Alcohol withdrawal
Hydroflouric acid
burns
Methanol poisoning
Poisoned patients
ALCOHOL WITHDRAWAL
Alcohol withdrawal is a complex syndrome, which usually presents with more than one of: tremor,
seizures, hallucinations, perspiration, hyperthermia, anxiety or agitation.
Though there is a large spectrum of individual susceptibility it usually peaks at 48 hours post
withdrawal.
ASSESSMENT
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ABCs
Assess symptoms and signs of withdrawal as per “Alcohol Withdrawal Rating Scale” at least 4
hourly
Assess hydration.
Nutritional Status
INVESTIGATIONS
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Electrolytes and Creatinine
Glucose
LFTs
FBC
MANAGEMENT
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Keep in a quiet area
Detoxification with diazepam as per “Guidelines for the Management of Alcohol Withdrawal in
Hospital”
IV fluids if dehydrated but avoid overhydration
Thiamine 100mg IV (Decreases risk of Wernicke’s but does not alter seizures or delirium)
In the elderly or those with severe liver dysfunction consider using oxazepam rather than
diazepam, which has no active metabolites and therefore less risk of accumulation.
DISPOSITION
1.
HOME – if mild symptoms, with information regarding eg


GP Review
CADs (Community Alcohol & Drug Service
Ph: 6232323 Central
8366166 West
5882701 North
2778080 South
 Home Detox Service / Inpatient Unit
50 Carrington Road, Pt Chevalier
Ph:
8155830
 Social Detoxification Centre
203 Federal Street
Ph:
3033016

Alcoholcs Anonomous
PO Box 5373, Wellesley St, Auckland
Ph: 366 6688
Consider a short-term prescription for diazepam prior to GP or Detox
review if withdrawal symptoms. If not withdrawing suggest continue
drinking enough alcohol to prevent symptoms prior to GP / CAD’s
review.
2.
ADMISSION TO HOSPITAL
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3.
Hepatic decompensation
Infection or fever >38.5
Severe dehydration
Acute haematemesis / malaena
Malnutrition
Cardiovascular collapse / cardiac arrhythmias
Wernicke’s encephalopathy
Recent head injury with loss of consciousness
Acute alcohol poisoning
ADMISSION TO A DETOXIFICATION SERVICE.

Contact Admissions Coordinator
Grafton Regional Detoxification Service
88 Grafton Rd, Grafton
Phone: 377 0370
Fax: 377 0380

Admission indicated if there is a high risk of medical danger eg:
 History of withdrawal seizures
 Medical problems – IDDM, IHD
 Severe symptoms – but not requiring hospital admission
 Pregnant especially first trimester

Detox will not consider a patient for a crisis admission solely on the basis of social issues
unless the patient is the primary care giver of children whose safety is at risk

