What is Alcohol Poisoning?

Overview

Although any alcohol can be toxic if consumed in sufficient quantities, toxic alcohol has traditionally referred to isopropanol, methanol, and ethylene glycol. Acute intoxication with any of the alcohols can cause respiratory depression, aspiration, hypotension, and cardiac arrest. Prompt identification and treatment of people drunk with these drugs can minimize morbidity and mortality associated with these alcohols.

Alcohol Poisoning meaning

Alcohol Poisoning is a potentially fatal condition that arises as a consequence of drinking an excessive amount of alcohol within a short period of time. When the level of alcohol in blood increases over the recommended maximum level, an individual is at risk of alcohol poisoning. The person then starts showing the symptoms of disorientation, labored breathing, decreased temperature, or can even slip into a coma.

Alcohol Poisoning can be life-threatening and requires immediate medical attention. Children or adults may also unintentionally drink household products containing alcohol that can lead to alcohol poisoning.

How common is Alcohol poisoning?

Although no demographic group is immune to the effects of alcohol, teenagers and young adults are the most likely to seek treatment for intoxication and poisoning. They are also more prone to undergo severe injuries caused by alcohol. Alcohol usage is responsible for around 3.3 million fatalities and is the fourth highest avoidable cause of mortality in the United States. One in every twelve individuals has an alcohol use problem, which is defined as having more than three drinks per day in men and more than two drinks per day in women, or binge drinking.

Ethanol intoxication is frequent in older adolescents and adults. An adult's toxic dosage is 5 mg/dL, whereas a child's hazardous dose is 3 mg/dL. Children are more likely than adults to develop hypoglycemia after a single ingestion. The majority of isopropanol ingestions occur in youngsters under the age of six. The majority of methanol and ethylene glycol ingestions occur in individuals over the age of 19.

What are the Causes of Alcohol Poisoning?

Alcohol in the form of ethanol is used in many alcoholic beverages; ingestion of these products in large quantities within a short period of time can lead to alcohol poisoning. Isopropyl alcohol and methanol in common household items like mouthwash, some cooking condiments, medications, and cleaning products can cause toxic poisoning that may require immediate medical attention.

The liver filters out alcohol, a toxin, from the body in specific time intervals. When a person consumes excessive amounts of alcohol within a short period of time, the liver fails to filter out the excess toxins causing it to fail. When the rate of filtration decreases, the alcohol present in the bloodstream hampers the normal functioning of the body resulting in many complications.

An important cause of poisoning is binge drinking among individuals. Binge drinking is a pattern of drinking too much alcohol within a very short period of time. In the case of a man, if he drinks more than 5 alcoholic beverages within 2 hours, it can be termed as binge drinking. For a woman, however, it is 4 glasses of alcoholic drink within 2 hours. Binge drinking results in an increased level of alcohol concentration in the bloodstream since the body absorbs alcohol much faster than nutrients. This higher level of alcohol concentration causes the liver to filter out the toxins inefficiently and thus becomes fatal.

Alcohol poisoning may also occur in individuals who are under certain medications. Drinking while under prescribed medication may lead to fatal outcomes.

What are the Associated Risk Factors?

There are numerous risk factors for alcohol poisoning. Some of them include:

Overall state of health of the concerned individual.
Body weight and body mass index of the concerned individual.
The alcohol tolerance level of the body.
Intake of other intoxicants or prescribed drugs.
Intake of food.
The alcohol percentage in the beverage.
The amount and rate of alcohol consumption.

Pathophysiology

Ethanol

Ethyl alcohol is a low molecular weight hydrocarbon produced from sugar and grain fermentation. It is commonly accessible as a beverage and as a component of food extracts, cough and cold treatments, and mouthwashes.

Ethanol is quickly absorbed through the stomach mucosa and the small intestine, reaching a peak concentration 20-60 minutes after intake. It is transformed to acetaldehyde after absorption. Three distinct enzymes are involved in this conversion: the microsomal cytochrome P450 isoenzyme CYP2E1, the cytosol-based enzyme alcohol dehydrogenase (ADH), and the peroxisome catalase system. Acetaldehyde is subsequently turned to acetate, which is then transformed to acetyl Co A, carbon dioxide, and water.

