8.3 Toxicology Alcohol Abuse, Dependence And Withdrawal

Front 1

Which of the following is incorrect regarding

Alcohol abuse ?
A. Alcohol withdrawal is a potentially life-threatening medical condition.
B. Up to 20% of Emergency Department presentations are alcohol

related.
C. The CAGE questionnaire and AUDIT tool assists identification of

potentially hazardous ethanol consumption in ED patients.
D. The "FRAMES"acronym has been shown to decrease alcohol

consumption in those with early detection of alcohol problems.

Back 1

C. Up to 30-40 %

[ 50% in Trauma Patients ]

Front 2

The CAGE Questionaire detects alcohol abuse and dependence with a sensitivity 45-95% and specificity 70-95%. What are the 4 components ?

Back 2

1. Cut down - Have they tried to cut down?
2. Annoyed - Have they been annoyed at

criticism of drinking?
3. Guilty - Do they feel guilty about their

drinking?
4. Eye-opener - Do they feel the need for an

eye-opener in the morning?

Front 3

What are the 4 main pathophysiological

mechanisms of Acute alcohol withdrawal?

Back 3

1. GABA excess ( down regulation of

neuro- inhibitory GABA receptors)

2. Reduced inhibition of excitatory NMDA

glutamate receptors
3. Increased dopaminergic neurotransmission
4. Increased noradrenergic neurotransmission.

Front 4

Which is incorrect regarding the spectrum of severity of Acute alcohol withdrawal ?

A. Alcohol withdrawal syndrome develops within 12-24 hours.
B. Autonomic excitation occurs peaks at 24-48 hours of cessation.
C. Neuroexcitation occurs within 12-48 hours of cessation.
D. The mortality of Delerium Tremens is < 8%

Back 4

A. AWS develops within 6-24 hours.

D. Dunn: Mortality 15% untreated

Front 5

List the 8 medical co-morbidities associated with alcohol abuse.

Back 5

1. Dehydration
2. Electrolyte abnormalities
3. Alcoholic gastritis and GI bleeding
4. Pancreatitis
5. Alcoholic Liver Disease and hepatic encephalopathy
6. Subdural haemorrhage
7. Wernicke's encephalopathy
8. Alcoholic ketoacidosis

Front 6

(Dunn) In regards to acute alcohol withdrawal, and the maximum score possible on the Toronto AWS, which of the following is correct?
A. 30
B. 47
C. 67
D. 50

Back 6

C.

** many different forms of the alcohol

withdrawal scale exist, using different cut-off points for grading severity and treatment.

Front 7

(Dunn) What AWS score is considered

"very severe"?

Back 7

AWS > 25 = very severe

Front 8

(Dunn) What are the ranges for the Alcohol

withdrawal score?

Back 8

Mild = 6-10
Moderate -severe = 11-25
Very severe = > 25

Front 9

Which is correct regarding Delerium Tremens?
A. It is rare before the second day of abstinence.
B. Occurs in approximately 5% of cases acute alcohol withdrawal.

C. It has a 25% mortality untreated.
D. It has delerium + autonomic hyperactivity + cardiovascular collapse.

Back 9

Delerium Tremens :

D. =Delerium + Autonomic hyperactivity + cardiovascualr collapse

A = rare before 3rd day
B = 1% cases
C. 8-15% mortality

Front 10

Which is incorrect regarding the management of alcohol withdrawal?
A. Carbamazepine and valproate can be used as second line agents

after BZD.
B. Phenytoin is ineffective.
C. Oral and IV Benzodiazepines are the treatment of choice.
D. Alcohol can be prescribed as a treatment option.

Back 10

D. No indications for its use.

Front 11

What is the main Alcohol withdrawal scale

used-and how many domains does it have?

Back 11

CIWA-Ar score

Developed by the Addiction Research

Foundation Clinical Institute of Toronto

10 domains

Front 12

Which is incorrect regarding the CIWA-Ar

Alcohol withdrawal score scale?
A. Headache and Nausea/vomiting are not actually domains in this

scoring system.

B. The maximum score is 67
C. It has 10 domains
D. It is sensitive BUT not specific for alcohol withdrawal

Back 12

A. Yes they are

Front 13

List the 10 domains of the Toronto Alcohol

Withdrawal Score?

Back 13

1. Nausea and vomiting
2. Tactile disturbances
3. Tremor
4. Paroxysmal sweating
5. Auditory disturbances
6. Visual disturbances
7. Anxiety
8. Agitation
9. Headache
10. Orientated / Clouding of Sensorium

Front 14

What end points encompass the alcohol

withdrawal score and treatment with

benzodiazepines?

