Alcohol Summary

My summary card for alcohol abuse.

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.

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.

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

Drinkline - The National Alcohol Helpline
0800 917 8282 - (England and Wales, Mon -Fri, 9am -11pm)
Drinkline offers free, confidential information and advice on alcohol.

 

Alcoholics Anonymous 

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.

 

Al-Anon Family Groups UK and Eire
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.

 

Alcohol Concern
Tel: 020 7928 7377; email: contact@alcoholconcern.org.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.

www.downyourdrink.org.uk

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.

 

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

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-LfH
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.

Back Pain

HAP2 on back pain and CAP3 include more than you think they might. Life threatening and abdominal causes of back pain are covered elsewhere. Here are some links on general back pain, cauda equina, spinal cord compression and osteoporosis.

Enlighten Me
Back pain module  
Back pain in a young person -
I've gone numb down there
Paediatric Back Pain
Not what I was expecting

BMJ Learning
Metastatic Spinal Cord Compression
Back Examination
Cord Compression
Osteoporosis

Doctors.net
Back Pain
Osteoporosis

Back Pain

Low back pain: pain between the lower costal margin and gluteal folds, which may be accompanied by leg pain.

Back pain is common and has a huge socio-economic cost, and can be life threatening for the patient. We should not use the bio-medical model of injury (emphasis on looking for pathological lesion that causes back pain) as this is likely to cause over-investigation.

5% of people have a diagnosable condition
<1% have a serious medical condition
Most resolves in 6-8 weeks

History and examination should cover red flags, yellow flags, and nerve root problems.

Red Flags: for possible serious spinal pathology when assessing back pain:

• non-mechanical pain
• past history carcinoma, steroids, HIV
• generally unwell
• unexplained weight loss
• widespread neurological symptom or signs
• structural deformity
• thoracic pain
• Age <20 years or >55 years has also been considered a red flag, but it should be borne in mind that non-specific back pain is not uncommon in these age groups. Significant trauma may raise the possibility of vertebral fracture.

Yellow Flags:  risk factors for developing and or maintaining long-term pain and disability
- Belief that pain and activity is harmful
- Belief that pain will persist
- Sickness, avoidant and excessive safety behaviours (like extended rest, guarded movements)
- Low or negative moods, anger, distress, social withdrawal
- Treatment that does not fit with best practice
- Claims and compensation for pain-related disability
- Problems with work, sickness absence, low job satisfaction
- Overprotective family or lack of support
- Placing responsibility on others to get them better (external locus of control)

Indicators for nerve root problems:
- Unilateral leg pain and low back pain
- Radiates to foot or toes
- Numbness or paraesthesia in same distribution
- Straight leg raising test induces more leg pain
- Localised neurology (limited to one nerve root)

Examination
Sacroiliac joints: Lie supine and apply firm downward pressure over both sides of the pelvis

Straight leg raise test: suggestive of nerve root pain.
    Ask the patient to lie flat on their back
    Raise the patient's leg and ask them to tell you when they feel pain in thigh, buttock, and calf
        The leg must be completely straight
        The test is positive if pain occurs with the leg at an angle of less than 70°
    It is normal to experience pain with the leg at an angle of 80-90° with the bed.

Sciatic stretch test:
    Dorsiflex the foot with the leg still raised
        The test is positive if the patient experiences further discomfort in the thigh, buttock, and calf
    The pain should be relieved by bending the knee.

You should repeat both tests on the unaffected leg. You should suspect a prolapsed intervertebral disc in patients who experience pain in the affected leg when you raise the unaffected leg. You should make an urgent referral in these patients because they are at risk of developing cauda equina syndrome.

The leg must be raised 30° above the bed. Below this angle the sciatic nerve is not stretched. You should consider an alternative diagnosis such as arthritis in patients who experience pain with the leg below a 30° angle.


Femoral Stretch Test:

Imaging
Imaging is unlikely to be helpful, even MRISs. In asymptomatic people, MRIs show:
- Bulging discs in 20% to 79%
- Herniated discs in 9% to 76%
- Degenerative discs in 46% to 91%.

Sciatica
50% of patients with sciatica will recover from the acute attack within 6 weeks. Over a third of back pain cases will have accompanying leg pain, true nerve root pain has a prevalence of around 4%, and "surgically important" root pain is as low as 2%.

