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Alcohol intoxication

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Alcohol intoxication
SpecialtyMedical toxicology Edit this on Wikidata

Alcohol intoxication (also known as drunkenness or inebriation) is a physiological state that occurs when a person or animal has a high level of ethanol (alcohol) in his/her blood.

Common symptoms of alcohol intoxication include slurred speech, euphoria, impaired balance, loss of muscle coordination (ataxia), flushed face, vomiting, reddened eyes, reduced inhibition, and erratic behavior. In severe cases, it can cause coma or death.

Toxicologists use the term “alcohol intoxication” to discriminate between alcohol and other toxins.

Acute alcohol intoxication results from a very high level of alcohol in the blood. This term is used by health care providers, often in emergencies.

Signs and symptoms

The signs and symptoms of alcohol poisoning include:

  • confusion
  • vomiting[1]
  • dangerous anger
  • seizures (fits)
  • slow breathing (fewer than eight breaths a minute)
  • pale, bluish skin
  • cold and clammy skin[2]

Pathophysiology

Development of a rational scale to assess the harm of drugs of potential misuse, The Lancet, 2007

Ethanol is metabolised to acetaldehyde by alcohol dehydrogenase (ADH), which is found in many tissues, including the gastric mucosa. Acetaldehyde is metabolised to acetate by acetaldehyde dehydrogenase (ALDH), which is predominantly found in liver mitochondria. Acetate is used by the muscle cells to produce Acetyl-CoA using the enzyme acetyl-CoA synthetase, and the Acetyl-CoA is then used in the Citric Acid Cycle.[3] It takes roughly 90 minutes for a healthy liver to metabolize a single ounce, approximately one hour per standard unit.

Ethanol's acute effects are largely due to its nature as a central nervous system depressant, and are dependent on blood alcohol concentrations:

  • 20–99 mg/dL - Impaired coordination and euphoria
  • 100–199 mg/dL - Ataxia, poor judgement, labile mood
  • 200–299 mg/dL - Marked ataxia, slurred speech, poor judgement, labile mood, nausea and vomiting
  • 300–399 mg/dL - Stage 1 anaesthesia, memory lapse, labile mood
  • 400+ mg/dL - Respiratory failure, coma and death

As drinking increases, people become sleepy, or fall into a stupor. Ultimately, the respiratory system becomes depressed, and the person will stop breathing. The most important thing for friends who witness someone "passing out" from too much alcohol is to get them emergency medical treatment. Commonly, comatose patients aspirate their vomit (resulting in vomitus in the lungs, which may cause "drowning" and later pneumonia if survived). CNS depression and impaired motor co-ordination along with poor judgement increases the likelihood of accidental injury occurring.[4] It is estimated that about one third of alcohol related deaths are due to accidents (32%), and another 14% are from intentional injury.[5]

In addition to respiratory failure and accidents caused by effects on the central nervous system, alcohol causes significant metabolic derangements. Hypoglycaemia occurs due to ethanol's inhibition of gluconeogenesis, especially in children, and may cause lactic acidosis, ketoacidosis and acute renal failure. Metabolic acidosis is compounded by respiratory failure. Patients may also present with hypothermia.

Alcohol is metabolized by a normal liver at that rate of about one ounce (one "highball", a normal beer, a regular sized glass of wine) every 90 minutes.[citation needed] An "abnormal" liver, one with hepatitis, cirrhosis, gall bladder disease, cancer, and so on, will have a slower rate of metabolism.

Pharmacology

In the past alcohol was believed to be a non-specific pharmacological agent, affecting many neurotransmitter systems in the brain.[6] However, molecular pharmacology studies have shown that alcohol has only a few primary targets. In some systems these effects are facilitatory and in others inhibitory.

