Monday December 22, 2014  

First Aider's Guide to Alcohol

by Rick Curtis, Director, Outdoor Action

As Outdoor Action Leaders you are trained in first aid to be able to respond to emergencies on trips. With that training comes the responsibility to respond to other first aid scenarios you may witness on campus. Probably the most common dangerous situation you will have to treat on campus is severe intoxication or acute alcohol poisoning. You need to understand the physiology and the proper care for friends, acquaintances, and even strangers that you might come upon.

 

The "Evolutionary Onion"

If you've taken a wilderness first aid course you've learned about the human brain as the "evolutionary onion." The outer regions of the brain, the cerebrum, are the centers for higher thinking  As you move deeper into the core of the brain to structures like the cerebellum and the brain stem you reach more primitive areas of the brain which are responsible for basic life functions like breathing and involuntary muscle control. What this means is that anything which affects the central nervous system is first seen impacting the higher brain functions (the outer levels of the onion). This is why checking level of consciousness in your Patient Assessment System (PAS) is so important. Any change on the AVPU scale (see below) means that the brain is being affected. A continued decline on the AVPU scale means that deeper and deeper levels of the brain are being affected.

A Alert Alert and oriented to time, place
V Responds to verbal stimuli The person will respond verbally to questions but will not initiate speech
P Responds to pain stimuli Rubbing the sternum with your knuckles or pinching the earlobe results in wincing, pulling away, or other nonverbal responses
U Unresponsive Unconscious

 

What Affects the Brain

The human brain, as the body's control center, is the most sensitive organ in the body. All sorts of changes in the outside environment or the body's internal chemistry can alter brain function and even cause death. The mnemonic STOPEAT is use to identify the various factors which can affect the brain and the central nervous system. STOPEAT is typically used as the set of possible reasons for someone having a seizure.

S Sugar Lack of blood sugar or too much insulin
T Temperature High temperature "cooking the brain" as in Heat Stroke or low temperature as in Hypothermia
O Oxygen Lack of oxygen to the brain
P Pressure Increasing intracranial pressure from swelling or an internal bleed in the brain
E Electricity Lightning
A Altitude High altitude can cause swelling in the brain
T Toxins Chemicals in bloodstream like alcohol

 

Alcohol Impacts on the Brain

Blood Alcohol Level
Part of Brain Controls Alcohol Effects
Cerebrum advanced functions like recognition, vision, reasoning, and emotion. lowers inhibitions, and affects judgement. As alcohol levels increase, vision, movement, and
speech are impaired.
.01% -.30%
Cerebellum coordinating movement problems with coordination, reflexes, and balance .15-.35%
Medulla controls basic survival functions such as breathing and heartbeat your brain's ability to control respiration and heart rate is severely diminished. Your heart rate
can drop and breathing cease, causing death
as low as .30%

 

Signs & Symptoms

Alcohol is a central nervous system depressant. This means that as more alcohol enters the bloodstream vital body functions will be depressed. At high levels things like blood pressure, pulse and respiration can decrease. Expect to see the following changes in vital signs in someone who has had too much to drink.

Vital Signs

Vitals Early Signs Late Signs
AVPU Alert; possibly confused and/or combative Decreasing to V, P, then U = "passed out"
Respiratory Rate Normal Decreases
Pulse Normal Decreases
Blood Pressure Normal Decreases
Temperature Normal Normal
Skin Red, flushed from vasodilatation (evident in lightly pigmented people only) Pale, cool, clammy

 

The "-Umbles"

Stumble, mumble, grumble, fumble - all common signs that the highest level functions of the Central Nervous System have been affected. We are used to watching for these things in cases of Hypothermia and High Altitude Cerebral Edema. They are also common signs of CNS effects due to alcohol. The person's gross motor coordination has been impaired leading to falling and stumbling. The individual may become belligerent and even violent. The person may be incoherent. While people typically laugh at such "drunken behavior" it is in fact a clear indication that higher brain function is impaired. This is someone who has begun to slide down the AVPU scale. If more alcohol is absorbed into the bloodstream what is viewed as "silly drunken behavior" can have tragic consequences. The most important thing for you to realize as a first aider is that the impact of alcohol on the brain is just as potentially deadly as any of the STOPEAT factors! 

