Poisons and Toxidromes PDF

Poisonings and Toxidromes Poisonings  Poison  Any substance that produces harmful physiological or psychological effects  Poisonings  Poisonings by drugs, medicinal and biological substances represent 90 percent of hospitalizations. The most common medi...

Poisonings and Toxidromes Poisonings  Poison  Any substance that produces harmful physiological or psychological effects  Poisonings  Poisonings by drugs, medicinal and biological substances represent 90 percent of hospitalizations. The most common medications include tranquillizers, antidepressants and acetaminophen.  What is poisoning?  Poisoning includes the pathologic effect and clinical symptoms which occur as a result of the toxic effect of the substance. The poisoning can be acute or chronic. The place that the poison got in the organism through is called entry. If the toxin gets directly into the blood, the poisoning as a rule develops faster.  The poisonings may be intentional (murder, suicide), as a result of carelessness, or accidental. Poisonings  Out of 28,581 hospital admissions for poisoning, the 25 to 44 age group accounted for 42.8 percent. Of these, 78 percent were classified as suicide or self-inflicted  The majority of serious self-inflicted injuries are suicide attempts.  Canadian Institute for Health Information (CIHI) National Trauma Registry Bulletin: Poisoning Injury Hospitalizations in Canada, 1999/2000. Toronto (ON): 2002. Routes of Absorption  Poisonsmay enter the body through: Ingestion Inhalation Injection Absorption Toxicology  The name "toxicology" comes from the Greek word toxicon meaning "poison". Toxicology is the science of poisons and poisonings. It focuses on general toxic effects; toxic doses; poison action; clinical symptoms and organ damages; methods of extracting and proving of poisonous substances; therapy and prophylaxis. Types of Toxicological Emergencies  Accidental poisoning  Dosage errors  Idiosyncratic reactions  Childhood poisoning  Environmental exposure  Occupational exposure  Drug/alcohol abuse  Intentional poisoning/overdose  Chemical warfare  Assault/homicide  Suicide attempts General Guidelines  Most poisoned patients require only supportive therapy to recover  Ensure adequate airway, ventilation, and circulation  Obtain a thorough history and perform a focused physical examination  Consider hypoglycemia in an unconscious or convulsing patient  Administer oxygen to a patient with respiratory depression General Guidelines  If overdose is suspected, obtain an overdose history from the patient, family, or friends  Frequently reassess the patient; monitor ABC’s, vital signs and ECG  Safely obtain any substance or substance container of a suspected poison and transport it with the patient  Transport the patient for physician evaluation Poisoning by Ingestion  About 80% of all accidental ingestions of poisons occur in children 1 to 3 years of age  Most result from household products  Poisoning in adults is usually intentional, although accidental poisoning from exposure to chemicals in the workplace also occurs.  Toxic effects of ingested poisons may be immediate or delayed, depending on the substance ingested Poisoning by Ingestion  Early hospital management focuses on:  Removing the toxin from the stomach (Gastric Lavage via Nasogastric tube) OR  Binding the toxin to prevent absorption before the poison enters the intestines  (having the patient ingest Activated Charcoal liquid to bind to the drug) Poisoning by Absorption Many poisonings by absorption result from exposure to organophosphates and carbamates that are available for commercial and public use as flea collars and home and commercial insecticides  Organophosphates and carbamates are among the most toxic chemicals currently used in pesticides  They are well absorbed by ingestion, inhalation, and dermal routes Poisoning by Absorption  Many substances enter the body through the skin. The sap or juice of certain plants will cause skin irritation. The most common are poison ivy, oak, and sumac. The poison comes from the leaves, but it also may come from their roots and stems. The smoke from burning brush containing these plants has been known to carry the poison considerable distances. Other substances are insecticides and industrial, lawn, and garden chemicals.  