Showing posts with label alcohol. Show all posts
Showing posts with label alcohol. Show all posts
Tuesday, 5 November 2013
Alcohol Mnemonics
CAGE
yes to 3/4 indicates dependence
Cut down
Angry
Guilty
Eye opener
Paddington Alcohol Test (PAT)
1. Quite a few people have times when they drink more than usual - what is the most (in total number of units per day) you will drink in any one day?
2. If you drink more than 8 units a day for men or 6 units a day for women is this at least once a week?
If yes, PAT positive –> alcohol advice
If no, question 3
3. Do you feel your current attendance at the emergency department is related to alcohol?
Yes –> PAT positive
No –> interpret carefully
Hazardous drinking: more than twice the recommended daily limit. Advice and information.
Dependent drinking: more than twice recommended daily limit every day, or other signs of dependence. Do not benefit from brief intervention.
Signs of dependence –> compulsion to drink
Signs of tolerance --> repeated failed attempts to stop drinking?
CIWA score - out of 67
Nausea and vomiting
Tactile disturbances
Tremor
Auditory disturbances
Paroxysmal sweats
Visual disturbances
Anxiety
Headache, fullness in head
Agitation
Reduced orientation and clouding of senses Risk assessments
characteristic of the act of self-harm - violence, evidence of planning
characteristic of the person - intention to die, previous self-harm, mental illness or personality disorder, substance misuse.
social circumstances and provoking events
SAD PERSONS
Sex: male 1
Age: 15-24, 45-54, >75 1
Depression/hopelessness 1
Prior history 1
Ethanol 1
Rational thinking loss 1
Support system lack 1
Organised plan 1
No significant other 1
Sickness (cancer, HIV) 1
0-2 Discharge with follow up
3-4 Discharge with close monitoring
5-6 Consider admission
7-10 Definite admission
DSM-IV criteria for major depression
5 or more = major depressive episode
Low mood for most of the day every day
Fatigue
Recurrent suicidal ideation
Lack of concentration
Weight loss >5%
Low self-esteem
Disturbed sleep
Weight loss
Loss of interest
Agitation
(Loss of libido, poor concentration also worth asking about)
All Brides Should Make Tea Cakes in Summer
Appearance
Behaviour - remember to ask about circumstances leading to hospital attendance, if the act had any significance, and if they believed their behaviour is strange or unusual.
Speech - pressure of speech, knight’s move thinking, clang associations, word salad
Mood
Thought - worthlessness, low self-esteem, flight of ideas, delusions of grandeur, delusions
Cognition - orientation, memory, concentration, calculation skills. Spell world backwards.
Insight - are you ill?
Summary - don’t forget focussed medical and psychiatric history.
Sections
Section 2
Compulsory admission for up to 28days
2 practitioners (one approved)
Application made by social worker or nearest relative
Section 4
Emergency section when an urgent admission is required
To be used when the patient poses a significant risk to others or themselves
Can be used when there is not enough time to get a second medical practitioner.
Section 5(2)
Cannot be used in the emergency department.
yes to 3/4 indicates dependence
Cut down
Angry
Guilty
Eye opener
Paddington Alcohol Test (PAT)
1. Quite a few people have times when they drink more than usual - what is the most (in total number of units per day) you will drink in any one day?
2. If you drink more than 8 units a day for men or 6 units a day for women is this at least once a week?
If yes, PAT positive –> alcohol advice
If no, question 3
3. Do you feel your current attendance at the emergency department is related to alcohol?
Yes –> PAT positive
No –> interpret carefully
Hazardous drinking: more than twice the recommended daily limit. Advice and information.
Dependent drinking: more than twice recommended daily limit every day, or other signs of dependence. Do not benefit from brief intervention.
Signs of dependence –> compulsion to drink
Signs of tolerance --> repeated failed attempts to stop drinking?