Treatment

When we see these signs and symptoms, what should our reaction as first aiders be? This is serious! If the person were hypothermic we would immediately begin active steps to rewarm the person. If the person was at high altitude, we would start to get them to descend immediately before they became unable to walk. Should we do anything less aggressive in our treatment of someone who has a compromised central nervous system caused by alcohol rather than by cold or high altitude? No way!

Like any first aid situation, you must carefully monitor the person. The most reliable sign of a serious problem is a decrease in AVPU. This means that just "letting the person sleep it off" could have disastrous consequences. If the person is asleep you have no way of knowing if AVPU is declining. It is possible for someone who is in acute alcohol poisoning to go into respiratory arrest while they are asleep. If you see a decline in AVPU to the V level you have a potentially serious situation on your hands. If someone passes out it means they are U on the AVPU scale. You should know what this means from first aid. Brain function is severely impaired and death can be the result. Make sure this person is constantly monitored and/or transport them to McCosh Health Center or to the Princeton Medical Center ASAP. Remember, this is potentially just as serious as a person with increasing ICP. Death is the Anticipated Problem. So make the right treatment choice early. Better to be cautious and safe (and even have to deal with a disgruntled friend in the morning) than end up asking yourself why you didn't act and someone died.

As part of our SOAP Note we have created a general list of Anticipated Problems and Treatment Plans for someone who is intoxicated. AS you can see, simple intoxication can lead to serious medical emergencies and death. One common scenario is vomiting. For a person who is at the top of the AVPU scale and is fully alert this probably presents little risk. However, for the person who is sliding down the AVPU scale, vomiting carries a serious risk of aspirating the vomit and obstructing the airway. Many times people who are intoxicated are left passed out on a bed by themselves. They vomit (body purging toxin) and then in their unconscious state aspirate on the vomit and stop breathing. If left alone death is common. 

As AVPU continues to decline and deeper levels of the brain become affected the more insidious aspects of alcohol poisoning become evident. Too much alcohol can affect the respiratory drive and the person may stop breathing.

SOAP Note

Problem List Anticipated Problems Treatment Plan
Intoxication Acute Alcohol Poisoning as more alcohol is absorbed into the bloodstream building up to toxic levels Call 911. Monitor the patient and arrange transport to Advanced Life Support (ALS).
  Vomiting leading to possible aspiration leading to possible airway blockage and respiratory arrest Call 911. Monitor the patient's airway, place patient on his/her side. Be prepared to manage the airway. Arrange transport to Advanced Life Support (ALS).
  Seizures Call 911. Don't attempt to restrain the patient during a seizure. Just try to keep them away from objects which might cause injury. Carefully monitor the airway and breathing after the seizure. Be prepared to give Positive Pressure Ventilation or CPR. Arrange transport to Advanced Life Support (ALS).
  Decreased respiratory drive leading to possible respiratory arrest Call 911. Monitor respiration. Be prepared Positive Pressure Ventilation,  call 911, and transport to Advanced Life Support (ALS).
  Cardiac arrest secondary to respiratory arrest Call 911. Be prepared to initiate CPR. Watch for vomiting during CPR and manage the airway. Call 911 and transport to Advanced Life Support (ALS).
  Death Call 911. Initiate CPR, arrange transport to Advanced Life Support (ALS).

 

Response Plan

If your friend is conscious and showing changes in AVPU...

  • Stay with this person at all times. NEVER, EVER leave your friend alone!! As a first aider this would be considered abandonment. Even if she/he is conscious now, AVPU may start to decline as more alcohol is absorbed in the blood stream and makes its way to the brain. If you leave the person alone, you aren't there when they may need you most.
  • Guess what, your friend may tell you to "get the hell out of here!" If your friend is belligerent or violent and does not want you to stay, just hang in there anyway. Don't take what is said personally. Sit quietly in the corner if you have to and monitor the person.
  • Medical attention may be required at any time. This means you need to be ready, at a moment's notice, to call the Proctors and/or transport the person to McCosh. If the person is conscious but combative (an AVPU change) don't force help on your own. Ask other friends or neighbors for assistance or call the Proctors Office. 
  • The best possible care for this person is to get him or her to McCosh Health Center where professional medical personnel can monitor and manage the person. 
  • Here is what happens when someone is taken to McCosh. Health Center staff may draw blood and check the blood alcohol level. If the level is dangerously high, the person will be transported by ambulance to Princeton Medical Center for Advanced Life Support Care (see ALS below).

