and chronic alcoholism. It can accelerate the excretion of ethanol and its metabolites acetaldehyde and ketone bodies, and belongs to drugs for promoting alcohol metabolism.
Metadoxine can resist the decrease of ATP and intracellular reduced glutathione (GSH) caused by acute alcoholism, maintain the balance of antioxidant system in vivo, antagonize the oxidative stress caused by acute and chronic alcoholism, improve the liver function damage caused by drinking, and improve the psychological and behavioral abnormalities caused by alcoholism. Metadoxine can be used for patients with moderate and severe alcoholism, especially those with aggressive behavior and emotional abnormalities.
0.9g/ time, given by intravenous drip, forbidden for lactating patients and patients with bronchial asthma, and there is no reliable data for children's application. Proper rehydration and vitamin B 1, B6 and C are beneficial to the oxidative metabolism of alcohol.
② Naloxone, a sober drug, can specifically antagonize various effects mediated by endogenous morphine-like substances. Some foreign studies doubt its curative effect on acute alcoholism. But experts in this field believe that naloxone can relieve the central inhibition of alcoholism and shorten the coma time. The difference of curative effect may be related to ethnic differences and dosage.
It is suggested that the first dose of moderate poisoning should be 0.4~0.8mg plus 10~20mL of normal saline for intravenous injection; Repeat the dose if necessary; In severe poisoning, the first dose of 0.8~ 1.2mg plus 20mL of normal saline was injected intravenously. After 30 minutes, it can be repeated 1 time, or 2mg plus 5% glucose or physiological saline in 500mL, and injected intravenously or by micropump at a speed of 0.4mg/h until consciousness is awake.
Namephen hydrochloride is a long-acting opioid receptor antagonist with high selectivity and specificity, and it has good therapeutic effect in theory. It has been reported that it is used in acute alcoholism, but more clinical research is needed to evaluate its therapeutic effect and application method in acute alcoholism.
③ Sedatives should be used with caution in acute alcoholism. Diazepam can be used in cases of irritability or overexcitation. Intramuscular injection is safer than intravenous injection. Pay attention to breathing and blood pressure. The first generation antipsychotic drugs such as haloperidol are the first choice for manic patients, and the second generation such as olanzapine should also be a feasible choice. Oral administration is safer than intravenous injection. Avoid chlorpromazine, morphine and phenobarbital sedatives.
④ Gastric mucosal protective agent: Patients with severe poisoning can routinely use gastric mucosal H2 receptor antagonists or proton pump inhibitors, especially those with obvious digestive tract symptoms. Proton pump inhibitors may have a better protective effect on gastric mucosa.
(4) Blood purification therapy and indications:
Alcohol is soluble in water and has strong lipophilicity. It is controversial that hemoperfusion can remove ethanol from the body. Hemodialysis can directly and quickly remove ethanol and its metabolites from blood. It is suggested that hemodialysis should be the first choice when necessary, and continuous bedside hemofiltration (CRRT) is also a feasible choice, but it is expensive. Blood purification treatment is feasible if the condition is critical or worsens after routine treatment, and in any of the following circumstances.
① Blood alcohol content exceeds 87 mmol/L (400 m dl); ② Deep coma with severe respiratory and circulatory depression; ③ acidosis (pH 7.2) with shock; ④ Acute renal insufficiency caused by severe poisoning; ⑤ If poisoning or other poisoning is highly suspected to be life-threatening, the blood purification method should be selected as appropriate according to the characteristics of poisons.
(5) Application of antibiotics:
There is no indication to use antibiotics to treat simple acute alcoholism unless there is clear evidence of concurrent infection, such as vomiting and aspiration leading to lung infection. Note that the use of antibiotics can induce disulfiram-like reactions, among which cephalosporins are the most common among β-lactams, cefoperazone is the most common, and others are metronidazole and furazolidone, so it is advisable to stay in hospital for observation during medication.
(6) Symptomatic and supportive treatment
The airway and ventilation function should be evaluated in patients with lethargy and coma, and tracheal intubation is necessary. To do a good job in patient safety protection, if necessary, give appropriate protection and restraint to those who are agitated or excited, pay attention to keeping warm, lie on the side of the coma to prevent catching cold and heatstroke, and use bed bars to prevent accidents. Maintain the balance of water, electrolyte and acid-base, correct hypoglycemia and brain edema, give dehydrating agent, and apply traditional Chinese medicine Xingnaojing.
5. Matters needing attention in emergency handling
In the diagnosis and treatment of acute alcoholism, we should not only avoid delaying diagnosis and treatment due to insufficient evaluation of the condition, but also avoid excessive medical treatment and waste of resources. Third-class hospitals should have special sober-up observation rooms to meet the clinical needs of the increasing number of acute alcoholism cases.
(1) Indications for hospitalization observation:
Hospitalization observation or hospitalization is suitable for patients with moderate and severe poisoning.
(2) Reasonable application of auxiliary inspection:
In moderate and severe poisoning, blood electrolytes and glucose concentration should be routinely checked. If conditions permit, it is feasible to carry out blood gas analysis and determine the alcohol concentration in blood or exhaled gas. Those with basic diseases or complications should be examined accordingly.
In general, head CT examination should be carried out under the following circumstances:
① Coma patients who have a history of head trauma but can't explain the specific situation in detail; ② those who show signs of neurolocalization after drinking; ③ The alcohol consumption or alcohol concentration is inconsistent with the disturbance of consciousness; ④ After routine treatment such as naloxone to wake up for 2 hours, the state of consciousness did not improve, but worsened.
Patients with acute alcoholism who are unconscious or unable to accurately describe their medical history should have routine electrocardiogram examination, especially those with previous heart disease history or high-risk factors, and be reexamined when necessary.