Among the neurotransmitter systems with enhanced functions are: GABAA,[7] glycine,[7] serotonin,[8] nicotinic acetylcholine receptors.[9]

Among those that are inhibited are: NMDA,[8] dihydropyridine-sensitive L-type Ca2+ channels[10] and G-protein-activated inwardly rectifying K+ channels.[11]

The result of these direct effects are a wave of further indirect effects involving a variety of other neurotransmitter and neuropeptide systems, leading finally to the behavioural or symptomatic effects of alcohol intoxication.[6]

Diagnosis

See also: Blood alcohol content

In determining if someone is intoxicated it is necessary to observe their behavior while the subject is sober to establish a baseline, ruling out a preexisting condition such as hypoglycemia, usage of narcotics besides alcohol, mental health issues, and so on. Several well known criteria can be used to establish a probable diagnosis. For a physician in the acute treatment setting, acute alcohol intoxication can mimic other acute neurological disorders, or is frequently combined with other recreational drugs that complicate diagnosis and treatment. Definitive diagnosis relies on a blood test for alcohol, usually performed as part of a toxicology screen. Many patients are uninhibited, especially when legal consequences are unlikely (for example, when no police are present), so they disclose information that simplifies the diagnosis.

Many informal intoxication tests exist. Because they are self-tests, they are inherently unreliable and are not recommended as deterrents to excessive intoxication.

For example, in New England there is a test which should be considered an urban legend or folklore. Most commonly referred to as the Pinch Test or the Swipe Test, it requires the drinker to rub the thumb and forefinger [of each hand] from the top of the nose downward and outward across the nose, or alternatively across the cheeks to the chin (as if stroking a beard). The test is supposedly based upon one's perception of the rubbing. If the sensation of contact persists (that is, if you still feel your fingers on your face after removing them), then you are not intoxicated. If the sensation does not persist, it is suggested that you stop drinking.

There also exist several breathalyzer units which are sold by various producers. Because they are most likely not the same models as those used by police, it is advised that such devices be used only for personal reasons rather than for detecting one's ability to legally operate a motor vehicle.

Management

Emergency treatment for acute alcohol intoxication strives to stabilize the patient and maintain a patent airway and respiration, while waiting for the alcohol to metabolize:[12] Also:

  • Protect vital signs by monitoring ABCs, or Airway, Breathing, and Circulation, that is, if the person is thought to be at risk for severe respiratory depression, consider an Endotracheal tube to protect the airway and assist with breathing.
  • Protect the airway from aspirating stomach contents that could cause aspiration pneumonia.
  • Treat Hypoglycaemia (low blood sugar) with 50ml of 50% dextrose solution and saline flush, as ethanol induced hypoglycaemia is unresponsive to glucagon.
  • Administer the vitamin thiamine, to prevent Wernicke-Korsakoff syndrome, which can cause a seizure (more usually a treatment for chronic alcoholism, but in the acute context usually co-administered to ensure maximal benefit).
  • Check urea and electrolytes to guide fluid replacement.
  • Apply Haemodialysis if the blood concentration is dangerously high (>400 mg%), and especially if there is metabolic acidosis.
  • Provide oxygen therapy as needed via nasal cannula or non-rebreather mask.

Additional medication may be indicated for treatment of nausea, tremor, and anxiety.

Prognosis

A normal liver detoxifies the blood of alcohol over a period of time that depends on the initial level and the patient's overall physical condition. An abnormal liver will take longer but still succeed, provided the alcohol doesn't cause liver failure.[13]

People who have been drinking heavily for several days or weeks may have withdrawal symptoms after the acute intoxication has subsided.[14]

A person who consumes a dangerous amount of alcohol persistently can develop memory blackouts and idiosyncratic intoxication or pathological drunkenness symptoms.[15]

Long-term persistent consumption of excessive amounts of alcohol can cause liver damage and have other deleterious health effects.

Epidemiology

The condition is found in those who ingest excessive amounts of alcohol. Common causes for excessive consumption include depression, alcoholism, inexperience with controlling the amount of alcohol consumed, lack of self-control, and so on.

Society and culture

Laws on drunkenness vary between countries. In the United States, for example, it is a criminal offense for a person to be drunk while driving a motorized vehicle (driving under the influence), operating an aircraft, or (in some states) assembling or operating an amusement-park ride.[16] This is also the case in the United Kingdom and many other countries. In some countries it is also an offense to serve alcohol to an already intoxicated person and often alcohol can only be sold by staff qualified to serve responsibly through Alcohol Server Training.

The blood alcohol content (BAC) for legal operation of a vehicle is typically measured as a percent of unit volume of blood. This ranges from a low of 0.00% in Romania and the United Arab Emirates, to 0.05% in Australia and Germany, to 0.08% in the United Kingdom, the United States, and New Zealand.[17]

Additionally, the U.S. Federal Aviation Administration prohibits crewmembers from performing their duties with a BAC greater than 0.04%, within 8 hours of consuming an alcoholic beverage or while under the influence of alcohol.[18][19]

Minesites in Australia enforce a 0.0% BAC[clarification needed] while on shift, and thus regularly conduct alcohol tests across all personnel.

