Snapshot A 22-year-old male is brought in by police after being removed forcefully from a bar. According to the police report, the patient had fallen several times during an altercation with another bar patron. In the ED, he is agitated and cannot follow questions. Introduction One of the most commonly abused substances Particularly dangerous when combined with stimulants (caffeine, cocaine) Presentation Symptoms (in order of increasing EtOH plasma level) disinhibition emotional lability slurred speech gait disturbances blackouts coma Evaluation Blood alcohol level Treatment Pharmacologic nutritional - in chronic alcoholics or if you suspect deficiency thiamine must give prior to glucose administration folate multivitamin sedative-hypnotics with taper (for agitation) e.g., clonidine or propranolol haloperidol if severe aggression or psychosis intubation - if airway loss is concern withdrawal long-acting benzodiazepines with taper addiction disulfiram inhibits acetaldehyde dehydrogenase → aversive conditioning naltrexone decreases desire to drink gabapentin topiramate also an anti-seizure and anti-migraine medication Prognosis, Prevention, and Complications Complications Mallory-Weiss syndrome repeat wretching/vomiting causes bleeding of mucosa best initial step: IV fluids best next step: endoscopy for diagnosis, photocoagulation, rubber band ligation for treatment ultimate refractory therapy: Blakemore catheter (usually the WRONG answer) Boerhaave Syndrome - esophageal perforation (repeat vomiting) best next step: gastrografin swallow followed by surgical repair (after ABC's) Wernicke-Korsakoff syndrome best next step: thiamine, multivitamin, IV fluids followed by glucose (order matters) may require mechanical ventilation much greater risk of physical harm e.g., homicides, suicide, car accidents, fires, etc. ED Management Inpatient Management Chronic Management Prevent further ethanol intake Prevent individual from harming self or others Sedate patient if agitated or aggressive Order urine toxicity screen Stabilize vitals if necessary Administer (in order) thiamine and Mg2+ multivitamin B12/folate IV fluids + dextrose Begin CIWA and benzodiazepine taper if signs of withdrawal Do not administer medications that lower seizure threshhold (bupropion, haloperidol) Begin psychotherapy (must occur with medications) individual group (AAA) Begin medication immediately disulfiram naltrexone acamprosate gabapentin topiramate