Back 14

1. Aim for AWS < 10 (mild)
2. Obtain advice when oral diazepam total > 120mg
3. AWS of > 25 = MEDICAL EMERGENCY
4. 5mg IV diazepam can be given 5-10 minutely in the first 30 minutes for AWS > 25 .

Front 15

(Dunn ) Which is correct regarding alcoholic

ketoacidosis?
A. It is primarily due to high levels of acetoacetate
B. It is uncommon in heavy alcohol users
C. It produces a normal anion gap metabolic acidosis.

D. It is treated with both 0.9% saline and dextrose

Back 15

D.

A = betahydroxybutyrate
B = Usually occurs in heavy alcohol users who have had a high intake over the preceding days
C = HAGMA

Front 16

What triple acid-base disturbance can be

produced by a patient presenting with

moderate-severe alcoholic ketoacidosis?

Back 16

1. High anion gap metabolic acidosis HAGMA
2. Respiratory alkalosis

( withdrawal-related hyperventilation)
3. Metabolic alkalosis (protracted vomiting)

Front 17

(Dunn )Which is incorrect regarding the

proposed Pathophysiology of alcoholic

ketoacidosis?
A. The serum glucose is typically normal .
B. The malnourished state + decreased glycogen stores contribute
C. Lipolysis increases circulating free fatty acids and ketoacid production
D. There is increased circulating catecholamines -that enhance ketoacid production.

Back 17

A. Glucose may be normal , low or slightly

elevated.

Front 18

(Dunn)
Which is incorrect regarding Alcoholic

ketoacidosis?
A. Administration of glucose is necessary to terminate ketogenesis.
B. Administration of glucose is necessary to replenish glycogen stores.
C. Ketogenesis occurs from lipolysis and circulating free fatty acids.
D. Thiamine is not necessary when treating alcoholic ketoacidosis.

Back 18

D. Thiamine used to prevent Wernicke's

Encephalopathy.

Front 19

Which is incorrect regarding alcohol (s) and metabolic acidosis?
A. Clinically significant metabolic acidosis does not occur with acute ethanol intoxication.
B. Alcoholic ketoacidosis is an "Ethanol abstinence Syndrome" that

produces marked increases in acetoacetate AND beta hydroxybutyrate.
C. An osmolar gap > 35 mOsm/kg is 88% specific for a toxic alcohol.
D. A quick method for determining the presence of a toxic alcohol is

calculation of the OSMOLAL GAP.

Back 19

C. An Osmolar Gap > 25 mOsm/kg : is 88%

specific for the presence of a toxic alcohol

(Ethylene glycol or methanol)

Front 20

Thrombocytopenia and platelet dysfunction in Chronic Alcohol abuse occurs from which of the following ?

A. Folate deficiency
B. Hypersplenism
C. Qualitative platelet defects
D. Bone marrow depression

Back 20

All

Front 21

Which is incorrect regarding coagulopathy

associated with Chronic alcohol abuse?
A. The main affected coagulation factors a II , VII , IX and X.
B. The dysfunction is from both - poor diet AND hepatobiliary

dysfunction.
C. FFP is more likely to be helpful than Vitamin K in the bleeding alcoholic.
D. All coagulation factors are affected, except factor IX.

Back 21

D. Factor VIII is the only coagulation factor not affected by chronic alcohol use.

Front 22

List the main causes for acute agitation in the

alcoholic.

Back 22

1. Hypoglycaemia
2. Hypoxia
3. Closed head injury (SDH)
4. URINARY RETENTION
5. Alcohol withdrawal.

Front 23

What are the criteria for the diagnosis of

Wernicke-Korsakoff Syndrome?

Back 23

Any 2 of the following 4 signs:
1. Confusion: Altered mental state

( memory impairment)
2. Oculomotor abnormalities:
a. Nystagmus (Horizontal and vertical)
b. Disorders of conjugate gaze
3. Cerebellar dysfunction - ataxia
4. Dietary deficiencies.

Front 24

Which is incorrect regarding Wernicke's

Encephalopathy?

A. 80% have a polyneuropathy
B. The ocular manifestations are almost always permanent.
C. Improvement is usually apparent within several hours of thiamine treatment.
D. The plasma thiamine level may be normal.

Back 24

B. Recovery is nearly always complete.

Front 25

Which is incorrect regarding Korsakoff's

Syndrome.
A. Korsakoff's is a loss of long term memory, with an alert and

responsive patient.
B. Confabulation is a feature.
C. Memory and learning are effected out of proportion to the other

cognitive functions.
D. It involves the thiamine-sensitive transketolase areas such as the mamillary bodies and hypothalamus.

Back 25

A. Korsakoff's = Short term memory loss