-Acute alcohol intoxication: the main problems are hypoglycaemia, respiratory depression, airway protection and, in severe cases, fitting.
-Alcohol as a component of deliberate self-harm
-Alcohol dependence as a cause of deliberate self-harm
-Acute alcohol withdrawal syndromes: characterised by tremor, sweating, apprehension, nausea and vomiting, weakness and syncope, insomnia, auditory and visual hallucinations, fitting and severe confusion.
-Alcohol-induced disease: alcoholic gastritis, acute variceal bleeding, alcoholic liver disease or pancreatitis.
-Other alcohol-associated medical conditions: unexplained vomiting, atypical chest pain, binge-associated acute atrial fibrillation, hypertension, depression, unexplained falls and confusion in the elderly.
It is important to take a good drinking history to establish the amount and pattern of drinking and the level of dependence.
The CAGE questionnaire:
-Have you felt you should Cut down?
-Have you been Annoyed by criticism of your drinking?
-Have you felt Guilty about your drinking?
-Do you ever have an Eye-opener in the morning to steady your nerves?
Two or more positive answers to the four questions suggests alcohol dependence.
-Ensure patient´s safety.
-Check observations regularly and GCS.
-Monitor GMAWS.
-Observe for signs of trauma, nausea or pain.
-Look for signs of Wernicke´s encephalopathy : acute neuro-psychiatric reaction to severe thiamine deficiency common in alcohol misuse, characterised by acute onset of one or more of the following: acute confusional states, nystagmus and/or ataxia. It can progress to Korsakoff´s psychosis.
-Administer Pabrinex and Thiamine as prescribed, Librium (Chlordiazepoxide) should be prescribed as required.
-Provide a calm and reassuring environment as these patients are often frightened or apprehensive.
SUBSTANCE ABUSE
Cocaine
Cocaine imparts its desired effects by stimulating the release of the stress hormones (noradrenaline, adrenaline and dopamine) to inapppropriately high levels. The effects are dramatic, as may be the side-effects - notably stroke, heart attack and aortic dissection.
The nature of the cardiac damage includes cocaine-related chest pain, acute coronary syndrome, acute myocardial infarction, acute arrythmias and, with prolonged use, cocaine induced heart muscle damage. The sudden changes in pulse rate and blood pressure can trigger cerebral infarction, cerebral haemorrhage and can tear major blood vessels (aortic and coronary artery dissection).
Treatment of all of these complications should follow conventional lines except that beta-blockers are contra-indicated and that high-dose benzodiazepines may be needed to reduce cocaine-induced agitation.
Ecstasy, or MDMA, has amphetamine-like properties which provide hyperstimulation, combined with the exertion of prolonged dancing, can result in:
-dehydration and electrolyte disturbance
-hyperarousal - agitation, tachycardia, hypertension
-muscle breakdown (rhabdomyolysis) and kidney failure
-hyperthermia up to 40°C
-convulsions
-acute liver failure
-severe acidosis
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Management: reassurance and IV fluids are the main measures. Hyperthermia is managed by active cooling and with IV dantrolene 1mg/kg repeated as needed (maximum 10mg/kg). Acute agitation and convulsions respond to benzodiazepines. Acidosis may need correction with sodium bicarbonate.
Heroin abuse
Intravenous drug users are often admitted acutely with multiple complex medical, social and behavioural problems. There is frequently a conflict between the perception of the patient that withdrawal symptoms and pain are not being addressed and that of the carers who view challenging behaviour and "drug seeking". The key is an emphatic approach which is non-judgmental and focuses on the key issues of communication, co-operation and confidentiality (sometimes with the need to set defined limits to behaviour).
Heroin abuse is associated with several major health-related and psychosocial problems: HIV, hepatitis B and C, superficial and deep soft tissue sepsis, venous thromboembolic disease, opiate overdose, social isolation and crime.
Methods of heroin ingestion: inhaled (chase the dragon), smoked or injected (mainlining).
Heroin overdose
Patients are usually deeply comatose, with pin-point pupils. Treatment is with IV naloxone, the specific antidote, but reversal can be dramatic, leading to acute agitation, aggression and violence.
The current recommendations for a methadone treatment program are:
-only methadone syrup, not tablets, should be prescribed
-daily prescriptions should be given
-the effective maintenance dose should not exceed 50-100mg of methadone daily
Methadone programmes are carefully supervised and managed with a system of daily supply and directly observed ingestion. Apart from using methadone syrup, effective treatment programmes monitor drug ingestion with blood and urine testing.
Source:
-A nurse´s survival guide to acute medical emergencies, R. Harrison and L. Daly, Elsevier 2011
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