Alcohol-Related Emergencies (ALS) >

History Of Present Illness

Your EMS crew is dispatched to the scene of an apparently intoxicated 30-year old
man that has fallen in his garage. He states that he hit his head against the floor
when he fell. There has been no loss of consciousness, no nausea or vomiting. He
denies any neck pain. When questioned, he says nothing else hurts and he has no
other complaints. He has not been ill recently. He tells our crew that he had about
24 beers earlier in the day and that he called 911 himself. The scene is secure.

Past medical history:  Cirrhosis

Medications:  None 

Allergies:  None 

Social history:  Smokes 1 pack per day, 24 beers per day, no drugs

Last meal:  3 hours ago

Vital signs:

 Temp  98.6°F (37°C)

 BP  130/72

 Resp  16

 Pulse  84

 O 2 sat  99% on room air

Blood sugar:  150 mg/dL (8.33 mmol/L)
Physical Exam

General:  Calm, cooperative, non-threatening 

HEENT:  Pupils are equal and reactive to light, extraocular motions intact, no JVD,
non-bleeding 2-3 cm facial lacerations
Neck:  No midline tenderness 
Lungs:  Clear bilaterally
Cardiac:  Regular rate and rhythm, no bruising to chest wall 
Abdomen:  Soft, non-tender, no bruises or signs of trauma 
Back:  No evidence of trauma, non-tender
Extremities:  No evidence of trauma, non-tender
Skin:  Warm and dry, no other wounds
Neuro:  Alert and oriented x3, no motor deficits, nonfocal exam, no facial
asymmetry, speech is slurred

Assessment Of This Case

In this scenario, the crew arrives on scene and is presented with a 30-year old male
sit- ting on the floor in his garage. He states that he fell and hit his head while
working on his lawnmower. The  lead  medic notices that the floor is littered with
beer cans and that the patient, while cooperative, appears to be intoxicated. In
addition, he notes the presence of some flammable liquids in close proximity to a
burning ashtray in the garage area so he immediately calls for a scene survey to
ensure scene safety.
As EMS personnel, you are frequently called to respond to situations where alcohol
is involved. Alcohol is the most commonly used and abused  drug  in the U.S. more
than 100 million Americans regularly consume alcohol. 2  It contributes to about
100,000 deaths per year and is a contributing factor in an astounding 40% of motor
vehicle accident deaths. It is not surprising that we as EMS professionals commonly
interact with the patient that is either under the influence of alcohol or suffering
from the ill effects of alcohol abuse. Studies show that a staggering 15-40% of
Emergency Room patients have alcohol detected in their blood. An important
teaching point is that alcohol intoxication can be a challenge with patient
assessment because it often masks critical  symptoms , which aid in making a
diagnosis. It is critical when you are treating a patient with an alcohol-related injury
to be extremely thorough. It is important to look beyond a patient’s
obvious  signs  and symptoms and to be a real detective to ensure that
serious  injuries  do not go undetected.
Our patient’s airway is clear, breathing is normal, and pulses are regular. Alcohol is
immediately suspected, as the crew smells an odor of beer on the patient’s breath,
notice the  physical evidence  littered about the garage, and observes our
patient’s  behavior . An important teaching point in this scenario is the need for
cervical spine immobilization at the very beginning of the call. Notice how the crew
in this situation correctly performs cervical spine immobilization with a standing
takedown while simultaneously perform- ing the ABCs.
Encountering intoxicated patients is not uncommon for EMS professionals. Being
famil- iar with the many potential pitfalls in treating the alcoholic patient is very
important for the practicing EMS professional. The fact that our patient admits to
drinking and appears intoxicated changes a seemingly simple fall into a much more
potentially com- plicated call.

Facts About Alcohol

 Most frequently used and abused intoxicant in the U.S.

 40% of motor vehicle fatalities related to ethanol

 25% of interpersonal trauma involve ethanol use

 Ethanol is commonly involved in domestic abuse

In 2007, According To The U.S. Poison Control Centers:

 Toxic adult dose of ethanol is 5 mg/dl

 Toxic pediatric dose of ethanol is 3 mg/dl

 Children are at higher risk of developing hypoglycemia with ethanol

intoxication

 7,447 cases of isopropanol ingestions

 Most isopropanol ingestions are found in children under 6 ears old

 2,252 cases of methanol ingestions

 5395 cases of ethylene glycol ingestions

 Most cases of methanol and ethylene glycol ingestions occur in adults older
than 19 years old.