The pace of metabolism is affected by genetic variants coding for alcohol dehydrogenase, the amount of alcohol consumed, and the rate at which ethanol is consumed. Ethanol is metabolized at a rate of 20-25 mg/dL in nonalcoholics but at a higher rate in chronic alcoholics.

Isopropanol

Isopropyl alcohol is a hydrocarbon with a low molecular weight. It is frequently used as a solvent as well as a disinfectant. Many mouthwashes, skin lotions, rubbing alcohol, and hand sanitizers include it. It is often used as an ethanol replacement due to its broad availability, absence of purchase restrictions, and deep intoxication qualities.

Isopropanol is quickly absorbed through the stomach mucosa, reaching a peak concentration 30-120 minutes after intake. Isopropanol is predominantly converted to acetone by alcohol dehydrogenase. In the urine, a little amount of isopropanol is eliminated unaltered. Acetone concentrations do not reach their peak until around 4 hours after intake. Acetone depresses the central nervous system and has a fruity odor on the breath.

Methanol

Methyl alcohol is a common industrial and marine solvent, as well as a paint stripper. It's found in photocopier fluid, shellac, and windshield-washing fluid. Although toxicity is most commonly caused by eating, it can also be caused via prolonged inhalation or skin absorption.

Methanol is quickly absorbed from the stomach mucosa and reaches a peak concentration 30-90 minutes after intake. Methanol is predominantly converted to formaldehyde in the liver by alcohol dehydrogenase. Formaldehyde is then converted into formic acid by aldehyde dehydrogenase, which is then converted into folic acid, folinic acid, carbon dioxide, and water. The lungs discharge a tiny amount of it unaltered.

The majority of the toxicity associated with methanol is caused by formic acid. Methanol undergoes zero-order metabolism in the absence of competition for alcohol dehydrogenase and is consequently excreted at a rate ranging from 8.5 mg/dL/h to 20 mg/dL/h. When methanol is competitively inhibited by ethanol or fomepizole, its metabolism shifts to first order. The excretion half-life in this later condition ranges from 22 to 87 hours.

Ethylene glycol

Ethylene glycol is a colorless, odorless liquid with a pleasant taste that is utilized in a variety of manufacturing operations. It is most often found in antifreeze in the United States. It is quickly absorbed from the gastrointestinal system, with peak concentrations reported 1-4 hours after consumption.

Ethylene glycol is not harmful in and of itself, but it is converted into dangerous chemicals. Ethylene glycol is converted into glycoaldehyde by alcohol dehydrogenase, which is subsequently converted into glycolic acid by aldehyde dehydrogenase. The conversion to glycolic acid is quite quick. The conversion of glycolic acid to glyoxylic acid, on the other hand, is slower and the rate-limiting step in the ethylene glycol metabolism.

Glyoxylic acid is then converted into a variety of metabolites, including oxalic acid (oxalate), glycine, and alpha-hydroxy-beta-ketoadipate. Pyridoxine is required as a cofactor for the conversion to glycine, whereas thiamine is required for the conversion to alpha-hydroxy-beta-ketoadipate. Calcium oxalate crystals are formed when oxalic acid reacts with calcium.

The excretion half-life of ethylene glycol is approximately 3 hours in the context of normal renal function and no competing inhibition for alcohol dehydrogenase. Alcohol dehydrogenase, on the other hand, is competitively inhibited in the presence of fomepizole or ethanol, and the resulting excretion half-life increases to approximately 17-20 hours.

What are the Symptoms of Alcohol Poisoning?

Blood Alcohol Concentration or BAC is the measure of alcohol levels in the blood of an individual. A sober person would have a BAC of 0.0, while a BAC of 0.08 is considered to be intoxicated. BAC of 0.40 can be fatal.

Symptoms of mild alcohol poisoning include:

Disorientation.
Confusion.
A sudden drop in body temperature.
Abnormal or slow breathing.
Vomiting.
Stupor.

Symptoms of severe alcohol poisoning include:

Heart attack.
Severe lung infections.
Dehydration that may potentially lead to brain damage
Seizures due to a sudden drop in glucose levels.
Might stop breathing.
A sudden drop in body temperature.
Pale skin with a blue tinge.
BAC of 0.40 or higher can potentially lead to the onset of coma.

If any of the above-mentioned symptoms are detected in a person, it is advisable to seek medical help immediately.