In the UK and US, police can arrest those deemed too intoxicated in a public place for public intoxication, being "drunk and disorderly" or even being "drunk and incapable". In the UK and Australia, being "drunk in a public place" is an offence in itself.[20] There are often legal penalties for the sale of alcohol to intoxicated persons.[21]

Religious views

Many religious groups permit the consumption of alcohol but prohibit intoxication. Some prohibit alcohol consumption altogether. In the Qur'an,[22][23][24] there is a prohibition on the consumption of grape-based alcoholic beverages, and intoxication is considered as an abomination in the Hadith. Islamic schools of law (Madh'hab) have interpreted this as a strict prohibition of the consumption of all types of alcohol and declared it to be haraam ("forbidden"), although other uses may be permitted.[25]

Some Protestant Christian denominations prohibit the drinking of alcohol[26] based upon Biblical passages which condemn drunkenness (for instance, Proverbs 23:21,[27] Isaiah 28:1,[28] Habakkuk 2:15.[29]), but others allow moderate use of alcohol.[30] Wine is an essential part of the historic Christian rite of communion (see Christianity and alcohol). Proverbs 31:4–7 states a prophecy of King Lemuel,

It is not for kings, O Lemuel, it is not for kings to drink wine; nor for princes strong drink:
Lest they drink, and forget the law, and pervert the judgment of any of the afflicted.
Give strong drink unto him that is ready to perish, and wine unto those that be of heavy hearts.
Let him drink, and forget his poverty, and remember his misery no more.[31]

In The Church of Jesus Christ of Latter-day Saints, alcohol consumption is forbidden,[32] to the point where teetotalism has become a distinguishing feature of its members.

In Buddhism, intoxication is prohibited in both monastics and lay followers. Lay followers observe the Five Moral Precepts of which the fifth precept forbids consumption of intoxicants substances (except for medical reasons). Monastic precepts are even stricter. In the Bodhisattva Vows of the Brahma Net Sutra, observed by some monastic communities and even some lay followers, distribution of intoxicants is likewise discouraged, in addition to consumption.

In Vaishnavism, specifically Gaudiya Vaishnavism, one of the four regulative principles is to abstain from taking any intoxicant. This excludes the consumption of alcohol.

See also

Wikisource has the text of the 1911 Encyclopædia Britannica article "Drunkenness".