Signs and symptoms of poisoning by absorption include:  1. Rash, itching, burning, swelling skin and blisters.  2. Difficulty breathing and increased pulse rate.  3. Fever, headache, and general body weakness. Poisoning by Inhalation  Many industrial processes produce air contaminants. Workers or passersby could inhale the air contaminants and suffer adverse health affects. Routine cleaning, painting, and preservation produce toxic vapors, gases, and dusts. You can see and smell some toxic air contaminants; however, others are invisible and odorless, like cyanide gas.  Other hazardous air contaminants are by- products of certain processes that include exhaust gases from internal combustion engines; fumes or vapors from materials used in casting, molding, welding, and plating; gases associated with bacterial decomposition in closed spaces, and gases that accumulate in voids, empty fuel tanks, and similar spaces. Posioning by Inhalation (intentional)  Inhalant use refers to the intentional breathing of gas or vapors with the purpose of reaching a high. Inhalants are legal, everyday products which have a useful purpose, but can be misused. You're probably familiar with many of these substances -- paint, glue and others. But you probably don't know that there are more than 1,000 products that are very dangerous when inhaled -- things like typewriter correction fluid, air- conditioning refrigerant, felt tip markers, spray paint, air freshener, butane and even cooking spray.  HUFFING Inhalants are most commonly used among young adolescents because inhalants can easily be found in household products. These products are inexpensive, legal, and can easily be used as a social activity among peers.  1. Six percent of U.S. children have tried inhalants by the time that they reach fourth grade.  2. In 1999 about ten percent of eighth graders had abused inhalants  3. Inhalant is higher for boys than girls in grades 4 thru 6.  4. Adolescents abuse inhalants in both rural and urban areas. It is also common for adolescents that live in poverty, been abused, or dropped out of school to use inhalants. Assessment and Management  The primary goal of physical assessment of poisoned patients is to identify the poison’s effects on the three vital organ systems most likely to produce immediate morbidity and mortality:  Respiratory system  Cardiovascular system  Central nervous system Assessment and Management  Five signs of major toxicity  Coma  Cardiac dysrhythmias  GI disturbances  Respiratory depression  Hypotension or hypertension History  What was ingested?  When was the substance ingested?  How much of the substance was ingested?  Was an attempt made to induce vomiting?  Has an antidote or activated charcoal been administered?  Does the patient have a psychiatric history pertinent to suicide attempts or recent episodes of depression? Strong Acids and Alkalis  Strong acids and alkalis may cause burns to the mouth, pharynx, esophagus, and sometimes the upper respiratory and GI tracts  Ingestions of caustic and corrosive substances generally produce immediate damage to the mucous membrane and the intestinal tract  Acids generally complete their damage within 1 to 2 minutes after exposure  Alkalis, particularly solid alkalis, may continue to cause liquefaction of tissue and damage for minutes to hours Hydrocarbons  A group of saturated and unsaturated compounds derived primarily from crude oil, coal, or plant substances  Found in many household products and in petroleum distillates Hydrocarbons  Viscosity is the most important physical characteristic in potential toxicity  The lower the viscosity, the higher the risk of aspiration and associated complications  Clinical features of hydrocarbon ingestion vary widely, depending on the type of agent involved  May be immediate or delayed in onset Methanol (wood alcohol)  A common industrial solvent obtained from distillation of wood  Found in a variety of products, such as gas line antifreeze, windshield washer fluid, paints, paint removers, canned fuels, turpentine, varnishes and shellacs  Onset of symptoms after ingestion ranges from 40 minutes to 72 hours  Blurred vision, cramps, N/V, seizures  Ethylene Glycol  A colorless, odorless, water–soluble liquid  Commonly used in windshield deicers, detergents, paints, radiator antifreeze, and coolants  Commonly misused by alcoholics as a substitute for ethanol  The first symptom of ethylene glycol ingestion is similar to the feeling caused by drinking alcohol (ethanol). Within a few hours, more toxic effects become apparent. Symptoms may include nausea, vomiting, convulsions, stupor, or even coma.  