If your friend is unconscious....

  • If lying down, turn the person on his/her side to prevent aspiration of vomit (inhaling own vomit.)
  • Monitor airway and breathing
  • Watch for seizures 
  • This person is in a life or death situation and needs immediate advanced medical care. Call 911 to arrange transport to a medical facility before AVPU declines even more.

If you are the person who is intoxicated it may be a bad scene both for you and for your friends. You may be the only one who understands the seriousness of alcohol intoxication. That means you can't be watching out for anyone else, and no one may be watching out for you. Someone might toss you face up on the bed to let you "sleep it off." If you vomit and aspirate, and no one is watching you, you could die.

Advanced Life Support & Hospital Care

Hospital care may involve the following advanced treatment techniques that you as a first aider are not able to provide. This is why is is so critical to get the person to McCosh Health Center or Princeton Medical Center:

  • Insertion of a nasogastric tube through the nose and into the stomach and pumping the stomach to remove alcohol before more alcohol can be absorbed and to prevent aspiration of stomach contents into the lungs if the person vomits.
  • Administration of activated charcoal to absorb the alcohol in the stomach. The same treatment used for poisoning.
  • Intubation and use of a respirator if respiratory arrest occurs or respiratory drive is so decreased that the person is not breathing adequately on his/her own.

What Happens When I Call the Proctors or Take a Student to McCosh Health Center?

The bigger question is the potentially life-threatening things that can happen to the person if you don't. That's what this whole article is about. But there has been some confusion about what happens so let's clarify the Public Safety Office protocols and the McCosh Health Center Protocols. These have been verified with staff at Public Safety and Princeton University Health Services.

Taking Someone to McCosh Health Center

When you take someone to McCosh Health Center for alcohol intoxication the person will be seen by nurses and then if needed by a physician. Any admission to McCosh Health Center is treated as a confidential medical record. McCosh keeps records of the numbers of students admitted for any condition (including alcohol intoxication). The information about the reason for admission is not sent to any Deans or Directors of Studies.

What Happens When I Call Public Safety?

Public Safety's primary job is to safeguard students and staff at Princeton. These are the important points that many students are unclear on:

  • The Department of Public Safety's primary responsibility is to safeguard students, faculty and staff at Princeton University . You may call Public Safety at any time from campus or an eating club to request transportation for a medical emergency. Public Safety Communications Officers will ask fundamental questions regarding the nature of the emergency and the general condition of the person. In addition, the officer will ask the name, gender, age, and general condition of the individual and whether or not they have lost consciousness at any time. You should accompany the individual to University Health Services to attend to their needs while the Public Safety officer is operating the vehicle.
  • The Department of Public Safety completes reports for all medical transports, including those that involve alcohol. DPS forwards these reports to the Office of the Dean of Undergraduate Students so that the deans can provide the student the necessary support. As stated in Rights, Rules, Responsibilities (p. 49), neither intoxication nor seeking help for oneself or another student because of intoxication will result in disciplinary action.
  • Public Safety will generate an incident report when a New Jersey State or Federal Law has been violated or if there has been a violation of Princeton University policies as stated in Rights, Rules and Responsibilities. An incident report will also be generated for any person who is or has been unconscious, or who requires transportation via ambulance.

The bottom line is that your first priority must always be the health and safety of your patient. 

 

What Happens Afterwards

If you transported him or her to McCosh or the Princeton Medical Center the person may be upset or angry about it. You should remember that you acted for their personal safety. Remind the person that their intoxication placed you in a position of responsibility as a first aider, one that you could not walk away from. You took the necessary steps to place them in the safest environment. You do not deserve for them to angry with you. 

If this situation of getting dangerously drunk is a pattern then you potentially have someone with an alcohol dependence problem. You should seek advice from an Alcohol Peer Educator or from someone at eh Counseling Center for what you can do to get this person to get professional help for the problem.

Tricks of the Trail

Counting Backwards - when we were trekking in Nepal at over 15,000 feet one of our trip members, Ed, was a neurologist. He told me that one of the ways for us to tell if someone's higher brain function was affected was to asked them to count backwards by 9's from 100. If s/he couldn't do it, it meant that the Central Nervous System was being affected. This was a common clinical test that he used in his office with patients who had brain injuries and wroks the same to check for impairment sue to alcohol, lack of oxygen (high altitude) or hypothermia..