Evaluation of alcohol intoxication

The amount of the workup after consuming any form of alcohol is partially determined by the past. However, because the patient's sensorium is likely to be changed and a history is likely to be unavailable or erroneous, a comprehensive physical examination is required to assess for concealed injuries; laboratory hints can also be useful.

Acute alcohol intoxication induces lactic acidosis, hypoglycemia, hypokalemia, hypomagnesemia, hypocalcemia, and hypophosphatemia, among other metabolic disorders. A thorough electrolyte panel, as well as liver function tests, should be included in the laboratory analysis. Alcohol can have an immediate impact on the cardiovascular system, causing atrial and ventricular tachydysrhythmias.

An EKG should be performed. One phenomenon known as "holiday heart syndrome" might emerge, which is characterized by new-onset arrhythmias following acute alcohol drinking and can include new-onset atrial fibrillation. If an arrhythmia is discovered, serial EKGs should be performed because the majority will resolve with the removal of alcohol. If the EKG alterations continue, another reason should be investigated.

When a thorough history cannot be collected in the event of changed mental status, a CT scan of the brain should be conducted to rule out any intracranial disease contributing to the patients' mental status. Many inebriated patients express suicide thoughts or make suicidal gestures. A psychiatric examination should be carried out, and it may be necessary to repeat it when the patient becomes more conscious.

Alcohol poisoning Management

The prehospital care provider is responsible for a number of crucial duties. First, the prehospital caregiver should look for any empty containers in the vicinity of the patient. In addition, anyone who seems drunk should have their blood sugar level checked. Additional prehospital treatment for patients with changed mental status is dictated by local protocols and the provider's skill level.

Since alcohol poisoning can potentially be fatal, it is recommended to seek medical help immediately. While help arrives, the following assistance can be provided:

It is important to keep the person conscious.
Check for potential choking triggers and loosen any tight clothing especially around the neck and chest areas.
Try giving water to the patient, if the patient can drink it. Alcohol tends to dehydrate the body. Avoid giving caffeinated drinks like tea, coffee, and soft drinks. Caffeine may lead to dehydration.
Try to restrict any movement. Do not let the intoxicated person walk or run.
Put the person in a comfortable resting position, If the person appears to be unconscious.
Keep the person in a sitting position.

At the medical center, the person may be subjected to the following:

A tube might be inserted into their windpipe to facilitate normal breathing and reduce the risk of choking.
The person would be given drips for rehydration.
In some cases, the stomach may be pumped to flush out fluids with the help of a tube.
In a few cases, dialysis may be conducted for blood filtration.

During the recovery process of the person, he/she may experience anxiety, nausea, stomach cramps, headaches, and in some cases, tremors.

Occult thiamine deficiency and Wernicke encephalopathy are difficult to detect, and this illness has a significant fatality rate. As a result, the cost/benefit analysis favors providing thiamine. Patients with alcohol use problem may not benefit from IV fluids, and alcoholic cardiomyopathy must be considered in this patient population before providing fluids. Some individuals may become angry or aggressive as a result of their treatment.

Sedative medications, such as droperidol or haloperidol, may be necessary in certain cases, keeping in mind the drug's possible interaction with alcohol. Patients may need to be admitted to the hospital for additional treatment depending on the degree of the intoxication and consequences such as Wernicke encephalopathy, alcoholic hepatitis, or dysrhythmias.

Hemodialysis

Hemodialysis is commonly necessary in individuals who have consumed a large amount of methanol or ethylene glycol. The following are some of the reasons for hemodialysis:

Arterial pH < 7.10
A decline of >0.05 in the arterial pH despite bicarbonate infusion
pH < 7.3 despite bicarbonate therapy
Rise in serum creatinine level by 90 mmol/L
Initial plasma methanol or ethylene glycol concentration ≥50 mg/dL

What are the Complications Associated with Alcohol Poisoning?

Alcohol has a wide range of effects on many organ systems and can lead to issues with both acute and chronic consumption. Patients who are under the influence of alcohol are more prone to sustain trauma-related injuries. Trauma patients who are intoxicated have a longer hospital stay, a greater death rate, and are more prone to sustain severe injuries in the future.