 These numbers underestimate the true incidence of exposure due to the

large number of unreported cases

Alcohol Intoxication

Don't be fooled. There are many possibilities that can mimic alcohol intoxication
– hypoglycemia, hyperglycemia, intracerebral bleeding (i.e. subdural hematoma),
diabetic ketoacidosis, sepsis, meningitis, encephalitis, stroke, overdoses,
and metabolic abnormalities. The teaching point here is to thoroughly evaluate the
patient, and avoid making assumptions that may lead you down the wrong path. Be
thorough, do not make assumptions, avoid putting on blinders, and your chances of
making an unnecessary error in judgment will be significantly decreased.
Alcoholism And Liver Disease

It is important to ask the patient with potential alcohol abuse about any history of

liver disease. Alcoholics are susceptible to liver disease, which may vary from
alcohol hepatitis, an inflammation of the liver as a result of alcohol abuse, to
cirrhosis and liver failure. Alcoholics with liver disease may have an increased
tendency to bleed as many of the clotting factors in the blood are manufactured in
the liver. Alcoholics may also have low platelet counts, which can cause an
increased incidence of bleeding. The teaching point here is that the alcoholic patient
is the perfect set-up for serious bleeding injuries that can "fly under the radar". The
reason patients under the influence of alcohol are so challenging is that alcohol
intoxication can mask symptoms, with decreased perception of pain, and an
increased tendency to bleed – the perfect set-up for disastrous results.

Immediate Treatment

 Scene safety

 ABCs

 Maintain cervical spine immobilization

 History

 Vital signs

 Physical examination

 Dress facial wounds

 If paramedic care is available: IV, EKG, Blood sugar evaluation

 Frequent re-evaluations

Personal Protective Equipment

In a situation like this one it should be an automatic reflex to utilize personal

protective equipment like gloves and eye protection. You always want to protect
yourself from both body fluid exposures and infection.

Observations From Dr. Katz

"Always ask about alcohol use when you are taking a patient's social history. You
never know what information you will get just by asking. I can't count the number
of times I've innocently asked the elderly fall patient in the Emergency Department
if they drink, and to then be surprised to learn that they are heavy drinkers. Elderly
and homebound patients are not uncommon candidates for alcohol abuse. Even
when you don't think it is likely, always ask about alcohol! Remember, a trauma
patient that has consumed alcohol may be hiding other injuries because of their
alcohol intoxication. Another complicating factor when treating the alcohol
intoxicated patient is that these patients sometimes abuse other drugs as well. The
most commonly used drug in combination with alcohol is cocaine. Taking a careful
history will often reveal these valuable pieces of information, helping you avoid
making a mistake."

Pearls Of Wisdom

It is important to keep in mind when alcohol is suspected that intoxicated patients

may not experience pain even when they are severely injured. When you are
working with a trauma patient and alcohol might have been involved, you should
upgrade your suspicion that the patient may have a serious underlying injury. If
there is any possibility of a cervical spine injury, the patient should be fully
immobilized.

Do not make assumptions with the patient that you assume has symptoms of
alcohol withdrawal. Other issues which mimic the symptoms of alcohol withdrawal
include acute psychosis, meningitis/encephalitis, anticholinergic poisoning, and
withdrawal from sedatives (i.e. benzodiazepines)

What Is Your Treatment Plan?

Your treatment plan in this scenario is to maintain scene safety, dress the wounds,
and keep the patient safely positioned to avoid any unsafe behavior and to
transport to the nearest appropriate receiving facility. In this scenario, the patient
willingly agreed to be transported to the hospital without debate or resistance. In
many cases, this is not the case and the patient may need to be taken to the
hospital against their will. Most jurisdictions allow involuntary transport to the
hospital of patients deemed intoxicated, or at risk of hurting themselves or others.
This is a topic that is best reviewed with your agency and medical director to review
your agency’s policies and procedures about transporting a patient to the hospital
against their will that is not considered mentally competent. While en route,
continue to assess and reassess your patient’s vital signs and general condition.

 Common Clinical Findings In Alcoholics

 Increased bleeding tendencies

 Gastrointestinal bleeding
  Pancreatitis (usually presents with midepigastric abdominal pain)

 Liver failure

 Hypoglycemia

Tip Of The Month

Don't make the assumption that a patient's symptoms are all secondary to alcohol
intoxication. Consider the possibility of trauma, internal injuries, diabetic-related
emergencies, infection, metabolic disorders, and other possibilities to explain the
patient's symptoms.

What Happened To Our Patient?

Our patient had a subdural hematoma and a cervical spine fracture. It is interesting

to note that our patient never complained of neck pain. This is an extremely
important teaching point. Patients that are intoxicated often do not feel pain even if
they are severely injured. Any trauma patient with any suspicion of a spinal injury
should be fully immobilized and closely monitored. Treating the alcohol-impaired
patient can be extremely difficult. Alcoholic patients can vary from behavior that is
dangerous and aggressive, to mild mannered and calm. However, if you are
thorough in your approach, avoid making assumptions, and are aware of the
potential pitfalls of treating the alcohol intoxicated patient, you will find yourself
well-armed to treat this challenging subset of EMS patients.

Alcohol Withdrawal

Alcohol withdrawal should be considered in alcoholic patients that have evidence of

CNS stimulation. Usually begins 6-24 hours after a decrease or cessation in
an alcoholic’s usual ethanol intake.

 Minor withdrawal  – nausea, loss of appetite, mild

tremors, tachycardia, hypertension, anxiety, difficulty sleeping.

 Major withdrawal  – disorientation, hallucinations, sweating, fever, more

pronounced tachycardia and hypertension, fever.

 Delirium tremens  – rare. Gross tremors, significant confusion, fever,

incontinence, hallucinations, and dilated pupils. Mortality rate
15%. Benzodiazepines can be considered in prehospital setting.