The "Sobriety Test" - the police use it and so do mountaineers on Everest. Asking a person to walk a straight line heel to toe is a test of muscle coordination and higher brain function. If the person can't do it, it means that the Central Nervous System was being affected. On Everest this means immediate treatment with oxygen or descent before the person is unable to hike down on their own. On the highway it means that the person is no longer capable of safely operating a vehicle (either for his or her own safety and for the safety of other drivers or pedestrians). 

Drinking & Driving - Think about whether you would want your younger sister or brother in a car being driven by this person. If you aren't 100% sure that they do not have any decrease in AVPU then don't let them drive. It's for their safety and for everyone else's. Your motor coordination can be affected for as many as ten hours after you finished your last drink. So before you get in the car to drive home the morning after a party, think twice about your ability to drive safely.1 

 

Detoxifying the Body

Alcohol, while taken in moderation, is not toxic. However, like many substances, high levels of alcohol can be toxic to the body and can lead to death. This is typically referred to as alcohol poisoning. The level of alcohol in the blood stream is so high that the affect on the central nervous system is the same as if you had eaten a poisonous plant that has effects on the Central Nervous System. 

Unlike most foods or beverages which must be digested over several hours to be absorbed, alcohol is absorbed directly into the bloodstream through the tissue lining of the stomach and the small intestine. When your stomach is empty, alcohol gets absorbed into the bloodstream in roughly five minutes. Once it's in the bloodstream, it takes only 90 seconds for the circulatory system to have pumped it throughout the body organs and the the brain. So alcohol begins to have an effect on the body long before you are actually "drunk."1

So, what does your body do to get rid of a toxic chemical? Well just like any toxic substance if you still have some in your stomach, one of your body's defenses is to throw up to purge the toxin from the system. Vomiting can be extremely dangerous if the person is going down on the AVPU scale because of the possibility of aspiration and airway blockage. Once the alcohol is in the blood stream the only way for the body remove the alcohol is for the alcohol to be processed by the liver. Your liver can only metabolize about one ounce of alcohol per hour. 

Detoxification by the Liver

Alcohol Type Ounces % Alcohol Hours to Detoxify by the Liver
1 Glass Beer 12 oz. 4%  1 hour
1 Glass Wine 5 oz. 11%  1 hour
1 Glass Hard liquor  1.5 oz. 40%  1 hour

 

How Much Alcohol Does it Take?

The amount of alcohol it takes to affect a person's central nervous system depends on multiple factors including body size and weight, degree of hydration, amount of food in the stomach (food in the stomach slows alcohol absorption). To calculate blood alcohol level check out this chart.