CIWA score - out of 67
Nausea and vomiting
Tactile disturbances
Tremor
Auditory disturbances
Paroxysmal sweats
Visual disturbances
Anxiety
Headache, fullness in head
Agitation
Reduced orientation and clouding of senses Risk assessments
characteristic of the act of self-harm - violence, evidence of planning
characteristic of the person - intention to die, previous self-harm, mental illness or personality disorder, substance misuse.
social circumstances and provoking events
SAD PERSONS
Sex: male 1
Age: 15-24, 45-54, >75 1
Depression/hopelessness 1
Prior history 1
Ethanol 1
Rational thinking loss 1
Support system lack 1
Organised plan 1
No significant other 1
Sickness (cancer, HIV) 1
0-2 Discharge with follow up
3-4 Discharge with close monitoring
5-6 Consider admission
7-10 Definite admission
DSM-IV criteria for major depression
5 or more = major depressive episode
Low mood for most of the day every day
Fatigue
Recurrent suicidal ideation
Lack of concentration
Weight loss >5%
Low self-esteem
Disturbed sleep
Weight loss
Loss of interest
Agitation
(Loss of libido, poor concentration also worth asking about)
All Brides Should Make Tea Cakes in Summer
Appearance
Behaviour - remember to ask about circumstances leading to hospital attendance, if the act had any significance, and if they believed their behaviour is strange or unusual.
Speech - pressure of speech, knight’s move thinking, clang associations, word salad
Mood
Thought - worthlessness, low self-esteem, flight of ideas, delusions of grandeur, delusions
Cognition - orientation, memory, concentration, calculation skills. Spell world backwards.
Insight - are you ill?
Summary - don’t forget focussed medical and psychiatric history.
Sections
Section 2
Compulsory admission for up to 28days
2 practitioners (one approved)
Application made by social worker or nearest relative
Section 4
Emergency section when an urgent admission is required
To be used when the patient poses a significant risk to others or themselves
Can be used when there is not enough time to get a second medical practitioner.
Section 5(2)
Cannot be used in the emergency department.
Wernickes and Korsakoffs
There is a 70% reduction of thiamine absorption in malnourished patients who are abstaining from drinking alcohol. Absorption is further reduced if these patients continue to drink.
Wernicke's
Only 10% of patients present with the classical triad of Wernicke's:
Ataxia
Ophthalmoplegia - this is usually of the external recti muscles
Confusion or impairment of the short term memory.
Other symptoms include:
Nystagmus
Gaze palsies
Confabulation
Confusion.
It is important to know this because delayed management or incorrect treatment has a mortality rate of 17%. Incorrect treatment includes giving glucose before thiamine. Of the patients that survive, 85% will have permanent brain damage in the form of Korsakoff’s psychosis and 25% will need long term institutionalisation in order to receive full time care
Korsakoff’s syndrome
- Anterograde amnesia
This is an inability to formulate new memories - memories prior to the onset of Korsakoff's syndrome remain intact
- The preservation of immediate memory
- The preservation of implicit memory
The person is able to learn new motor skills or show an improvement in complex tasks, even if they do not remember learning these skills
- Confabulation
Korsakoff’s syndrome is also associated with a loss of spontaneity, drive, and emotional expression. The chronic form of this syndrome is known as Korsakoff's psychosis.
It is possible to improve some aspects of short term memory by:
- Encouraging the patient to stop drinking alcohol
- Improving the patient’s diet
- Advising regular vitamin supplements, including thiamine
- Rehabilitation.
General amnesia is usually irreversible in patients with Korsakoff’s syndrome. Patients can learn to live independently, but most need residential care.
Wernicke's
Only 10% of patients present with the classical triad of Wernicke's:
Ataxia
Ophthalmoplegia - this is usually of the external recti muscles
Confusion or impairment of the short term memory.
Other symptoms include:
Nystagmus
Gaze palsies
Confabulation
Confusion.
