“A Cup of Holiday Cheer?”
Pre-hospital Alcohol Emergencies
Presence Regional EMS
December 2015
Objectives
 Discuss the effects of ethyl alcohol on the human body
 Describe delirium tremens, signs and symptoms,
complications and management
 Outline physiological concerns specific to children
ingesting ethyl alcohol.
 List other emergency situations that might be masked by
alcohol intoxication
 Using a variety of scenarios discuss the assessment and
management of alcohol related emergencies
Alcohol and EMS Patients
 The common alcohol encountered in patient
interactions is Ethanol
 Alcohol is the most common substance of abuse
in the US and worldwide
 75% of Americans have at least one alcoholic
drink per year.
 Between 15% and 40% of EMS patients have
detectable levels of alcohol in their blood.
Alcohol and the Holiday Season
In American society, drinking alcohol is a
tradition during the Holiday Season.
Actions of Alcohol on the Body
 At low doses: excitatory and stimulating effects
with depressing of inhibitions
Aggressive behavior
Inappropriate behavior
 At higher doses: sedative effect, depresses
the central nervous system
Dulls sense of awareness
Slows reflexes, lack of coordination
Reduces reaction time
Stupor and coma
Physiology
Alcohol is completely absorbed from the
GI tract in 30-120 minutes.
Food in the GI tract slows absorption time
Concentrations in the brain rapidly approach
blood alcohol levels
Alcohol is broken down and eliminated
(metabolized) by the liver
Intoxication occurs when alcohol enters the
bloodstream faster than the liver can break it
down
Alcohol causes peripheral vasodilation
Flushing of skin
Feeling warm
Increased loss of body heat
Alcohol potentiates other drugs
(prescription and non-prescription)
Physiology cont.
Alcohol inhibits the hormone responsible
for conservation of water in the kidney
(vasopressin)
Increased urination
Dehydration
Alcohol ingestion can cause vomiting
Dehydration
Chance of aspiration
Blood Alcohol Concentrations
EMS providers have no way to determine
blood alcohol levels in the pre-hospital
setting.
Can sometimes estimate based on
assessment and patient behavior
Patients with long term alcohol use will not
have signs and symptoms until blood
alcohol levels are much higher
Blood Alcohol Concentrations
0.02 – 0.05 gm/dl diminished fine motor coordination
0.05-- 0.10 gm/dl impaired judgment and coordination
0.08 gm/dl LEAGALLY INTOXICATED IN ILLINOIS
0.10 – 0.15 gm/dl difficulty with gait and balance
0.15 – 0.25 gm/dl lethargy, unable to sit upright without
assistance
0.25 – 0.30 gm/dl
0.30 – 0.40 gm/dl
coma in the non-habitual drinker
respiratory depression
Scenarios
Alcohol (ethanol) ingestion can cause a
variety of pre-hospital emergencies.
For each scenario, determine:
 what is important about the scene size up
 initial assessment (Mental status, Airway, Breathing,
Circulation)
 SAMPLE history
 head to toe exam
 management of the patient (BLS & ALS)
Scenario 1
It is 2100 hours on New Year’s Eve
You are called to a family home for an
unconscious male.
You are lead by an anxious middle aged
woman to the basement family room.
You find 4 young men standing around
Tony, an 18 year old male lying on the
floor face down in vomit and blood.
The woman is Tony’s mother, she just got
home from going out to dinner and found
her son like this.
Initial Assessment
 Level of Consciousness: Arouses to pain only
 Airway: occluded with vomit
 Breathing: labored and slow
 Circulation: pulse 90 at carotid strong, radial
pulse weaker, skin warm and sweaty
 Chief Complaint: Altered level of consciousness
What do you do now??
What is Tony in immediate danger of?
SAMPLE
 Allergies– none
 Medications – none but vitamins
 Past Medical History – none healthy young
senior in high school
 Last Meal – some chips and snacks since 7 pm
 Events – to celebrate New Year’s Eve Tony had
a bottle of vodka. He has been drinking a shot
with orange juice for each of his birthdays. He
got to shot 10 and passed out flat on his face.