An overdose of ethylene glycol can damage the brain, liver, kidneys, and lungs. The poisoning causes disturbances in the body's chemistry, including metabolic acidosis. The disturbances may be severe enough to cause profound shock, organ failure, and death. Ethylene Glycol  As little as 120 ml (approximately 4 fluid ounces) of ethylene glycol may be enough to kill an average-sized man.  Ethylene glycol toxicity should be suspected in anyone who is severely ill after drinking an unknown substance, especially if they initially appear drunk and do not have a smell of alcohol on their breath. Antizol (fomepizole) Isopropanol (isopropyl alcohol)  A volatile, flammable, colorless liquid with a characteristic odor and bittersweet taste  Rubbing alcohol is the most common household source of this agent  Used in disinfectants, degreasers, cosmetics, industrial solvents, and cleaning agents  Common routes of toxic exposure  Intentional ingestion as a substitute for ethanol  Accidental ingestion  Inhalation of high concentrations of local vapor, as from alcohol sponging of febrile children (a harmful and inappropriate procedure) Isopropanol (isopropyl alcohol)  More toxic than ethanol but less toxic than methanol or ethylene glycol  A potentially lethal dose in adults is 150 to 240 mL  In children, any amount of ingestion should be considered potentially toxic  After ingestion, the majority of isopropanol (80%) is metabolized to acetone Metals  Infants and children are high-risk groups for accidental iron, lead, and mercury poisoning due to their immature immune systems or increased absorption as a function of age  Iron Poisoning  Approximately 10% of the ingested iron (mainly ferrous sulfate) is absorbed each day from the small intestine  After absorption, the iron is converted, stored in iron storage protein, and transported to the liver, spleen, and bone marrow for incorporation into hemoglobin When someone takes too much iron, the first effect is irritation and ulceration of the stomach lining. This results in nausea, abdominal pain and vomiting as early as 20 minutes after the ingestion. This can be followed by an apparent recovery, which is very deceptive because a few hours later the person can go into pro- found shock with a severe blood chemistry imbalance. When too much iron gets into the bloodstream, it goes to all the organs and can damage the stomach, liver, kidneys, lungs, blood vessels and brain. Lead Poisoning  Metallic lead has been used by humans for more than 5000 years  Was not widely recognized as a potential health hazard until 1978 when it was banned from household paints in the United States and Canada  Young children under the age of six are especially vulnerable to lead's harmful health effects, because their brains and central nervous system are still being formed. For them, even very low levels of exposure can result in reduced IQ, learning disabilities, attention deficit disorders, behavioral problems, stunted growth, impaired hearing, and kidney damage. At high levels of exposure, a child may become mentally retarded, fall into a coma, and even die from lead poisoning Lead Poisoning  In adults, lead can increase blood pressure and cause fertility problems, nerve disorders, muscle and joint pain, irritability, and memory or concentration problems. It takes a significantly greater level of exposure to lead for adults than it does for kids to sustain adverse health effects. Most adults who are lead poisoned get exposed to lead at work.  Occupations such as house painting, welding, renovation and remodeling activities, smelters, firing ranges, the manufacture and disposal of car batteries, and the maintenance and repair of bridges and water towers, are particularly at risk for lead exposure.  Workers in these occupations must also take care not to leave their work site with potentially contaminated clothing, tools, and facial hair, or with unwashed hands.  