[10.26] Toxicology_ Management of Withdrawal and Intoxication V2.1.pdf

Intoxication

What is the reversible substance specific syndrome due to recent ingestion or exposure?

Withdrawal

What is the development of a substance specific maladaptive behavioral change due to cessation or reduction of use?

Tolerance

What is the need for greatly increased amounts of a substance to achieve intoxication or desired effect?

Behavior tolerance

What is the ability to perform tasks despite a high level of substance intoxication?

Cross tolerance

What is the condition where tolerance to one drug leads to tolerance to another in the same class?

Dependence

What is the cluster of cognitive, behavioral, and physiological symptoms indicating that an individual continues use despite significant problems?

Psychological dependence

What is also known as habituation or a craving for the substance s effects?

Misuse

What refers to the incorrect use of prescribed medications?

Substance, dose, duration, individual degree of tolerance, and person s expectations

What five factors determine the clinical picture of intoxication and withdrawal?

Rapidly acting substances

What substances are more likely to produce immediate intoxication compared to slower acting ones?

Longer acting substances

Which substances may produce longer withdrawal durations?

Parallel

How does the half life of a substance relate to aspects of withdrawal?

Less intense

Generally, the longer the acute withdrawal period, what is the intensity of the syndrome?

Toxidrome

What is the term composed of the words toxic and syndrome describing consistent groups of signs?

Mental status

Which CNS manifestation is checked during a toxidrome assessment?

Pupil size

Which ophthalmic system sign is checked in a toxidrome?

Peristalsis

Which gastrointestinal sign is checked in a toxidrome?

Dryness vs diaphoresis

What dermatologic system sign is checked in a toxidrome?

Treat the patient rather than the poison

What is the first basic principle of management?

Mental status and vital signs

Besides pupil size, skin moisture, and bowel sounds, what should be re evaluated in suspected overdose?

Anticholinergics

Which toxidrome presents with delirium, dilated pupils, and urinary retention?

Cholinergics

Which toxidrome presents with salivation, lacrimation, diarrhea, and fasciculations?

Ethanol or sedative hypnotics

Which intoxication presents with depressed mental status, ataxia, and hyporeflexia?

Opioids

Which intoxication presents with depressed mental status, pinpoint pupils, and decreased respiratory rate?

Sympathomimetics

Which toxidrome presents with agitation, tremors, seizures, and dilated pupils?

Withdrawal from ethanol or sedative hypnotics

Which syndrome presents with agitation, disorientation, tremors, and seizures?

Withdrawal from opioids

Which syndrome presents with normal to anxious mood, piloerection, and yawning?

Regular drinker

Who is defined as a person who drinks 4 or more times per week?

Heavy drinker

Who is defined as a person who drinks more than 12 drinks on an average drinking day?

4.8 percent

Among drinkers, what percentage are heavy drinkers?

6.6 percent

What percentage of male drinkers are heavy drinkers?

1.3 percent

What percentage of female drinkers are heavy drinkers?

15 to 20 mg/dL

How much does one drink increase the blood alcohol level of a 150 pound man?

12 oz

How many ounces of beer equals one drink?

5 oz

How many ounces of wine equals one drink?

1.5 oz

How many ounces of liquor equals one drink?

Small intestine

Where is the majority of alcohol absorbed?

30 to 90 minutes

When is peak blood concentration of alcohol typically reached?

Empty stomach

What condition enhances alcohol absorption?

90 percent

What percentage of alcohol is metabolized in the liver?

1 drink per hour

Approximately how much alcohol can the body metabolize per hour?

15 to 20 mg/dL/hour

At what rate does blood alcohol level generally decrease?

13 to 15 mg/dL/hour

What is the rate of alcohol metabolism for non alcoholics?

More than 30 mg/dL/hour

What is the rate of alcohol metabolism for chronic alcoholics?

Zero order kinetics

What kinetic model does alcohol follow in cases of intoxication?

100 mg/kg/hour

In zero order kinetics, alcohol metabolism is constant at what rate?

0.08 to 1.15 g/dL

What is the legal definition range of blood alcohol level for intoxication?

Mood lability, impaired judgment, and ataxia

What are the three core presentations of alcohol intoxication?

Thiamine 100 mg, D50 50 fast drip, and Folic Acid

What are the three medications for managing alcohol intoxication?

20 to 30 mg/dL

At what alcohol level is slowed motor performance and decreased thinking likely?