Head to Toe
 Vomit on face and mouth, continues to vomit
frequently requiring suction
 Approximately 1 inch gash over right eyebrow
that is bleeding
 Pupils equal and slow to react
 Chest sounds are congested on right side
 Abdomen soft but Tony groans to palpation.
 No injuries noted on arms and legs.
 Tony has been incontinent of urine.
Vital Signs
BP 100/70 Pulse 90 Respirations 6
Oxygen saturation 90% on room air
Blood Glucose 80
How do you manage Tony? What are
your concerns?
Management??
BLS
Keep airway open with suctioning
Assist ventilations with BVM and high flow
oxygen
Control bleeding of laceration
Monitor level of consciousness for potential
head injury
Determine how to extricate from basement
Consider spinal motion restriction
Transport/ call for intercept
ALS
Continue BLS
Monitor airway and breathing – lung congestion could
mean aspiration
Begin IV fluids for rehydration
Monitor blood glucose -- acute intoxication can cause
blood sugar to drop
Consider Zofran 4 mg for vomiting control
Continue to monitor neurological status for
head injury
Rule Out:
 Other reasons Tony may have an altered level of
consciousness
Head injury
Seizure
Sepsis
Drug overdose
Hypoglycemia
Stroke
Hypoxia
Hypothermia
Hyperthermia
Binge Drinking
 National Institute on Alcohol Abuse and
Alcoholism: consuming alcohol to reach a blood
alcohol level of 0.08 gm/dl in < 2 hours
 One in six adults binge drinks 4 times a month
with an average of 8 drinks
 Although binge drinking is more common among
young adults (18-24 years) drinkers 65 years
and older binge more often (5-6 times a month)
 Binge drinking is more common in high income
households
 In addition to acute alcohol poisoning, binge
drinking is associated with:
 unintentional injuries
 Motor vehicle crashes
 Drowning
 Burns
 Falls
 intentional injuries
 Domestic violence
 Sexual assault
 Firearms injures
 medical emergencies
 Poor control of diabetes
 Liver disease
 Hypertension– cardiovascular disease and stroke
Scenario 2
 You respond to a residence where a 3-year-old
girl has been found unconscious.
 The parents tell you that the child, Ellie was
fine when put to bed at eight the night before.
They awoke this morning to find Ellie “asleep”
on the living room floor, they are unable to
arouse her.
 You note partially filled cocktail glasses on the
coffee table and an open bottle of bourbon on its
side on the floor. Some of the glasses have
cherries in them. The parents admit that they
were too tired to clean up after a party last night.
 What could be going on? What happened to this
Ellie? How sick is she?
General Assessment: PAT
Appearance
Unresponsive, lying
sprawled in a pool of
red vomit with cherry
stems
Work of Breathing
Normal
Circulation to Skin
Normal
What is your general impression?
General Impression and Management
Priorities
 General impression:
 Ellie is Sick
Brain dysfunction; likely a
metabolic/toxic cause
What else could cause this?
Seizure
Infection
Head trauma
Other toxic ingestion
What do you need to know to manage
Ellie?
Initial Assessment: ABCDEs
 Airway — open, vomit in mouth – lips and tongue are
red and vomit contains bits of cherry and cherry stems
 Breathing — RR 16; symmetric chest rise; clear lungs;
SaO2 94%
 Circulation — HR 90; skin moist; capillary refill 2
seconds; BP 80/60
 Disability — AVPU = P; pupils sluggish but equal;
decreased tone
 Exposure — breath and clothes smell of alcohol; no
signs of trauma
 Chief complaint – Altered level of consciousness
What is the most likely toxin?
Sedative
Sleepy
Central nervous system depression
Decreased respirations, heart rate and BP
Suggested by open containers of alcohol and smell
of alcohol on child’s breath and clothing
Eating the sweet cherries out of the leftover drinks
could contain enough alcohol to incapacitate a small
child
Management Priorities
 The patient is in impending respiratory failure
because of alcohol ingestion.
 BLS:
Consider airway adjunct. (OPA)
Prepare for bag-mask ventilation.
 Arrange for transport.
 ALS:
Check blood glucose
Treat documented hypoglycemia.
Establish IV access.