Mercury Poisoning  Mercury is the only metallic element that is liquid at room temperature  Used in thermometers, sphygmomanometers, and dental fillings  Various compounds of mercury are used in some paints, pesticides, cosmetics, drugs, and in certain industrial processes  All forms of mercury (except dental amalgam) are poisonous  After a large, one-time inhalation exposure of mercury vapor, the lungs are the main target of mercury poisoning, although other symptoms develop as well. Symptoms may develop within a few hours and include chills, metallic taste, mouth sores, swollen gums, nausea, vomiting, abdominal pain, diarrhea, headache, weakness, confusion, shortness of breath, cough, chest tightness, bronchitis, pneumonia and kidney damage. Food Poisoning  A term used for any illness of sudden onset (usually associated with stomach pain, vomiting, and diarrhea) suspected of being caused by food eaten within the previous 48 hours  Infectious (bacterial) types  Infectious (viral) types  Noninfectious types Food Poisoning—Management Guidelines  Onset of signs and symptoms from food poisoning varies by cause and by how heavily the food was contaminated  As a rule, symptoms usually develop:  Within 30 minutes in the case of chemical poisoning  In 1 to 12 hours in the case of bacterial toxins  In 12 to 48 hours with viral and bacterial infections Plant Poisoning  Toxic plant ingestion is a frequently reported category of poisonings  Second only to ingestion of cleaning substances  The majority of these exposures occur in children less than 6 years of age Common plants include: Amaryllis, Mistletoe, Castor bean, Chrysanthemum, Daffodil, English ivy, Foxglove, Hydrangea, Lily-of-the-valley, Many types of mushrooms and fungi Poisoning by Inhalation  Accidental or intentional inhalation of poisons can lead to a life—threatening emergency  The type and location of injury caused by toxic inhalation depend on the specific actions and behaviors of the chemical involved  Toxic gases can be classified in three categories: simple asphyxiants, chemical asphyxiants, and irritants/corrosives  Ammonia, Chlorine, Bromine, Household cleaners General Management—Inhaled Poisons  Scene safety  Personal protective measures  Rapidly remove the patient from the poison environment  Adequate airway, ventilatory, and circulatory support  Initial assessment and physical examination  Irrigation of the eyes (as needed)  Regular monitoring of vital signs and ECG  Rapid transport to an appropriate medical facility Cyanide  Cyanide poisoning may result from:  Inhalation of cyanide gas (most rapid effects)  Ingestion of cyanide salts, nitriles, or cyanogenic glycosides  Infusion of nitroprusside  S&S: rapid, deep breathing and shortness of breath, followed by convulsions (seizures) and loss of consciousness. Poisoning by Injection  Human poisonings from injection may result from:  Drug abuse  Arthropod bites and stings  Reptile bites  Hazardous aquatic life  Injected poisons are often mixtures of many different substances, which may produce several different toxic reactions  Be prepared to manage reactions in many organ systems simultaneously  Tragic Death  Australian naturalist and television personality Steve Irwin has been killed by a stingray during a diving expedition off the Australian coast. Mr Irwin, 44, died after being struck in the chest by the stingray's barb while he was filming a documentary in Queensland's Great Barrier Reef.  Paramedics from Cairns rushed to the scene but were unable to save him. Arthropod Bites and Stings  Hymenoptera (bees, wasps, and ants) and Arachnida (spiders, scorpions, and ticks) cause the highest incidence of need for emergency care  Reactions to venoms are classified as local, toxic, systemic, and delayed  Hymenoptera  Hymenoptera venom is used for defense and subjugation of prey  Stingsare most commonly inflicted on the head and neck followed by the foot, leg, hand, and arm COMMON TOXIDROMES Anticholinergics Cholinergic Hallucinogens Opiate / Narcotic Sedative / Hypnotics Sympathomimetics ANTICHOLINERGIC SYNDROME “Hot as a hare, Dry as a bone, Red as a beet, Mad as a hatter” “THE DRY PATIENT”  Dryness of mouth  Flushed, hot, dry skin  Dilated and nonreactive pupils  Tachycardia, hyperthermia, hypertension  