200 to 300 mg/dL

At what alcohol level are marked slurring of speech and blackouts likely?

Greater than 300 mg/dL

At what alcohol level are impaired vital signs and possible death likely?

Rising

Are symptoms more intense when the blood alcohol level is rising or falling?

Amnesia

What do blackouts refer to regarding events during intoxication?

Falling

When the BAL is doing what does the individual become progressively more depressed and withdrawn?

Anesthesia

At very high BAL, a non tolerant individual may enter the first stage of what?

Questionnaires

Which screening tool for alcohol has greater sensitivity and specificity than lab tests?

GGT or Gamma glutamyl transferase

What is the most sensitive lab test for monitoring alcohol abstinence?

35 U/L

A positive GGT test is defined as a level greater than what?

CDT or Carbohydrate deficient transferrin

Which lab test is elevated in 80 percent of those who drink heavily for at least a week?

MCV or Mean corpuscular volume

Which lab test is elevated in about 1/4 of long term heavy drinkers?

4 to 12 hours

How soon after cessation or reduction does alcohol withdrawal begin?

2nd day

When does alcohol withdrawal reach peak intensity?

4th or 5th day

When does alcohol withdrawal markedly improve?

3 to 6 months

How long can anxiety and insomnia persist at lower intensities after alcohol cessation?

Fewer than 3 percent

What percentage of individuals develop tonic clonic seizures in alcohol withdrawal?

6 to 12 hours

When do minor withdrawal symptoms like tremulousness and mild anxiety appear?

12 to 24 hours

When does alcoholic hallucinosis generally develop?

24 to 48 hours

When do withdrawal seizures typically occur after alcohol cessation?

48 to 72 hours

When does alcohol withdrawal delirium typically begin?

5 days

When does alcohol withdrawal delirium reach its peak?

CIWA or Clinical Institute Withdrawal Assessment for Alcohol

What scale assigns numerical values to orientate and manage alcohol withdrawal?

Total score greater than 8

At what CIWA score are medications typically given?

Age greater than 30

What age factor is a risk for Delirium Tremens?

Previous DT history

Name a historical risk factor for Delirium Tremens.

Benzodiazepines

Which drug class reduces the risk of seizures and provides comfort in alcohol withdrawal?

Antipsychotics

What drug class should be avoided in alcohol withdrawal because it decreases the seizure threshold?

Symptom triggered therapy

What is the preferred method of pharmacologic treatment for alcohol withdrawal?

Diazepam 5 to 10 mg every 6 to 8 hours

What is the standard diazepam dose for alcohol withdrawal?

Lorazepam or Oxazepam

Which BZDs are given if there is severe liver dysfunction?

Thiamine

Which supplement treats or prevents Wernicke s and cerebellar ataxia?

100 mg IM or IV for 5 days

What is the dosage of thiamine for alcohol withdrawal recovery?

D50 50 100 mL fast drip IV

What is given to maintain euglycemia in withdrawal?

Loperamide

Name an antidiarrheal agent used p.r.n. in withdrawal.

Reality orientation

Name a non pharmacologic treatment for alcohol withdrawal.

GABA mediated chloride channels

All sedative hypnotics enhance the function of which channels?

Glutamate

Sedative hypnotics decrease the effects of which excitatory neurotransmission?

Lipophilicity

What property determines how fast sedative hypnotics penetrate the blood brain barrier?

Short duration of action

Besides high lipophilicity, what makes a BZD more addicting?

Anterograde amnesia

What memory impairment is a prominent feature of sedative hypnotic intoxication?

Alcoholic blackouts

Anterograde amnesia in BZD intoxication resembles what?

20 to 30 percent

What percentage of individuals in untreated BZD withdrawal may have grand mal seizures?

Withdrawal delirium

What is characterized by disturbances in consciousness and cognition with hallucinations?

Underlying medical or psychological illness

Besides half life and dosage, what determines the severity of BZD withdrawal?

10 hours or less

Withdrawal symptoms begin in 6 to 8 hours for BZDs with a half life of what?

2nd week

When is the peak intensity of withdrawal for BZDs with longer half lives?

Flumazenil

What is the competitive BZD antagonist used for overdose?

Arrhythmias and withdrawal reactions

What are two risks of giving Flumazenil?

Tapering too fast

What is the most common detoxification mistake for BZDs?

Convert to a longer elimination half life drug

What is the first step in the correct process of BZD detoxification?