Blood Alcohol Levels and Your Body's Response

Blood Alcohol Level (BAL) Responses1
.02%-.03% You feel mildly relaxed and maybe a little lightheaded. Your inhibitions are slightly loosened, and whatever mood you were in before you started drinking may be mildly intensified.
.05%-.06% You feel warm and relaxed. If you're the shy type when you're sober, you lose your feelings of shyness. Your behavior may become exaggerated, making you talk louder or faster or act bolder than usual. Emotions are intensified, so your good moods are better and your bad moods are worse. You may also feel a mild sense of euphoria.
.08%-.09% You believe you're functioning better than you actually are. At this level, you may start to slur your speech. Your sense of balance is probably off, and your motor skills are starting to become impaired. Your ability to see and hear clearly is diminished. Your judgment is being affected, so it's difficult for you to decide whether or not to continue drinking. Your ability to evaluate sexual situations is impaired.
.10%-.12% At this level, you feel euphoric, but you lack coordination and balance. Your motor skills are markedly impaired, as are your judgment and memory. You probably don't remember how many drinks you've had. Your emotions are exaggerated, and some people become loud, aggressive, or belligerent. If you're a guy, you may have trouble getting an erection when your BAL is this high.
14%-.17% Your euphoric feelings may give way to unpleasant feelings. You have difficulty talking, walking, or even standing. Your judgment and perception are severely impaired. You may become more aggressive, and there is an increased risk of accidentally injuring yourself or others. This is the point when you may experience a blackout. 
.20% You feel confused, dazed, or otherwise disoriented. You need help to stand up or walk. If you hurt yourself at this point, you probably won't realize it because you won't feel pain. If you are aware You've injured yourself, chances are you won't do anything about it. At this point you may experience nausea and/or start vomiting (keep in mind that for some people, a lower blood alcohol level than .20% may cause vomiting). Your gag reflex is impaired, so you could choke if you do throw up. Since blackouts are likely at this level, you may not remember any of this.
.25% All mental, physical, and sensory functions are severely impaired. You're emotionally numb. There's an increased risk of asphyxiation from choking on vomit and of seriously injuring yourself by falling or other accidents.
.30% You're in a stupor. You have little comprehension of where you are. You may suddenly pass out at this point and be difficult to awaken. (But don't kid yourself: Passing out can also occur at lower BALs. But, at lower blood alcohol levels, you may decide You've had enough to drink and go "pass out." With an alarming BAL like .30%, your body will be deciding to pass out for you.) In February 1996, an 18-year-old student died of alcohol poisoning with a BAL of .31% after attending two parties the night before.
.35% This blood alcohol level also happens to be the level of surgical anesthesia. You may stop breathing at this point. In February 1996, a second student, age 20, died of alcohol poisoning with a BAL of .34% after drinking six beers and twelve shots in two hours. 
.40% You are probably in a coma. The nerve centers controlling your heartbeat and respiration are slowing down. Death may be imminent. In April 1994, a 21-year-old student died of alcohol poisoning with a BAL of .40% after a Hell Night party.

 

Alcohol Myths2

1. Myth: Alcohol improves my sexual performance.

Fact: Although you may think that drinking makes you better in bed, alcohol reduces your sexual performance. In decreases the ability for men to have an erection and dries up vaginal secretions in women.

2. Myth: I can drink and still be in control.

Fact: Drinking impairs your judgment, which increases the likelihood that you will do something you'll later regret such as having unprotected sex, being involved in date rape, damaging property, or being victimized by others.

3. Myth: Drinking isn't all that dangerous.

Fact: One in three 18 to 24 year olds admitted to emergency rooms for serious injuries are intoxicated. And alcohol is also associated with homicides, suicides, and drowning

1. Myth: I can sober up quickly if I have to.

Fact: It takes 2-3 hours to eliminate the alcohol content of two drinks, depending on your weight. Nothing can speed up this process - not even coffee or cold showers.

5. Myth: It's ok for me to drink to keep up with my boyfriend.

Fact: Women process alcohol differently. No matter how much he drinks, if you drink the same amount as your boyfriend, you will be more intoxicated and more impaired.

6. Myth: There is no point in postponing drinking until I'm over 21.

Fact: Research shows that the longer you postpone drinking, the less likely you are to ever experience alcohol-related problems.

2. Myth: I can manage to drive well enough after a few drinks.

Fact: About one-half of all fatal traffic crashes among 18 to 24 year olds involve alcohol. Your impairment is related to your blood alcohol concentration (BAC). Depending on your weight, you can have a BAC of 0.02% after only one drink, which can slow your reaction time and make it difficult to concentrate on two things simultaneously. A BAC of 0.03% can significantly impair your steering. At 0.04% your vision begins to focus on the center of the road and you cannot respond as well to street signs, traffic signals and pedestrians. By 0.05% your driving will be noticeably erratic, especially to the police.

8. Myth: I'd be better off if I learn to "hold my liquor."

Fact: If you have to drink increasingly larger amounts of alcohol to get a "buzz" or get "high," you are developing tolerance. This increases your vulnerability to many serious problems, including alcoholism.

9. Myth: I have to drink to fit in.

Fact: Your peers don't drink as much as you think they do. A recent survey of more than 44,000 college students shows that most students drink little or no alcohol on a weekly basis.

10. Myth: Beer doesn't have as much alcohol as hard liquor.

Fact: A 12-ounce bottle of beer has the same amount of alcohol as a standard shot of 80-proof liquor (either straight or in a mixed drink) or 5 ounces of wine. 

Other Web Info

Alcohol and Other Drug Use - McCosh Health Center

Footnotes:
  1. Facts on Tap Web Site: http://www.factsontap.org/yourbody/Yourbody.htm
  2. Source:National Institute on Alcohol Abuse and Alcoholism (National Institute of Health)