If there are no detoxification beds available, discuss with Medical team regarding hospital
admission.
REFERRENCES
1.
Pharmacological management of Alcohol Withdrawal. A meta- analysis and Evidence Based
Guidelines. American Society of Addiction Medicine Working Group on Pharmacological
Management of Alcohol Withdrawal. JAMA. 278(2):144 – 51. 1997
2.
Guideline for the Management of Alcohol Withdrawal in Hospital. Professional Practice Manual.
Auckland Healthcare.
ALCOHOL WITHDRAWAL RATING SCALE
GUIDELINES FOR MANAGEMENT OF ALCOHOL WITHDRAWAL IN
HOSPITAL
HYDROFLUORIC ACID BURNS
INTRODUCTION
Hydrofluoric acid (HF) is one of the strongest inorganic acids.
A severe burn can be considered if:
1.
2.
3.
HF of 50% concentration or greater burns >1% body surface area
HF of any concentration to >5% body surface area
Inhalation of >60% HF concentration
Mechanism of toxicity:
1.
2.
3.
Local tissue damage secondary to hydrogen ions
Local tissue damage secondary to fluoride ions forming insoluble salts with calcium and
magnesium
Systemic effects of hypocalcemia, hyperkalaemia, hypomagnesaemia, including cardiac
arrhythmias / sudden death
Burn manifestations:
1.
2.
3.
Relatively little surface reaction.
Delayed severe pain in the region.
Time of onset is related to the concentration of HF.
MANAGEMENT OF HYDROFLOURIC ACID BURNS
ABC's
ECG
IV access
Bloods, including urgent Ca, K, Mg
Monitoring
Systemic Hypocalcaemia
- long QT
- low serum Ca 2
- clinical
Local burn
Decontamination
Remove clothing
Copious irrigation with water
20ml 10% Ca Gluconate stat
continue with 10ml aliquots as per response
May require very large dose
2.5% Calcium Gel* topically
e.g. fill a glove applied over the
hand
Liaise with DCCM
regarding admission
Symptomatic at 30 minutes
FURTHER TREATMENT
Upper Limb:
- Bier's block using 10mls of 10% calcium gluconate and 5,000
units heparin diluted to 40mls in normal saline rather than
prilocaine. Duration 20 minutes with gel reapplied post-treatment
Elsewhere:
- Subcutaneous infiltration of 0.5ml / square cm of burn of 10%
Ca gluconate. Extend 0.5cm beyond the margin of obviously
burned tissue.
- Local intra-arterial infusions may be considered
Liaise with Plastic
surgery in large lifethreatening burns.
Surgical debridement
may be live saving
* If gel not available dissolve 10% calcium gluconate in 3 times the volume of KY jelly.
METHANOL POISONING
Background
The vast majority of methanol poisonings seen in Auckland ED are due to ingestion
of methylated spirits (95% ethanol, 2-5% methanol). Those consuming methylated
spirits are often chronic methanol/ethanol abusers. There is good evidence that in this
subgroup of patients significant methanol toxicity does not occur regardless of
methanol level. This subgroup of patients can simply be treated as if drunk and
discharged as soon as they are safely sober. Those who are not chronically alcohol
tolerant and those who consume preparations containing fractions of methanol above
5% are at risk of developing significant toxicity.
Relevant history
Formulation of methanol ingested (usually methylated spirits as
above)
Time of ingestion
Amount ingested
Any coingestions
Reasons for ingesting (recreational, self harm)
Significant medical conditions
Physical findings
The initial presenting signs of methanol toxicity are similar to
ethanol intoxication.
Significant toxic signs and symptoms develop after a latency of between 10 and 30
hours in general appearing sooner with larger poisonings.
Gastrointestinal effects due to chemical irritation of mucosa
Ocular disturbances due to direct and preferential toxicity of the optic nerve (blurred
vision, whiteout)
Severe metabolic acidosis manifest as dyspnoea, tachypnoea, Kussmaul’s respiration
and cardiovascular collapse
Laboratory
investigation
U&E’s, glucose, ethanol and methanol levels
ABG
Consider paracetamol/salicylate levels if self harm suspected
(methanol toxicity may mask symptoms of salicylate poisoning)
Management
Is treatment indicated. See background note above
Attend to ABC’s as required.
Decontamination ineffective unless significant coingestants
Aggressive correction of metabolic acidosis with Sodium Bicarbonate (Doses
>500mmol in first few hours commonly required)
Antidotal therapy with ethanol (ethanol level > 20mmol/L will completely inhibit
methanol metabolism). If initial ethanol level is greater than 20mmol/L a loading
dose is not required
10% ethanol loading dose 10ml/kg
10% ethanol maintenance dose
@1ml/kg/hr in non alcohol tolerant
@2.5mg/kg/hr in alcohol tolerant
Check ethanol levels after 4 hours and adjust.
Ethanol infusion should continue until methanol levels are <6mmol/L and acidosis
has completely resolved
Consider haemodialysis in anyone who has any of the following
(discuss with consultant)
1.
2.
3.
4.
Disposition
Metabolic acidosis of any degree and visual disturbance
Severe metabolic acidosis (base deficit > 15 mmol/L)
Ingestions of methanol estimated at > 40mls