Heavy alcohol consumption within a short period of time may lead to severe complications. Some of them are:

Choking. Alcohol induces nausea that might lead to vomiting. It also suppresses your gag reflex, this might lead to choking especially if you have passed out.
Dehydration. Alcohol leads to severe dehydration which in turn may cause low blood pressure and rapid heart rate.
Seizures. Excessive alcohol consumption can lead to seizures.
Abnormal Heartbeat. Your heartbeat might get irregular or even stop
Decreased Body Temperature.
Brain Damage. Alcohol poisoning may lead to irreversible brain damage.
Coma and Death. Alcohol poisoning may cause the onset of coma and death as well.

Wernicke Encephalopathy

When compared to non-drinkers, heavy drinkers have a substantially greater risk of heart failure. Wernicke syndrome, also known as Wernicke encephalopathy, is caused by thiamine deficiency and is characterized by ataxia, oculomotor abnormalities, and generalized disorientation. It takes days to weeks to develop. While it is most typically encountered in people with alcohol use disorder, it can develop in any condition that results in a thiamine shortage.

Wernicke syndrome is characterized by neurobehavioral symptoms such as poor attention, impaired memory, and disorientation. In its most extreme form, it can cause coma. Wernicke encephalopathy, if left untreated, can proceed to Korsakoff syndrome, which is characterized by anterograde and retrograde amnesia without reduced alertness, attention, or extraocular movement signs. Chronic alcohol use can result in dementia, cerebellar degeneration, and peripheral neuropathy.

Differential Diagnosis

Alcohol poisoning has a very broad differential diagnosis that encompasses anything that might produce a change in mental state. Trauma, sepsis, CNS infections, seizures, nonalcoholic toxicologic ingestion, hypo- or hyperthermia, hypo- or hyperthyroidism, hypoxia, and metabolic derangements are all factors to consider. Many of these can coexist with alcohol poisoning, therefore having a low threshold for obtaining laboratory workup and CNS imaging is critical.

The possibility that the patient would consume non-beverage alcohol, such as cologne, cough syrup, and isopropyl alcohol, complicates the diagnosis of alcohol poisoning. This might be unintentional, as in pediatrics, or deliberate, as in people with alcohol consumption disorder who are unable to get alcohol.

Toxicity of ethylene glycol, methanol, and isopropyl is described in different sections; please visit these articles for further information. Once alcohol usage has been proven, other diagnoses such as Wernicke encephalopathy and hepatic encephalopathy must be investigated.

Prognosis

The prognosis for ethanol poisoning is determined by a number of factors, including the duration of usage, the level of intoxication, accompanying traumatic injuries, and end-organ damage. Patients with simple ethanol poisoning have a favourable prognosis and should be advised to abstain from alcohol. Most chronic issues caused by ethanol poisoning can be eased, and in some cases reversed, by abstaining from alcohol.

What are the Necessary Preventive Measures?

Consumption of excessive alcohol on a regular basis impacts the body in a number of ways. Drinking too much can affect the functionality of your liver, endocrine system, immune system, and can also result in behavioral changes.

Here are a few ways to prevent alcohol poisoning.

Consume alcohol in moderation. Drinking alcohol slowly in small amounts helps the body flush it out efficiently. The recommended safe amount of alcohol for men is less than two drinks a day and one drink for women.
Avoid drinking on an empty stomach. Always have a proper meal before consuming alcohol. Keeping your stomach full may help in reduced absorption of alcohol by your body
Keep yourself hydrated by drinking water
Avoid drinking alcohol when you are under medications.
Avoid drinking games that might lead you to binge drink.
Teach yourself and your loved ones on the dangers of binge drinking and consuming too much alcohol.
Keep alcoholic beverages out of reach from children
Store household products containing alcohol carefully.

Conclusion

Consuming alcohol in moderation is the key to preventing alcohol poisoning. Since every individual is unique an reacts differently to alcohol, it is imperative for everyone to be aware of the risks and benefits posed by alcohol on their bodies. Being aware of the dangers of alcohol consumption can help the individual in the long run. Drinking responsibly and in accordance with their health is what healthy living is all about.

In our culture, alcohol intoxication and usage are and will certainly continue to be common. It is critical to thoroughly check the inebriated patient for immediate organ dysfunction or damage caused by their intoxication, as well as educate them about the necessity of moderation in preventing or slowing the development of chronic disorders. When there is a suspicion of or knowledge of alcohol toxicity, the whole interprofessional healthcare team must work together to enhance patient outcomes.