Emergency Medicine

ALTERED CONSCIOUS LEVEL

86 General Medical Emergencies

3 Other general medical problems in patients who drink

(i) Epileptic seizure.

(ii) Acute poisoning.

(iii) Meningitis, chest infection, etc.

(iv) Cerebral haemorrhage.

(v) Unrecognized trauma such as a rib fracture, wrist fracture,

abdominal injury.

(vi) Hypothermia.

4 An acute condition more prevalent in chronic alcoholics

(i) Pneumococcal pneumonia, aspiration pneumonia or

tuberculosis.

(ii) Cardiac arrhythmia, cardiomyopathy.

(iii) Gastrointestinal haemorrhage, including variceal.

(iv) Pancreatitis.

(v) Liver failure.

(vi) Hypokalaemia, hypomagnesaemia, hypocalcaemia.

(vii) Withdrawal seizures or delirium tremens.

(viii) Ketoacidosis.

(ix) Acidic acidosis.

(x) Renal failure.

(xi) Wernicke’s encephalopathy.

5 Thus, many patients smelling of alcohol will require admission to exclude

the above conditions.

6 Always admit if in doubt, and do not discharge until medically well, sober

and safe.

Alcohol withdrawal

This is caused by an absolute or relative decrease in the usual intake of alcohol,

that may be intentional through lack of funds or unintentional following deten-

tion in hospita l or by t he police.

DIAGNOSIS AND MANAGEMENT

Two conditions are recognized: the alcohol withdrawal syndrome, and the

progression to delirium tremens.

1 Alcohol withdrawal syndrome

(i) This is common, occurring within 12 h of abstinence and lasting

a few days. It is characterized by agitation, irritability, fine

tremor, sweats and tachycardia.

(ii) Commence diazepam 10–20 mg orally 2–6-hourly until the

patient is comfortable, plus thiamine 100 mg i.v. or i.m. once

daily.