 Fluid bolus of 20 ml/kg or 10 ml/pound for dehydration
Perform electronic monitoring.
Consider intubation for airway protection if ALOC and
absent gag reflex.
Case Progression
 Blood glucose is 30 mg/%.
IV started on scene.
10% Dextrose 1-2 ml/pound (2-4 ml/kg) IV
administered.
 Patient becomes somewhat more
responsive, but she remains sleepy.
 If problem was hypoglycemia alone she
should wake up quickly. She is
depressed because of the sedative
effects of alcohol. There is no antidote
for alcohol
Key Concept: Hypoglycemia
 Hypoglycemia is common complication of
alcohol ingestion in young children.
 If the patient is awake, ask the caregiver to
give oral glucose (soda or juice).
 If patient is not alert or the gag reflex is
depressed, give 10% Dextrose IV.
Key Concept: Risk Assessment of
Poisoning
 Determine:
The substance ingested.
Toxicity
Dose ingested: mg toxin ingested per/kg
body weight.
Time since exposure.
 Call:
Poison center (1-800-222-1222) or medical
oversight to help with risk assessment.
Key Concept: Ingestions by Toddlers
Toddlers frequently ingest household
products: solvents, cosmetics, plants,
and cleaning liquids.
Most ingestions in this age group
involve single toxins.
Few ingestions require charcoal or any
specific treatment.
Case Progression
En route: patient remains stable, with
progressive improvement in the level
of consciousness.
ED Course
 In the ED: repeat blood glucose 58. IV glucose
infusion started, electrolytes, blood gas, and
blood alcohol level sent. Social work consult
obtained to evaluate home safety.
 Diagnosis: alcohol ingestion; hypoglycemia
 Outcome: social work call to children’s
protective services (CPS) reveals an open
case, with a past report of child neglect. Child is
discharged the following day in the care of the
maternal grandmother, pending CPS
investigation.
 Toddlers are highly susceptible to the metabolic
effects of alcohol, particularly hypoglycemia.
 Accidental ingestions peak in the 2- to 3-year
age group.
 Prevention of poisoning in the home requires
constant vigilance by caregivers and multiple
rounds of “childproofing!”
Scenario 3
You are dispatched at 2230 hours to a
local tavern for an altercation
On arrival you find 32 year old Dale sitting
at the bar with a bloody towel to his face.
What issues do you need to consider in
this scene as you are approaching Dale?
Dale states he got “sucker punched” in the
nose.
Police are on the way.
The person who hit Dale has left the bar.
Initial Assessment
 Mental Status: Dale is awake with slow measured
speech
 Airway: mouth is clear, but nose is grossly deformed
and swollen with blood coming from both nostrils
 Breathing: Unlabored at about 20/minute
 Circulation: Face flushed, skin warm and sweaty.
Radial pulse strong and regular at 92/minute
 Chief Complaint: “I think that #&^* broke my nose”
SAMPLE





Signs/Symptoms: pain and swelling of the nose
Allergies: none
Medications: none
Past Medical History: none
Last Meal: supper at about 6:30 p.m. and has been at
the tavern since about 8 p.m. He says he has had about
4 beers and 1 “Jack and coke”. (confirmed by bartender)
 Events: Dale got into an argument with another patron
and Dale got punched in the face. Bystanders state he
did not lose consciousness
Head to Toe
Pupils equal and react
Alert to person, place, time and events
Nose is swollen and deformed with
bleeding from both nostrils
No other injuries found: chest, abdomen,
arms, legs
BP 150/96
Pulse 92/minute
Respirations 20/minute
Oxygen saturation 94% room air
Refusal??
Dale says he doesn’t want to go to the
hospital. He just wants to get in his truck
and go home?
Can he do that?
Autonomy
All patients have the right of autonomy or
the right to make decisions about their
care.
A patient does not lose their right to
autonomy simply because they have been
drinking alcohol.
The challenge is to determine if the patient
is competent to make these decisions.
EMS providers are familiar with the signs
of alcohol intoxication:
Diminished fine motor coordination
Decreased social inhibitions
As alcohol intoxication increases
Impaired judgement
Impaired coordination, difficulty walking
Agitation and combativeness
Altered mental state
Slurred speech
Warm flushed skin
Quick Confusion Scale
A tool will soon be available to help
providers determine how confused
someone is due to alcohol.