It is important to know this because delayed management or incorrect treatment has a mortality rate of 17%. Incorrect treatment includes giving glucose before thiamine. Of the patients that survive, 85% will have permanent brain damage in the form of Korsakoff’s psychosis and 25% will need long term institutionalisation in order to receive full time care
Korsakoff’s syndrome
- Anterograde amnesia
This is an inability to formulate new memories - memories prior to the onset of Korsakoff's syndrome remain intact
- The preservation of immediate memory
- The preservation of implicit memory
The person is able to learn new motor skills or show an improvement in complex tasks, even if they do not remember learning these skills
- Confabulation
Korsakoff’s syndrome is also associated with a loss of spontaneity, drive, and emotional expression. The chronic form of this syndrome is known as Korsakoff's psychosis.
It is possible to improve some aspects of short term memory by:
- Encouraging the patient to stop drinking alcohol
- Improving the patient’s diet
- Advising regular vitamin supplements, including thiamine
- Rehabilitation.
General amnesia is usually irreversible in patients with Korsakoff’s syndrome. Patients can learn to live independently, but most need residential care.
Thursday, 24 October 2013
Alcohol Abuse - Discharge Advice
- Assess all patients prior to discharge from hospital
- Offer the patient a referral to social services in order to help them address any social problems which may be contributing to their alcohol dependence
- Offer the patient either:
- Brief interventions with the liaison nurse or a member of the liaison team
These are interviews to explore why the patient has alcohol dependence and to advise them on how they can prevent harmful drinking in the future
- Referral to a psychiatrist
Patients with a history of mental health problems should have a longer course of treatment which is overseen by a psychiatrist.
Patient Contacts
- Offer the patient a referral to social services in order to help them address any social problems which may be contributing to their alcohol dependence
- Offer the patient either:
- Brief interventions with the liaison nurse or a member of the liaison team
These are interviews to explore why the patient has alcohol dependence and to advise them on how they can prevent harmful drinking in the future
- Referral to a psychiatrist
Patients with a history of mental health problems should have a longer course of treatment which is overseen by a psychiatrist.
Patient Contacts
Drinkline - The National Alcohol
Helpline
0800 917 8282 - (England and Wales, Mon -Fri, 9am -11pm)
Drinkline offers free, confidential information and advice on alcohol.
0800 917 8282 - (England and Wales, Mon -Fri, 9am -11pm)
Drinkline offers free, confidential information and advice on alcohol.
Helpline: 0845 769 7555; email: helpline@alcoholics-anonymous.org.uk
Contact details for all English AA meetings. There is a quiz to determine whether AA is the right type of organisation for an individual, and a frequently asked question section about AA and alcoholism.
Contact details for all English AA meetings. There is a quiz to determine whether AA is the right type of organisation for an individual, and a frequently asked question section about AA and alcoholism.
Al-Anon Family Groups UK and
Eire
Helpline: 020 7403 0888 (10am -10pm, 365 days a year); email: enquiries@al-anonuk.org.uk
Helpline: 020 7403 0888 (10am -10pm, 365 days a year); email: enquiries@al-anonuk.org.uk
Support group for friends and families of alcoholics. Includes
a frequently asked questions section, pamphlets and other
literature, and information on group meetings in the UK.
This site provides information and articles on a range of
topics surrounding alcoholism. Includes 18 excellent factsheets
crammed with information that would be very useful for
professionals such as Alcohol and the Law and Drink-drive
accidents, a search engine, and a good list of alcohol related
links.
Giveupdrinking.co.uk
50 Ways To Leave Your Lager
If you believe you’re drinking too much, or you know alcohol is having a detrimental effect on your life, this website can help.
Based at University College London Medical School, and managed
by the charity Alcohol Concern, this site is designed to help you
work out whether you're drinking too much, and if so, what you can
do about it.50 Ways To Leave Your Lager
If you believe you’re drinking too much, or you know alcohol is having a detrimental effect on your life, this website can help.
Foundation 66
Foundation 66 works with individuals, communities and policy makers to reduce the harm caused by problem alcohol and drug use. Email: info@foundation66.org.uk
Foundation 66 works with individuals, communities and policy makers to reduce the harm caused by problem alcohol and drug use. Email: info@foundation66.org.uk
Alcohol Assessment
Alcohol and substance abuse has its own separate curricular component in HST. Core training integrated alcohol into most of the individual components.