Other Alcohols
Other alcohols, besides ethanol, may mimic the clinical presentation of ethanol.
They may be consumed as an attempt to get intoxicated when ethanol is not
available, as a suicide attempt, or by accident.

Isopropanol

 Commonly found in rubbing alcohol, industrial solvents, many skin and hair
products

 Twice as potent as ethanol

 Duration of action is 2-4 times longer than ethanol

 Large ingestions may cause hypotension and upper GI bleeding

 Sometimes agent used in suicide attempts

 Patients may have a fruity odor of acetone or odor of rubbing alcohol on

breath

 Children are very susceptible to its toxicity, even with minimal ingestions

Methanol

 Found in many industrial solvents; product of wood distillation

 Distinctive odor

 Very toxic; death can occur with very small ingestion

 Symptoms may be delayed for 12 to 18 hours after ingestion

 Clinical presentation may include hypotension, bradycardia, visual

disturbances (including blindness), abdominal pain, nausea, and vomiting,
altered mental status

Ethylene Glycol

 Commonly found in antifreeze

 Sweet tasting

 Symptoms may include CNS depression (may appear drunk), slurred speech,
hallucinations

 May not have scent on breath

 Common symptoms: tachycardia, hypertension, tachypnea

Taking a good clinical history, performing a thorough scene survey, and looking for
important clues can help uncover the possibility of ingestions that may mimic
ethanol (i.e. isopropanol, methanol, ethylene glycol).

Clinical Spectrum Of Ethanol Consumption

 Lack of inhibitions

 Diminished fine motor control

 Impaired judgment

 Impaired coordination

 Slurred speech

 Gait and balance disturbance

 Altered mental status

 Coma

 Respiratory depression

Alcohol Is A CNS Depressant

Symptoms often include slurred speech, lack of inhibitions, and decreased motor
coordination/control. Decreased peripheral vascular resistance can sometimes
result in hypotension, particularly with standing. This is why folks that are
intoxicated from alcohol will sometimes fall down when they suddenly stand from a
sitting position. Respiratory depression and hypoglycemia may also be seen.

Taking A History From Patients With Apparent Alcohol Intoxication

 Have you drunk any alcohol today? How much?

 Do you have a history of diabetes or hypoglycemia?

 Any fall or recent trauma?

 Do you have a headache? Neck pain?

 How much do you drink on a daily basis?

 Did you take any medications?

 Have you taken any pills or chemicals or drugs?

 Have you been treated for liver disease or bleeding abnormalities?

Glossary

Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may

be physical, sexual, psychological, or financial/material.
Anticholinergic  : Of or pertaining to the blocking of acetylcholine receptors, resulting
in inhibition of transmission of parasympathetic nerve impulses.
Behavior  : The way people act or perform, for example how they react/respond to a
situation.
Benzodiazepines  : Any medications of a group of psychotropic agents used as
antianxiety, muscle relaxants, sedatives, or hypnotics.
Body  : In the context of the uterus, the portion below the fundus that begins to
taper and narrow.
Clotting Factors  : Substances in the blood that are necessary for clotting; also called
coagulation factors.
Depression  : A persistent mood of sadness, despair, and discouragement; may be a
symptom of many different mental and physical disorders, or it may be a disorder
on its own.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate
circumstances and in the appropriate dose.
Drugs  : Any chemical compounds that may be used on humans to help in diagnosis,
treatment, cure, mitigation, or prevention of disease or other abnormal conditions.
Hematoma  : An accumulation of blood in the tissues beneath the skin; a potential
complication of IV therapy.
Hypoglycemia  : Abnormally low blood glucose level.
Incidence  : The frequency with which a disease occurs.
Injuries  : Any unintentional or intentional damage to the body resulting from acute
exposure to thermal, mechanical, electrical, or chemical energy or from the absence
of such essentials as heat or oxygen.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG
that shows the electrical conduction in the heart.
Metabolic  : Pertaining to the breakdown of ingested foodstuffs into smaller and
smaller molecules and atoms that are used as energy sources for cellular function.
Mortality  : Deaths caused by injury and disease. Usually expressed as a rate,
meaning the number of deaths in a certain population in a given time period divided
by the size of the population.
Patient History  : Information about the patient's chief complaint, present symptoms,
and previous illnesses.
Perception  : The way a person processes the data supplied by the five senses.
Physical Evidence  : The evidence that ties a suspect or victim to a crime. It may
include body materials, objects, and impressions.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
and so on.
Subdural Hematoma  : An accumulation of blood beneath the dura but outside the
brain.
Suicide  : Any willful act designed to bring an end to one's own life.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Tachycardia  : A rapid heart rate, more than 100 beats/min.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result
of the rapid dissipation of energy delivered by an external force.

References


Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-Hill.
 Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th ed.). Massachusetts:
Jones and Bartlett Publishers.
 Levine, M.D. (Updated 2012, March 12). emedicine.medscape.com “Alcohol Toxicity Differential
Diagnosis” retrieved from emedicine.medscape.com/article/812411- differential.