Adapted from: Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: Comparison
with the mini-mental state examination. Am J Emerg Med 2001;19:461-464
The Quick Confusion Scale
Item
Scoring System
# Correct
X weight
=
What year is it now?
0 or 1 (score 1 if correct
and 0 if incorrect)
2
=
What month is it?
0 or 1
2
=
Total
Present memory phrase:
“Repeat this phrase after me and remember it: John Brown 42 Market Street, New York.”
About what time is it?
0 or 1
2
=
Count backward from 20 to 1.
0, 1, or 2
1
=
Say the months in reverse.
0, 1, or 2
1
=
Repeat the memory phrase.
(each underlined portion correct is
worth 1 point)
0, 1, 2, 3, 4 or 5
1
=
Final score is the sum of the totals:
=
Explanation of Scoring for Quick Confusion Scale
The highest number in category indicates correct response; decreased scoring indicates increased
number of errors
What year is it now?
Score 1 if answered correctly, 0 if incorrect.
What month is it?
Score 1 if answered correctly, 0 if incorrect.
About what time is it?
Answer considered correct if within one hour: score 1 if
correct, 0 if incorrect
Count backward from 20 to 1.
Score 2 if correctly performed; score 1 if one error, score 0 if
two or more errors
Say the months in reverse.
Score 2 if correctly performed; score 1 if one error, score 0 if
two or more errors
Repeat the memory phrase: John Brown
42 Market Street, New York.”
Each underlined portion correctly recalled is worth 1 point in
scoring; score 5 if correctly performed; each error drops
score by one.
Final Score is sum of the weighted totals; items one, two, and three are multiplied by 2 and summed
with the other item scores to yield the final score.
Max score = 15. Score  11 likely cognitive impairment; score 7
= substantial impairment.
Irons MJ, Farace E, Brady WJ, Huff JS: Mental status screening of emergency department patients: Normative study of the Quick
Confusion Scale. Acad Emerg Med 2002; 9:989-994.
What About Refusal?
 Complete the refusal form.
 Explain the benefits of medical treatment and
the risk of refusing treatment
 Strongly encourage Dale to seek treatment
 If he continues to refuse, contact Medical
Control.
 Involve local law enforcement to insure Dale is
safe.
 Dale scores 12 on the confusion scale (he cannot
repeat all of the memory phrase)
 Dale’s speech is progressively more slurred
He was drinking when you arrived at the tavern
 Local law enforcement help you encourage Dale
to seek treatment.
Scenario 4
 It is December 26 at 1330 hours.
 Bill has just arrived to visit his 88 year old
mother Emma. Bill is from out of town and has
not seen his mother since August.
 When she answered the door her gait was not
steady. Bill helped her to her recliner and
thought her speech was slurred and she was
“dopey” so he called 911 thinking she has had a
stroke.
Scene Size Up
 Emma lives in a well kept house in an older
neighborhood.
 The house is clean and tidy but full of
“collectables” and books.
 Emma is sitting in a recliner in the living room.
The table next to her has an empty glass and a
wastebasket full of papers and other trash is
next to the chair.
Initial Assessment
 Mental Status: Emma is awake but slow to
respond, with slightly slurred speech
 Airway: Open and clear
 Breathing: Respirations easy and deep at
16/minute. Breath smells of peppermint
 Oxygen saturation 93% room air
 Circulation: pulse is irregular at 88/minute, skin
is warm and dry
 Chief Complaint: “I’m fine Sweetie, just a little
tired.”
SAMPLE
 Signs/symptoms: unsteady gait and slurred
speech
 Allergies: morphine
 Medications: Vasotec 5 mg twice a day,
potassium 20 meq daily, Lipitor 30 mg daily,
Micronase 5 mg daily, Aspirin 81 mg daily
 Past Medical History: hypertension, high
cholesterol and Type II diabetes
 Last meal: Unknown for sure. Emma said she
had lunch at 11:00 am
 Events: Unknown
Head to Toe Exam
 Pupils hard to evaluate due to cataracts.