E-learning for health hospital pathway
BMJ Learning
Alcohol Liver Disease
Alcohol Withdrawal in the ED
Doctors.net
FOAM
Alcohol in Older Adults
Ethylene Glycol
Methanol
Royal College of Psychiatrists
RCPsych Leaflets
EMJ
The Scale of the Problem
- 33.5% of adults aged 16 and over have a disorder of alcohol use
- 39% of men and 28% of women
- 21% of men and 15% of women (18% overall) are thought to be binge drinkers
In York:
- 18% of all ambulance journeys were due to alcohol
- 9.8% of attendances were alcohol-related (553 patients)
- Between 21:00 and 09:00, this rose to 19.7%
- Alcohol was involved in 45% of mental health attendances
- The alcohol group was heavily over-represented in the patients removed by police (100%), refusing treatment (55%) and leaving prior to their treatment (41%)
- 10.3% of alcohol-related attendees remained in the ED for >4hours compared with 5.9% of non-alcohol-related attendees
In Northern Ireland:
- Alcohol misuse was a factor in 60% of patient suicides
- Become more common over the past 10 years.
- Alcohol a factor in 70% of suicides of young people known to mental health services.
- Alcohol dependence was also the most common clinical diagnosis in patients convicted of homicide, with more than half known to have a problem prior to conviction.
- In homicide and suicide generally, alcohol misuse was a more common feature in Northern Ireland than in the other UK countries
Simple withdrawal
This has a short duration of one to four days and is associated with nausea, tremors, anxiety, sweating, and seizures.
Complex withdrawal
This can sometimes last up to nine or 10 days. Symptoms and signs of complex withdrawal are more severe. It is associated with confusion, hallucinations, paranoia, and delirium tremens.
Seizures
- 50% of seizures occur on admission and 90% occur within nine hours of admission to hospital
- Seizures that relate to alcohol withdrawal are usually generalised and take place 12 to 48 hours after stopping alcohol
- Seizures occurring more than 48 hours after stopping alcohol are rare
Hallucinations
- 50% of hallucinations occur within 21 hours and 90% occur within 64 hours of admission to hospital
- Alcoholic hallucinations can occur in the absence of delirium tremens.
- These are transient tactile, visual, or auditory hallucinations in the setting of clear consciousness.
- Often in the form of a conversation in the second person and may be derogatory.
Delirium Tremens
- 50% will develop the symptoms within 46 hours
- 90% within 85 hours of admission to hospital.
- occurs in 20% of patients with alcohol withdrawal
- without treatment lasts 72 hours, and kills 15 - 20% of patients.
Higher Risk Patients include:
Are over 70 years old
Need invasive or non-invasive ventilation
Present with seizures on admission
Are admitted to hospital with other complications, for example cerebral injury or hypoxia
Have a delay of more than 24 hours prior to treatment.
Signs and symptoms of DT
Excessive sweating
Profound agitation
A fever greater than 38.5°C
Tachycardia - a heart rate of greater than 100 beats a minute.
Investigations
I can't find the evidence for this, but there is a suggestion we should do a full biochemical screen on all patients presenting with alcohol withdrawal:
Blood glucose
Full blood count
Urea and electrolytes
Magnesium
Clotting screen
Liver function tests.
Refer to gastro if suspected ALD - may need USS
Treatment
Reduce sensory deprivation and treat the patient as you would normal delirium - manage in a side room, supportive care with supportive nursing staff, reassure the patient, regular observation.
Chlordiazepoxide 25 mg to 50 mg, using the CIWA scale:
A score of 0 to 9 - you do not need to start treatment
A score of 10 to 14 - give 25 mg of chlordiazepoxide
A score of 15 or more - give 50 mg of chlordiazepoxide
In the presence of seizures:
Intravenous diazepam at a rate of 2 mg a minute to a maximum dose of 10 mg to 20 mg
Intravenous lorazepam at a rate of 2 mg a minute to a maximum dose of 4 mg to 8 mg.
Thiamine to all patients with actual or suspected alcohol dependence.
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