CASE 2.1:TOO MUCH TO DRINK!

Presenter: Arwa Hussain Al-Onayzan.ID: 215007943.Serial number: 4.

Our case• A 22-year-old man blacks out and falls, banging his chest on the corner of a table.

• He is brought to the A&E for examination immediately.

• On arrival, he smells of alcohol and only reacts to strong pain stimuli.

• He is wheezing and his breathing is shallow and slow.

• The left side of his thorax only moves minimally.

• Arterial blood gases are follows: PaO2 = 60 mmHg, PaCO2= 50 mmHg and pH = 7.3.

• Examination shows several ribs on the left side of his body are fractured.

Learning objectives The metabolism of Alcohol. What is the effect of alcohol generally on the body and

specifically on the nervous and respiratory system (Related to case).

Explain the abnormal PaO2, PaCO2, PH and their effect. Does the patient has tension pneumothorax? How can we diagnose the rib fracture? And the damage of

that? Respiratory Acidosis definition. Causes of Respiratory Acidosis. Complication and prevention. How can we improve this condition.

The metabolism of Alcohol• Alcohol is mainly metabolized in the liver.There are 2 enzymes help break apart the alcohol molecule:• Alcohol dehydrogenase (ADH).• Aldehyde dehydrogenase (ALDH).

Effect of Alcohol in the body system generally

Why the patient black out and falls?

Effect of Alcohol on the Brain• Alcohol affects brain chemistry by altering levels of

neurotransmitters.

• Neurotransmitters are chemical messengers that transmit the signals throughout the body

• The most important NTs with respect to alcohol are:• 1- Glutamate• is the major excitatory NT.• 2- Gamma aminobutyric acid (GABA),• is an inhibitory neurotransmitter.

Effect of Alcohol on the Brain• Neurotransmitters are either excitatory, or inhibitory.

• Alcohol increases the effects of the inhibitory neurotransmitter GABA in the brain.

• At the same time, alcohol inhibits the excitatory neurotransmitter Glutamate.

Why the patient is black out?Alcohol interferes with the receptors

in the hippocampus that transmit glutamate

During this interference,

alcohol prevents some receptors from working,

while activating others.

This process causes the

neurons to create steroids

Steroid preventneurons from

communicating with each other

properly

Thus disrupting long-term

potentiation (LTP), a process believed

necessary for learning and

memory

Why the patient is falling down?

Alcohol affect a part of brain

which is called

cerebellum

This cerebellum responsible

for coordinates

muscle movement.

Too much of alcohol

increases the effects of the

inhibitory transmitter

GABA in the brain

Muscle movements become less coordinated,less balance and lead to fall dawn.

Why the patient react only with strong pain stimuli?

• Too much of Alcohol can cause alcoholic neuropathy:

• Is the name given to peripheral neuropathy that affects some alcoholics.

• peripheral neuropathy:

• Is a term which describes damage to one or more of the peripheral nerves. 

• The damage means that the messages that travel between the central and peripheral nervous system are disrupted.

Why the patient breathing is shallow and slow?

• Medulla: This area of the brain handles such automatic functions as breathing.

• By acting on the medulla, alcohol slow and shallow breathing.

Acts as a depressant

for the (CNS)

Depress the medulla

Individual's heart rate and blood pressure can drop

Respirations will

significantly decrease

Does the patient has tension pneumothorax?

• A complete or incomplete fracture of any of the 12 ribs on either side.

• Could cause:1. Pneumothorax.2. Injure the liver if the right 11th and 12th ribs are fractured

and have jagged edges3. Rupture the spleen if the left 11th and 12th ribs are fractured

and have jagged edges. • However, we need to do more investigation to diagnose if the

patient has tension pneumothorax.

Diagnosis of fractured rib• Physical examination:• Inspection ( Rate and pattern of breathing).• Palpation (Doctor will press gently on the ribs).• Percussion ( Determine resonance within the lung tissue).• Auscultation (The quality and intensity of breath sound).

• imaging tests:

X-ray CT scan. MRI. Bone scan.