 Mouth has green/blue discoloration of the
tongue, lips and tongue are dry.
 Chest has some congestion
 Abdomen soft
 Multiple bruises on bilateral lower arms and
shins
 Ankles have bilateral edema
 Blood Sugar 280
FAST Assessment
Face – both sides move equally
Arms – both arms raise equally
Speech – slurred, Emma giggles when
she has trouble speaking
Time – Bill has not seen his mother since
August and has not talked to her on the
phone for 2 days.
 Your partner looks in the waste basket and finds
2 large bottles of blue mouthwash that are
empty.
 Emma tells you that she will admit she has been
drinking more since her friend Betty died this fall
because it makes her feel “happy”. She ran out
of Tequila and the weather was bad, so she has
been drinking mouthwash because it was in the
house and it tastes better.
Mouthwash???
 Ethanol is not only found in alcoholic beverages
but is a main ingredient in mouthwash, over the
counter cold medications (Nyquil™) and
perfume.
 Individuals who want to hide their ethanol intake
or who are unable to obtain alcohol may drink
other forms of ethanol.
 Household ethanol is also a danger for
accidental pediatric overdose.
Medical Side Effects of Ethanol
Poor control of diabetes
Hypertension
Liver disease
Stroke
Cardiovascular disease
What are your concerns about Emma?
How do you want to manage her care?
Management
BLS care
Monitor airway and breathing
Oxygen by cannula to an O2 Saturation of 94%
ALS care
IV access and fluid bolus (monitor lungs)
EKG monitoring for dysrhythmias
Her monitor shows
What is this?
What else does Bill need to consider
regarding his mother?
Bill needs to seek help to find other ways
for his mother to deal with the loss of her
friend other than drinking.
Scenario 5
Dispatched at 0730 hours
 For a middle aged woman who is “out of
her mind”
Scene Size Up
Upscale neighborhood
Well kept house
Small barking dog is held by husband who
answers the door.
General Impression
Disheveled middle aged woman, Edie,
sitting on kitchen floor
Hitting the floor with her slipper
Appears very anxious and frightened
Initial Assessment
Mental Status: awake but is distracted
and does not follow commands
Airway: open with very dry mucus
membranes
Breathing: 28, deep and rapid
Circulation: skin pale, cool and moist
Radial pulse fast, weak and thready
 Chief Complaint: “There are too many bugs”
Focused History
Allergies: codeine
Medications:
Alprazolam 1 mg BID
Inderal for blood pressure
Synthroid 150 mg
Ambien at nighttime for sleep
Past History
Hypothyroidism
“bad nerves”
Social drinker (averages 2 bottles of
Chardonnay or other wine every evening)
Last Meal
24 hours ago
 Events: Edie wanted to surprise her son for
Christmas, so she quit drinking 2 days ago.
She started feeling ill yesterday with feeling
weak and no appetite. This morning Edie is
shaky and confused. She says she sees black
bugs all over the kitchen (no one else can see
them). She feels them crawling all over her skin
and she is trying to rub them off.
Focused Physical
 VS: BP 100/60, P 120, R 28
 Pulse Ox: 94% on room air EtCO2 34
 Blood Sugar: 70
 Has trembling of arms
 Rubs on arms and legs trying to brush off bugs
 Red raw abrasions on both arms
 Poor skin turgor, and dry mucus membranes
 Very poor attention span. Does not listen to you.
 Edie’s husband says “she’s lost it and has gone
crazy”
Cardiac Rhythm What is this?
Long Term Alcohol Abuse
General Alcoholic Profile
Drinks early in the day, alone, or secretly.
Binges, blackouts, GI problems, chronic
flushing of face and palms.
Cigarette burns, tremulousness, and odor of
alcohol.
Alcohol Abuse
 Consequences of
Chronic Alcohol
Ingestion
 Poor nutrition
 Alcohol hepatitis
 Liver cirrhosis, pancreatitis
 Sensory loss in hands/feet
 Loss of balance and
coordination
 Upper GI hemorrhage
 Hypoglycemia
 Falls (fractures and
subdural hematoma)
Alcohol Withdrawal Syndrome
 Alcohol (ethanol) withdrawal syndrome can
begin as early as 6 hours after the fall of blood
alcohol levels and usually peaks between 24
and 36 hours. It can take up to 5 days after the
termination of drinking to resolve.