(3) Precautions for pre-hospital first aid:
Pre-hospital first aid should pay attention to the incidence of acute alcohol and study countermeasures. (1) When answering the call for help of acute alcoholism, ask the patient whether he is conscious or not, and whether he is accompanied by vomiting; (2) In case of vomiting, the personnel present should be instructed to change the patient's position, so that the head leans to one side, _ to clear the oral contents and avoid suffocation; (3) In case of unconsciousness and cardiac arrest, the patient's family members and witnesses should be instructed to keep the patient's respiratory tract unobstructed and perform cardiopulmonary resuscitation.
On-site treatment and transportation should closely observe vital signs, pay attention to airway patency, maintain respiratory and circulatory functions, and learn as much as possible about the injury history of drunk traffic accidents. The occupation of pre-hospital emergency resources by alcoholics should attract social attention.
(4) Education:
In view of the increase of alcohol abuse and the effect of emergency intervention, emergency medical staff should take the harm of alcohol and abstinence education as part of their work. According to the different psychological conditions of patients, communicate with patients and their caregivers in time, carry out health education, and publicize the harm of alcoholism to patients and their families after patients are awake and emotionally stable. Medical staff should protect themselves and pay attention to safety when receiving medical treatment.
6. Prognosis of acute alcoholism
Different kinds of alcohol do different harm to human body. Acute alcoholism can survive for more than 24 hours after treatment and can be recovered. Such as changes in heart, lung, liver and kidney, coma duration exceeding 10h, or blood alcohol concentration exceeding 87mmol/L(400mg/dL), poor prognosis, and prolonged course of severe pancreatitis and rhabdomyolysis.
The main causes of death are as follows. ① Drunk trauma, especially intracranial hemorrhage, is a common cause of death in hospital; ② Stroke and myocardial infarction induced by acute alcoholism are also common causes of death and disability; (3) It is not uncommon to vomit and suffocate after poisoning. If you can't intubate in time, you can die quickly.
7, the harm of alcoholism
1, central nervous system injury
Alcohol acts on the central nervous system, causing a series of symptoms. Cerebellar paralysis leads to unstable walking and drunken gait; Alcohol inhibits the brain and nerves, which easily leads to trance, fatigue, auditory hallucinations, hallucinations, memory loss and mental decline.
2. Liver damage
Alcohol decomposes and detoxifies through the liver, causing fatty liver and alcoholic hepatitis; Alcohol can cause liver cell degeneration, necrosis and fibrous tissue hyperplasia, leading to alcoholic cirrhosis or inducing liver cancer.
3. Kidney damage
After drinking, the kidney will directly transport water to the bladder without reabsorption, and the loss of water is equivalent to four times of the intake of water. It can also reduce the function of kidney, cause toxin accumulation, lead to oliguria, even nephritis, kidney calculi's disease and uremia.
4. Gastrointestinal injury
When alcohol enters the stomach, it will accumulate on the stomach wall after absorption and continue to harm the stomach. If you drink a lot at a time, it may cause acute gastritis, gastric ulcer, erosion or bleeding. Nausea and vomiting are common after drunkenness, and pyloric spasm caused by high alcohol concentration in the stomach is one of the reasons.
5, cardiovascular system damage
Excessive glutamate produced by drinkers leads to excitement, trembling, anxiety and hypertension, and then coronary heart disease, angina pectoris or myocardial infarction. Drinking alcohol will accelerate blood circulation, vasodilation, cerebral hemorrhage and stroke. Dehydration can cause headaches, and the contraction of the brain can affect the diaphragm connecting the brain and the skull, thus causing pain.
6. Endocrine system
Alcohol metabolism will be accompanied by the change of NADH/NAD ratio, galactose tolerance will decrease, triglyceride synthesis will increase, and lipid peroxidation will increase, so hypoglycemia will occur after drinking. When ethanol enters the liver, it will inhibit the transformation of hepatic glycogen into glucose and transport it to the blood, and it will also block the way for the body to maintain fasting blood sugar. Diabetic patients who normally take hypoglycemic drugs are more likely to have hypoglycemia due to fasting drinking because of the hypoglycemic effect of drugs.
7. Acute alcoholism
(1) Symptoms of headache, fatigue and nausea when the content of salt and potassium required for nerve and muscle maintenance is too low. Patients with chronic alcoholism have "withdrawal symptoms" after sudden abstinence, which are manifested as confusion, excitement, panic and hallucination, accompanied by delirium, convulsions, fever, sweating, elevated blood pressure, tachycardia, rough tremor of tongue, lips and limbs and dilated pupils.
(2) Chronic alcoholic polyneuropathy is a common complication of chronic alcoholism. May involve motor, sensory and autonomic nerves. It usually occurs after cognitive dysfunction in patients with chronic alcoholism 10 years, and the incidence rate accounts for about 34% of patients with chronic alcoholism.
(3) Toxic cerebellar degeneration is characterized by dyskinesia, limb ataxia and dysarthria. Patients with long-term drinking and chronic alcoholism have myalgia and swelling, and may have dyskinesia and painful spasm, accompanied by weakening or disappearance of tendon emission.
(4) Alcoholic dementia is the main characteristic dementia caused by the chronic influence of alcohol on brain tissue. It is an organic brain injury caused by long-term heavy drinking, which is characterized by tremor, delirium, spasm, personality change, mental retardation, memory disorder and so on.
(5) Alcoholic optic neuropathy, Wernicke encephalopathy, central pontine myelinolysis, Korsakov syndrome, etc.
Generally, gastric juice should be washed with 1% sodium bicarbonate solution or warm boiled water. The amount of gastric juice should not be too much, and the total amount should be 200mL-4000 ml at a time, so that the gastric contents can be sucked clean. Pay attention to airway protection during gastric lavage to prevent vomiting and aspiration.