Cauda Equina

Spinal Cord Compression

3-5% of patients with cancer develop bone metastasis. If they have a high risk cancer this rises to 20%. Mets may occur years after the primary cancer diagnosis.
Only about 1/2 of patients with SCC will have a high risk cancer. 20-25% have no existing cancer diagnosis.
17% of patients have lesions at two or more levels so the entire scan should be MRId. Spinal cord compression often occurs in the last year of life.

Symptoms:
    Back pain (95% of patients), radiating (in 37%) or localised (15%).
    Spinal pain aggravated by straining (for example, when coughing)
    Nocturnal spinal pain which interferes with sleep.

    

    Limb weakness (87% of patients)

    Paraplegia (18%) 

    Painless urinary retention

Signs:

Patients who have primarily compression of the posterior cord may lose proprioception, and so have difficulty walking, but may have normal muscle power on assessment.
Symptoms and/or signs of spinal cord compression may become more obvious if you load the patient's spine, eg by getting them to carefully stand and walk - providing they do not have significant movement related spinal pain

Imaging:

Plain x-rays need up to 50% bone loss before lesions become visible.
CT  may show supplemental information

MRI is the main imaging modality

Treatment:
Radiotherapy will help a tumour
Nurse patients flat wit neutral spinal alignment, log roll, and use a bed pan.
16mg dexamethasone

Osteoporosis

Think about prophylaxis before the patient gets a fracture. The FRAX score is very useful. 

Alendronate is the first line treatment. Alendronate can cause dyspepsia, but we shouldn't start at PPI because it’s not an acid related dyspepsia. There is  evidence to suggest that PPIs and H2RAs actually increase the risk of fracture.

Aortic Disection

Doctors.net 
EnlightenMe
Potential use of d-dimers
Hypertensive Emergency
Walking Problems
Chest X-ray
CEMPaedia
Collapse and Shock
Clot or Bleeding
 
BMJ Learning
Learning Module
Article

FOAM
http://emcrit.org/podcasts/aortic-dissection/
http://lifeinthefastlane.com/education/ccc/acute-aortic-dissection/
http://lifeinthefastlane.com/2010/03/cardiovascular-curveball-008/
http://lifeinthefastlane.com/2010/09/die-like-a-king/
http://lifeinthefastlane.com/2008/11/aortic-dissection-lecture-notes/
http://flippedemclassroom.wordpress.com/2013/06/07/aortic-dissection/
http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/

Pathophysiology
Aortic disection is caused by a disruption of the media layer of the aorta. For this to start, this needs a tear of intima with the formation of a false lumen between layers. An important variation of ATAD is an acute intramural haematoma - bleeding within the wall without an intimal defect. The treatment is the same.

There are three possibilities as to how the blood gets into the media:
-    Atherosclerotic ulcer leading to intimal tear
-    Disruption of vasa vasorum causing intramural haematoma
-    De novo intimal tear

Most tears occur in the ascending aorta due to greater pressure on the aortic wall. Once the dissection process occurs blood tracks through the media to varying degrees and may dissect down from the aortic root to the bifurcation of the common iliac arteries in a matter of seconds.

                  Location of primary aortic tear     Incidence
                  Ascending aorta                           70%
                  Descending thoracic aorta            15-20%
                  Arch of the aorta                          10%
                  Abdominal aorta                           <5%




Risk Factors
Thrombus - 2/3 of patients
Embolism - 1/3 of patients

White (79%)
Men (68%)
over 40



Inherited disease (especially younger patients < 40 yrs)
 - Marfan’s syndrome (fibrillin gene mutations)
 - Ehlers-Danlos syndrome type IV (collagen defects)
 - Turner syndrome
 - annulo- aortic ectasia
 - familial aortic dissection.

    
Aortic wall stress 
- Hypertension (72%)
- Previous cardiovascular surgery
- Bicuspid or unicommisural aortic valve
- Aortic coarctation
- Iatrogenic
- Infection (syphilis)
- Arteritis such as Takayasu’s or giant cell, aortic dilatation / aneurysm, wall thinning
- ‘crack’ cocaine (abrupt catecholamine-induced hypertension).

Reduced resistance aortic wall 
- Increasing age
- pregnancy (debatable).