 Delirium Tremens (DTs) is a life threatening
manifestation of ethanol withdrawal
characterized by tremors, hallucinations and
hypovolemic shock. DTs appear in 48-96 hours
and can persist up to 7 days.
Withdrawal Syndrome DTs
Signs & Symptoms
Coarse tremor of hands, tongue, eyelids
Nausea, vomiting, general weakness, anxiety
Tachycardia, sweating,
 Hallucinations – frightening or threatening visual
(seen) auditory (heard) and/or tactile (felt)
Signs and Symptoms cont.
Increased sympathetic tone -- seizures
 Orthostatic hypotension (BP drops when patient
stands up)
OR hypertension
Dehydration – hypovolemic shock
 Irritability or depressed mood, poor sleep
DTs are a serious
medical
emergency!!
Alcohol Abuse
 BLS Treatment
Establish and maintain the airway.
Determine if other drugs are involved.
Prevent self harm.
Be alert for seizures
Do not “buy into” the hallucinations
• Do not say that you see the hallucinations too
• Do not tell Edie that there are no bugs there
• Acknowledge that Edie is afraid and that she sees
bugs but that you can’t see them.
Treatment cont. ALS
Establish IV access.
•
•
•
•
Replace fluids at 20 ml/kg for dehydration
25g D50W if hypoglycemic or
1-2 ml/pound (in 50 ml boluses) of D10W if hypoglycemic
Versed 0.1 mg/kg for shaking or seizures
Transport, maintaining a sympathetic attitude, and
reassure the patient.
Review
 Answer the following questions as a group.
 If doing this CE individually, please e-mail your
answers to:
shelley.peelman@presencehealth.org
 Use “December 2015 CE” in subject box.
 You will receive an e-mail confirmation. Print
this confirmation for your records, and
document the CE in your PREMSS CE record
book.
 IDPH site code # 067100E1215
1. How does alcohol (ethanol) effect the
body?
a.
b.
c.
d.
Hallucinogen
Stimulant
Sedative
Opiate
2. How does a person usually respond to
low doses of alcohol?
a.
b.
3. How does a person usually respond to
higher doses of alcohol?
a.
b.
c.
4. Why do people get warm when they
drink?
5. Why do people wake up very thirsty after
drinking alcohol?
6. Name some other emergency conditions
that might be masked by alcohol
intoxication?
a.
b.
c.
7. What specific medical problem occurs
when children drink alcohol?
8. True/False Patients with alcohol on their
breath lose all their ability to make
decisions and must be transported to the
hospital.
9. If a person has no access to alcohol,
what other household items contain
ethanol and can be used to get
intoxicated?
10.Why are DTs dangerous?
Answers
1. How does alcohol (ethanol) effect the
body?
a.
b.
c.
d.
Hallucinogen
Stimulant
Sedative
Opiate
2. How does a person usually respond to
low doses of alcohol?
a. depression of inhibitions
b. aggressive or inappropriate behavior
3. How does a person usually respond to
higher doses of alcohol?
a. dulled sense of awareness
b. decreased coordination
c. decreased reaction time
stupor and coma
4. Why do people get warm when they
drink?
Alcohol ingestion causes peripheral vasodilation
which increases sense of being warm and loss of
body heat
5. Why do people wake up very thirsty after
drinking alcohol?
Alcohol is dehydrating and increases removal of
water through urination.
6. Name some other emergency conditions
that might be masked by alcohol
intoxication?
a. head injury
b. low blood sugar
c. infection
seizures/ post ictal state
hypoxia
7. What specific medical problem occurs
when children drink alcohol?
hypoglycemia (low blood sugar)
8. True/False Patients with alcohol on their
breath lose all their ability to make
decisions and must be transported to the
hospital. False
9. If a person has no access to alcohol,
what other household items contain
ethanol and can be used to get
intoxicated?
mouthwash, perfume, liquid cold
medicine
10. Why are DTs dangerous?
DTs can lead to seizures, hypotension
and hypovolemic shock.