• Chronic Alcohol-related ICU issues

🔷 1. Acute Ethanol Intoxication

📌 Features (dose-dependent CNS depression):

• Euphoria → slurred speech → ataxia → stupor → respiratory depression → coma
• Hypoglycemia (especially in children)
• Hypothermia, hypotension, and aspiration risk
• Risk of rhabdomyolysis, trauma, arrhythmia (holiday heart syndrome)

🩺 Management:

• Supportive (airway, IV fluids, glucose)
• Thiamine 100 mg IV before glucose (to prevent Wernicke’s)
• Watch for hypoglycemia, rhabdomyolysis, and aspiration

🔬  Lab Tests for Alcohol Use and Toxicity

Test	Utility	Comments
Blood Ethanol Level	Confirms acute intoxication	Levels >80 mg/dL = legal intoxication in many countries
Serum Osmolar Gap	Detects unmeasured alcohols (EtOH, MeOH, EG)	Osm gap >10–15 suggests toxic alcohols
Gamma-Glutamyl Transferase (GGT)	Marker of chronic alcohol use	High sensitivity, low specificity
Carbohydrate-Deficient Transferrin (CDT)	Most specific marker of chronic alcohol use	↑ with heavy alcohol over ≥2 weeks
MCV (Mean Corpuscular Volume)	Elevated in chronic alcoholics	Due to bone marrow suppression, B12/folate deficiency
Ethyl Glucuronide (EtG) / Ethyl Sulfate (EtS)	Detects recent alcohol use (up to 80 hrs)	Urine test — very sensitive

🍃  Breath Alcohol Analyzer Test

🔍 Principle:

• Based on infrared spectrophotometry or fuel cell sensor
• Measures ethanol content in exhaled air, which correlates with blood ethanol (Henry’s Law)

🔷 2. Wernicke’s Encephalopathy (WE)

🔑 Triad (only in ~20%):

• Confusion
• Ataxia
• Ophthalmoplegia (nystagmus, lateral rectus palsy)

🧠 MRI: Increased signal in mammillary bodies, thalami, periaqueductal gray

⚠️ High-Yield:

• Always give Thiamine before glucose in alcoholics
• Dose: 500 mg IV TID for 3 days, then 250 mg IV daily

🔹 3. Korsakoff Psychosis (Korsakoff Syndrome)

Definition:
A chronic neuropsychiatric syndrome due to irreversible damage following untreated or partially treated Wernicke’s encephalopathy, caused by thiamine (vitamin B1) deficiency.

📌 Core Features:

• Anterograde amnesia (can’t form new memories)
• Retrograde amnesia (loss of old memories)
• Confabulation – patient fabricates stories to fill memory gaps
• Lack of insight
• Apathy or flat affect

🧠 Pathophysiology:

• Neuronal loss in mammillary bodies, thalamus, hippocampus
• Often irreversible, unlike Wernicke’s which is reversible with early thiamine.

🔷 4. Alcoholic Ketoacidosis (AKA)

Seen in:

• Binge drinkers who stopped eating + vomiting

Labs:

• High anion gap metabolic acidosis
• Normal or low glucose
• ↑ serum ketones (β-hydroxybutyrate)

Management:

• Dextrose infusion (D5NS)
• Thiamine before glucose
• Correct electrolytes

🔹 6. Holiday Heart Syndrome (HHS)

Definition:
A paroxysmal cardiac arrhythmia, most often atrial fibrillation (AF), occurring after binge drinking, typically in healthy individuals without preexisting heart disease.

🔑 Clinical Scenario:

• Sudden onset palpitations, dyspnea, or syncope
• Usually occurs after heavy alcohol intake on weekends/holidays

📌 Key Features:

• Common arrhythmia: AF > atrial flutter > PVCs
• ECG: Irregularly irregular rhythm (AF)
• Often self-limiting within 24–48 hours
• May recur with repeated alcohol use

🩺 Management:

• Supportive (rate control with beta blockers or CCBs)
• Avoid antiarrhythmics initially unless unstable
• Counsel on alcohol abstinence to prevent recurrence

🔷 7. Complications in Chronic Alcoholics Admitted to ICU

System	Acute Effects	Chronic Effects
CNS	Sedation, impaired reflexes, slurred speech, coma (↑ GABA, ↓ NMDA)	Cerebellar atrophy, Wernicke-Korsakoff, peripheral neuropathy
CVS	Vasodilation, hypotension; arrhythmias (holiday heart)	Cardiomyopathy, hypertension, stroke risk
Respiratory	↓ Respiratory drive at high doses	Aspiration pneumonia, chronic bronchitis
GI/Liver	Gastritis, vomiting, pancreatitis	Fatty liver → hepatitis → cirrhosis, GI bleeds
Renal	Diuresis (inhibits ADH), dehydration	Hypomagnesemia, HypoMg²⁺, HypoK⁺, HypoPO₄³
Endocrine	Hypoglycemia (esp. in fasting), ↓ testosterone	Testicular atrophy, gynecomastia, menstrual irregularities
Heme/Immune	Platelet dysfunction, bleeding tendency	Macrocytic anemia, leukopenia, ↑ infection risk
Metabolic	Hypoglycemia, lactic acidosis, ketoacidosis	Electrolyte disturbances, thiamine/B12 deficiency
Psychiatric	Disinhibition, aggression, mood swings	Dependence, depression, psychosis
Musculoskeletal	Rhabdomyolysis in overdose	Osteoporosis, myopathy
Skin	Flushing (esp. with ALDH2 deficiency)	Spider angiomata, palmar erythema (chronic liver disease)

🔷  Alcohol Withdrawal Syndromes

Stage	Onset (hrs)	Features
Minor Withdrawal	6–12 h	Tremors, anxiety, GI upset, insomnia
Alcoholic Hallucinosis	12–24 h	Visual/auditory hallucinations
Withdrawal Seizures	12–48 h	Generalized tonic-clonic seizures
Delirium Tremens (DT)	48–96 h	Confusion, agitation, fever, HTN, tachycardia, hallucinations

🧠 Pathophysiology:

• Chronic alcohol ↑ GABA & ↓ NMDA → sudden withdrawal → CNS hyperexcitation

💉 Management:

• Benzodiazepines: Diazepam, Lorazepam (symptom-triggered dosing preferred)
• Thiamine IV before glucose
• Correct electrolytes: K⁺, Mg²⁺, PO₄³⁻
• ICU care for DT or seizures

🔷 4. Delirium Tremens (DT)

• Most life-threatening withdrawal syndrome
• Features: agitation, hallucinations, autonomic hyperactivity (↑HR, ↑BP, fever), disorientation
• Starts 48–96 hours after last drink
• Mortality up to 15–20% if untreated

Management:

• ICU-level care
• High-dose benzodiazepines
• Consider Phenobarbital or Dexmedetomidine for refractory cases
• Replete electrolytes, fluids, thiamine




🔷 Bonus Mnemonic – “WEAK DRUNK”

• W – Wernicke’s encephalopathy
• E – Electrolyte imbalances (K, Mg, PO₄)
• A – Alcoholic ketoacidosis
• K – Korsakoff’s psychosis
• D – Delirium tremens
• R – Respiratory depression (intoxication)
• U – Unconsciousness (coma)
• N – Nutritional deficiency
• K – Ketonemia without hyperglycemia