1- Using low levels of radiation.2- Often have problems revealing fresh rib fractures,especially if the bone is merely cracked.

1- Can uncover rib fractures that X-rays might miss.2- Injuries to soft tissues and BV are also easier to see on CT scans.

Help in the detection of more subtle rib fractures. 

This technique is good for viewing stress fractures.

Abnormal PaO2, PaCO2, PH and their effect

Values Normal measure In the case (Abnormal)

Pa O2 100 mmHg 60 mmHg Decreased

Pa CO2 40 mmHg 50 mmHg Increased

pH 7.35-7.45 7.3 Decreased

• As a result of shallow and slow breathing, tidal volume will decrease and that caused changes the ventilation and partial pressure of gases.

CO2

Water

Carbonic acid

Bicarbonate and

hydrogen ion

Combine

Form

Dissolve

Increase the amount of carbon dioxide will increase the

formation of hydrogen ions

Decrease pH

Acidosis

Abnormal PaO2, PaCO2, PH and their effect

According to the case information our patient most likely to have:

Respiratory Acidosis.

What is Respiratory Acidosis?• Also called respiratory failure or ventilatory failure.

• Is a condition that occurs when the lungs can’t remove enough of the carbon dioxide (CO2) produced by the body.

• Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic.

Causes of Respiratory Acidosis

• Diseases of the airways (such as asthma and 

chronic obstructive lung disease).

• Diseases of the chest (such as scoliosis).

• Diseases affecting the nerves and muscles.

• Drugs that suppress breathing.

• Alcohol.

• Severe obesity.

Complications of Respiratory Acidosis• Due to low O2 levels and increased amounts of carbonic

acid.• Such as, muscle twitching and muscle tremors.

Muscle Dysfunction

• Because of increased levels of CO2 in the CNS.• This can alter a patient's mental state and result in a

headache, anxiety and confusion.Narcosis

• Due to low oxygen concentrations in the blood.• organs which require extensive blood flow, such as the kidneys

and the heart.

Organ Failure

• impaired lung function, either due to problems with the lungs themselves or due to a decreased breathing rate.

Respiratory Failure

• Due to decreased O2 and increased CO2 content of the blood. • is marked by clammy skin, a rapid and weak heartbeat,

shallow breathing, and blue fingernails and lips.Shock

Treatment Options• Mechanical Ventilation:• Mechanical ventilation is a mechanism by which it is

possible to aid or substitute spontaneous breathing mechanically.

• Supplemental Oxygen Therapy:• In severe cases, it becomes essential to administer

oxygen to the patient.• Supplemental oxygen therapy and CPAP are usually

prescribed together as a treatment for hypoxemia.

Treatment Options• Transfusion of Packed RBCs:• Packed red blood cells can be transfused as a treatment

option for patients suffering from hypoxemia.• This is known to increase the oxygen-carrying capacity of

the blood. • Intravenous Fluids:• Mild cases of respiratory acidosis can be treated by administration of intravenous fluids.• For severe respiratory acidosis cases, sodium bicarbonate can be given as an intravenous fluid for direct effect.

Prevention of Respiratory Acidosis

Do not smoke. Do not drink Alcohol.

Losing weight. Be careful about taking sedating medicines.

Summary

We talked about

The effect of alcohol in the body system (Related to the case)

Abnormal PaO2,

PaCO2, PH and their

effect.

How can we diagnose the rib fracture?

Alcohol metabolism.

Respiratory Acidosis

definition, causes and

complication.

Treatment option.

Any Question?

Reference• HAMS website (How Alcohol Is Metabolized in the

Human Body by David S. Goodsell).• Dr. Purna’s lecture (Regulation of reparation).• Medline plus website (Prevention of Respiratory Acidosis).• Medscape website (Complications of Respiratory Acidosis).• Mayoclinic wesite (Broken-ribs diagnosis).• Healthline website (Respiratory acidosis Treatment and Respiratory acidosis definition).• Patient.info website (peripheral-neuropathy)• GUYTON AND HALL Textbook of Medical Physiology.