References

  1. ^ Hales, Dianne (2010). An invitation to health (Brief [ed]., 2010-2011 ed. ed.). Belmont, CA: Wadsworth Cengage Learning. p. 344. ISBN 9780495391920. {{cite book}}: |edition= has extra text (help)
  2. ^ NHS.uk
  3. ^ Smith, C., Marks, Allan D., Lieberman, Michael, 2005, 'Marks' Basic Medical Biochemistry: A Clinical Approach, 2nd Edtn, Lippincott Williams & Williams, USA, p. 458
  4. ^ McArdle, P (2004). Substance abuse by children and young people. Arch. Dis. Child. 89: 701-704
  5. ^ The World Health Organisation (2007) Alcohol and Injury in Emergency Departments
  6. ^ a b Vengeliene, V. Bilbao, A., Molander, A. & Spangel, R. (2008). "Neuropharmacology of alcohol addiction". Bristish Journal of Pharmacology. 154: 299–315. doi:10.1038/bjp.2008.30.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ a b Mihic, S. J., Ye, Q., Wick, M. J., Koltchine, V. V., Krasowski, M. D., Finn, S. E.; et al. (1997). "Sites of alcohol and volatile anaesthetic action on GABA(A) and glycine receptors". Nature. 389 (6649): 385–389. doi:10.1038/38738. PMID 311780. {{cite journal}}: Explicit use of et al. in: |last= (help)CS1 maint: multiple names: authors list (link)
  8. ^ a b Lovinger, D. M. (1999). "5-HT3 receptors and the neural action of alcohols: An increasingly exciting topic". Neurochemistry International. 35 (2): 125–130. doi:10.1016/S0197-0186(99)00054-6.
  9. ^ Narahashi, T., Aistrup, G. L., Marszalec, W. & Nagata, K. (1999). "Neuronal nicotinic acetylcholine receptors: A new target site of ethanol". Neurochemistry International. 35 (2): 131–141. doi:10.1016/S0197-0186(99)00055-8.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Wang, X., Wang, G., Lemos, J. R. & Treistman, S. N. (1994). "Ethanol directly modulates gating of a dihydropyridine-sensitive Ca2+ channel in neurohypophysial terminals". The Journal of Neuroscience. 14 (9): 5453–5460. PMID 7521910.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Kobayashi, T., Ikeda, K., Kojima, H., Niki, H., Yano R.,Yoshioka, T., & Kumanishi, T. (1999). "Ethanol opens G-protein activated inwardly rectifying K+ channels". Nature Neuroscience. 2: 1091–1097. doi:10.1038/16019.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Devi, G., Castro, V. J., Huitink, J., Buitelaar, D., Kosten, T., O'Connor, P. (2003). Management of Drug and Alcohol Withdrawal. NEJM 349: 405-407
  13. ^ Management of alcoholic hepatitis, Drug and Therapeutics Bulletin 2003;41:49-52; doi:10.1136/dtb.2003.41749
  14. ^ DeBellis, R., Smith, B. S., Choi, S., Malloy, M. (2005). Management of Delirium Tremens. J Intensive Care Med 20: 164-173
  15. ^ Gelder, M., Mayou, R. and Geddes, J. 2005. Psychiatry. 3rd ed. New York: Oxford. pp.186.
  16. ^ Texas Penal Code § 49.065
  17. ^ Blood Alcohol Concentration Limits Worldwide
  18. ^ Sec. 1.1 - General definitions.
  19. ^ Part 91 General Operating and Flight Rules
  20. ^ "[[Licensing Act 1872]]". Acts of the United Kingdom Parliament. Vol. 1872. 1872-08-10. Retrieved 2010-05-08. {{cite news}}: URL–wikilink conflict (help)
  21. ^ Camden.gov.uk
  22. ^ "Qur'an: 4:43". Usc.edu. Retrieved 2010-12-04.
  23. ^ "Qur'an: 2:19". Usc.edu. Retrieved 2010-12-04.
  24. ^ Qur'an: 5:90-91
  25. ^ Yilmaz, Ihsan (2004) [2005-01-31]. "Post-Modern Muslim Legality and its Consequences". Muslim Laws, Politics And Society In Modern Nation States: Dynamic Legal Pluralisms In England, Turkey And Pakistan. Ashgate Publishing. p. 158. ISBN 978-0-7546-4389-0. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)
  26. ^ Southern Baptist, Convention (2006) [20011-01-11]. "On Alcohol Use In America". sbc.net. {{cite web}}: External link in |chapterurl= (help); Missing or empty |url= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)
  27. ^ "Proverbs 23:21". Net.bible.org. Retrieved 2009-11-03.
  28. ^ "Isaiah 28:1". Net.bible.org. Retrieved 2009-11-03.
  29. ^ "Habakkuk 2:15". Net.bible.org. Retrieved 2009-11-03.
  30. ^ Lutheran Church, Missouri Synod (2003) [20011-01-11]. "Alcohol". lcms.org. {{cite web}}: External link in |chapterurl= (help); Missing or empty |url= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)
  31. ^ "Proverbs 31:4–7, King James Version".
  32. ^ "Doctrine and Covenants 89".

Bibliography

  • Bales, Robert F. "Attitudes toward Drinking in the Irish Culture". In: Pittman, David J. and Snyder, Charles R. (Eds.) Society, Culture and Drinking Patterns. New York: Wiley, 1962, pp. 157–187.
  • Gentry, Kenneth L., Jr., God Gave Wine: What the Bible Says about Alcohol. Lincoln, Calif.: Oakdown, 2001.
  • Rorabaugh, W.J. "The Alcoholic Republic," Chapter 2 & 5, Oxford University Press.
  • Sigmund, Paul. St. Thomas Aquinas On Politics and Ethics. W.W. Norton & Company, Inc, 1988, p. 77.
  • Walton, Stuart. Out of It. A Cultural History of Intoxication. Penguin Books, 2002. ISBN 0-14-027977-6.
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