Methanol level. 20mmol/L
Discharge if treatment not indicated and ingestion not due to
attempted self-harm.
Psychiatric referral if medically clear and self harm suspected
Medical admission if significant poisoning in susceptible patient requiring ethanol
infusion
DCCM admission if significant metabolic abnormality either on arrival or during
initial assessment and treatment.
References
Martensson E. et al. Clinical and Metabolic Features of EthanolMethanol Poisonings in Chronic Alcoholics. Lancet Feb 13 1988
Pg. 327-328
Kruse J.A. Methanol Poisoning (review). Intensive Care Medicine
1992 18:pg 391-397
Methanol/methylated spirits. Substance Abuse Database
POISONED PATIENTS
1.
INITIAL
RESUSCITATION
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2.
RELEVANT HISTORY
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3.
RELEVANT
EXAMINATION
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Identify drug/s
Quantity
Time taken and route
Any remedial treatment to date
Reason for taking
Significant medical conditions
Most acute toxicity presents as cardiorespiratory or
neurological symptoms or signs
Consider possibility of co-existent physical injuries
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4.
MINIMUM
INVESTIGATION SET
FOR DELIBERATE SELF
HARM
Airway – ensure / procure
Breathing
1. Supplemental 02 if any alteration of LOC
2. Ventilatory assistance if required
Circulation – IV access and fluids in initial management of
hypotension
1.
2.
3.
4.
U&E’s, glucose, ethanol, paracetamol, salicylate
ECG – if history of ingestion of cardiovascular drugs, drug
with known cardiovascular side effects, or any patient with
altered LOC or abnormal vital signs
Carboxyhaemoglobin level in suspected CO poisonings with
signs or history of decreased LOC
Additional investigations such as blood drug levels only useful
if likely to alter management i.e. digoxin, Li+, Fe++
Refer to Substance Abuse Database for advice
regarding these
5.
DECONTAMINATION
1.
2.
3.
6.
MONITORING
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Activated charcoal 50G to be given to all patients with
significant poisoning presenting within 1 hour of ingestion.
Ensure intact or protected airway.
Gastric lavage should only be considered in the severely
poisoned patient presenting within 1 hour of ingestion
(discuss with Consultant).
Surface decontamination – with soap and water for dermal
poisonings (i.e. organophosphate sprays). Ensure staff
barrier precautions.
In general asymptomatic patient with normal examination
and investigation as above should be observed for 6 hours
from the time of poisoning and may safely be medically
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7.
VIOLENT
UNCO-OPERATIVE
PATIENTS
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8.
ANTIDOTAL /
ANTAGONIST
THERAPIES
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9.
ENHANCED
ELIMINATION
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10.
PSYCHIATRIC
ASSESSMENT
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11.
RECREATIONAL DRUG
ABUSE
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12.
DISPOSITION
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cleared after this time.
Exceptions to this rule include those who have taken delayed
release preparations, and those with significant comorbidities (discuss with Consultant)
You have a legal mandate/obligation to detain and treat
suicidal patients and those whose mental competence to
refuse treatment is impaired by drugs or concurrent illness.
Chemical sedation is the preferred method of patient
restraint.
Appropriate drug regimens (unless prior allergy noted)
include:
1. Clonazepam 1mg aliquots IM / IV repeated as
required
2. Midazolam 5mg aliquots IM / IV repeated as
required
3. Haloperidol 5mg aliquots IM / IV repeated as
required
Available for a limited number of poisons
Refer to Substance Abuse Database for information
regarding indications for, and methods of use
Rarely required
Discuss possible indications with Consultant
Mandatory for all deliberate self poisonings prior to
discharge once medically cleared.
Contact:
 Psych Liaison 0800 – 2300
 On Call Psych Reg 2300 – 0800
Offer contact details of appropriate drug addiction services
prior to discharge (information is available at nurses station)
Likely dispositions include:
1. Discharge – medically and psychiatrically cleared.
2. Medical Admission – symptoms and signs of
toxicity persist >6 hours from time of poisoning or
ongoing antidotal treatment required.
3. DCCM – severe poisoning requiring ongoing
support of cardiorespiratory, neurological or renal
function
4. Psychiatric Admission – committal / voluntary
References:
1. Position Statement American Academy of Clinical Toxicology : European Association of Poisons
Centres and Clinical Toxicologists. Clinical Toxicology, 35(7) 699-762 (1997)
2.
Medicolegal Aspects of Managing Deliberate Self Harm in The Emergency Department. NZ Med
J 1998; 110 255-258.