Clinical Symptoms

The clinical symptoms vary depending on which branch vessel is occluded:
Coronary vessel(s)                    ST elevation myocardial infarction
Common carotid(s)                   any type of stroke
Subclavian(s)                            an acutely ischaemic upper limb
Coeliac/mesenteric vessel(s)      ischaemic bowel
Renal vessel(s)                          frank haematuria
Spinal artery(ies)                       sudden onset painless paraplegia

Ascending aorta:                       haemopericardium (syncope and /or sudden death)
                                                right haemothorax (invariably sudden death)
Arch of aorta:                           mediastinal haematoma
                                                interatrial septal haematoma (cardiac conduction defects)
                                                compression of pulmonary trunk/ artery
Descending aorta:                     left haemothorax (sudden death)
                                                rarely into oesophagus (profuse haematemesis)
Abdominal aorta:                      retroperitoneal haemorrhage (back pain with shock)
                                                rarely intraperitoneal haemorrhage (shock and acute abdomen)
Aortic root:                              aortic regurgitation can occur when the dissection process extends into or around the aortic valvular support. The aortic root can dilate so much that the aortic leaflets cannot fully appose during diastole, allowing regurgitation of blood. 

Pain
Pain is the most common symptom. 
The pain is said to be severe or ‘worst ever’ (90%), abrupt (90%), sharp (64%) or tearing (50%) retrosternal or interscapular pain (50%), migrating (16%), down the back (46%), maximal at onset (not crescendo build up, as in an AMI).

The pain in aortic dissection occurs in the anterior chest 70-80% of the time in patients with a type A dissection and back pain occurs only in 50% of all patients. Abdominal pain was found to be the third commonest site of initial pain and other sites described were the throat, neck and extremities.

Patients may also describe the classic migration of pain from the chest, back or abdomen to one or more limbs or to the neck and this is thought to be due to peripheral extension of the dissection from the primary intimal tear.

In 5-15% of patients however, no pain occurs at all. This is typically the case in those patients presenting with syncope, stroke, congestive cardiac failure or the elderly. 

Cardiac Signs
- Aortic incompetence (32%)
- cardiac tamponade, 
- myocardial ischaemia (although only 2-5% of ECGs mimick AMI)
-  BP differences >20 mmHg in arms
- missing pulse (15%).
        
Other Signs
- Pleural rub or effusion, haemothorax
- Altered consciousness
- syncope (13 %), 
- hemiplegia (5%)
- paraplegia.
 - abdominal pain (43% descending, 22% ascending)
- intestinal ischaemia 
- oliguria
 
Diagnosis
Transthoracic Echocardiography -  78.3% sensitivity and 83.0% specificity for diagnosing proximal dissection. Cannot accurately visualise the descending aorta in most patients. Can diagnose aortic incompetence. 
May identify a free intimal flap within the aortic lumen - sensitivity is approximately 80% for type A dissections but only 50% for type B. 

CT - 83-100% sensitive
  Will reveal pericardial fluid which will suggest dissection diagnosis in the right clinical context. 
 
ECG - normal in 30% of cases
   STEMI patterns in 3% (Changes consistently with AMI do not rule out dissection)
   15% acute ischaemic changes
   41% had non-specific ST segment and T wave changes

Chest X-ray - normal in 12% of cases
   Mediastinal widening in 60% of cases 
   Abnormal aortic contour 50% of cases
   Soft tissue shadow behind a calcified aortic annulus (15%)
   Globular heart (haemopericardium) 
   Pleural effusion (haemothorax)  


 
Bloods - D-dimer has a sensitivity of below 95%

Treatment
The most important step in treatment is diagnosis - 40% cases are initially misdiagnosed. Mortality increases every hour from onset of disease.


Even if there are signs of tamponade, do not perform pericardiocentesis. 

There are two main types of disection: 
     Stanford A: De Bakey 1 and II: Proximal
     Stanford B: Proximal
     Stanford B: DeBakey IIIa and IIIb: Distal
     Stanford A dissections normally have surgical treatment, and type B has medical management.  
 
 
Medical Management
Analgesia
Blood Pressure Control:
 - Control blood pressure with labetalol (a mixed alpha and beta blockers)
  - Causes vasodilatation and reduces cardiac contractility
 - Doesn't cause reflex tachycardia that is seen with other vasodilators. 
Best to use a mixture of beta blockers and vasodilators - so metoprolol and GTN

  
Ten year survival rates of patients who are discharged from hospital range from 30% to 60%