Hallucinations, delirium, restlessness, seizures Anticholinergic (“Dry” Patient Presentation)  Causative agents  Antihistamines (Gravol, Benadryl)  Antiparkinson medications  Atropine  Antipsychotic agents  Antidepressants (tricyclics)  Skeletal muscle relaxants  Many plants (e.g., jimson weed and Amanita muscaria)  (“Wet”) Patient Presentation  DEFECATION  URINATION  MIOSIS  BRONCHO- CONSTRICTION  BRADYCARDIA  EMESIS  LACRIMATION  SALIVATION DUMBELLS  CHOLINERGIC Causes  BETHANACOL  PILOCARPINE  CARBAMATE INSECTICIDES  NICOTINE  MYASTHENIA GRAVIS DRUGS  NERVE AGENTS  EDROPHONIUM  ORGANOPHOPHATES  PHYSOSTIGMINE  SOME MUSHROOMS Cholinergic Treatment Specific treatment—atropine, pralidoxime (2- PAM Chloride), diazepam (Valium), activated charcoal Sympathomimetic Overdose  Causative agents  Specific treatment  Cocaine  Minimal sensory  stimulation and Amphetamine calming measures  Methamphetamine  Over-the-counter decongestants Sympathomimetics  Common signs  Delusions  Paranoia  Tachycardia or bradycardia  Hypertension  Diaphoresis  Seizures, hypotension and dysrhythmias in severe cases Cocaine  One of the most popular illegal drugs in the world  Cocaine is a major CNS stimulant that causes profound sympathetic discharge  CLINICAL PRESENTATION  Tachycardia, Hypertension, Arrhythmia  Can also get Hypotension and reflex bradycardia  CNS stimulation  COCAINE and CRACK  TREATMENT  CNS sedation  Lower the BP  Treat hyperthermia  Time !!!!!!!! TRICYCLIC ANTIDEPRESSANTS (TCA)  TCA’s are commonly prescribed in the treatment of depression  Work by:  Blocking the uptake of norepinephrine, serotonin, or both, into the presynaptic neurons  Altering the sensitivity of brain tissue to the actions of these chemicals TRICYCLIC ANTIDEPRESSANTS  CLINICAL PRESENTATION  Mostare combination anticholinergic and sympatholytic  Coma  Seizures  Hypotension  Cardiac dysrhythmias TRICYCLIC ANTIDEPRESSANTS  TREATMENT  Gastric decontamination  Treat cardiac dysrhythmias  Treat seizures Opioids  Opioids are commonly prescribed because of their effective analgesic, or pain- relieving, properties. Medications that fall within this class-referred to as prescription narcotics-include morphine, codeine, oxycodone (e.g., OxyContin, Percodan, Percocet), and related drugs. Morphine, for example, is often used before and after surgical procedures to alleviate severe pain. Codeine, on the other hand, is often prescribed for mild pain. In addition to their pain-relieving properties, some of these drugs-codeine and diphenoxylate (Lomotil) for example-can be used to relieve coughs and diarrhea.  Street opioids include heroin and opium  OPIATES  CLINICAL PRESENTATION  Pinpoint pupils  Respiratory depression  Bradycardia  Hypotension  Hypothermia  Pulmonary edema  Seizures OPIATES  TREATMENT  Acute  Naloxone (Narcan) an direct acting opioid antagonist, but short acting  Chronic  Methadone  Catapres  Naltrexone  OPIATES  POSSIBLE  Among heroin withdrawal COMPLICATIONS symptoms are:   dilated pupils Aspiration  Pulmonary edema  piloerection (goose bumps)  Withdrawal symptoms  watery eyes  Need for repeated doses  runny nose  yawning  loss of appetite  tremors  panic  chills  nausea  muscle cramps  insomnia BENZODIAZIPINES  CLINICAL PRESENTATION  Respiratory depression  Drowsiness  Coma  TREATMENT  Generally requires no pharmacologic intervention  Flumazenil  Carbon Monoxide  CO is colorless, odorless and tasteless, making it almost impossible to detect. The symptoms of CO poisoning can be very vague, and they involve many of the body's systems. But immediate diagnosis is critical.  CO blocks the absorption of oxygen into the bloodstream from the lungs, and poisons the red blood cells so they cannot carry oxygen. If body tissues do not receive a constant supply of oxygen, they stop functioning. The brain is extremely vulnerable to oxygen deprivation. Most of the early symptoms of CO poisoning are the result of brain malfunction from the lack of oxygen.  Carbon Monoxide  Breathing CO in high concentrations can cause a feeling of tightness across the forehead, headache, throbbing in the temples, weariness or dizziness. If a person remains in the contaminated area, more serious symptoms will develop: nausea and vomiting, loss of strength and muscular control, increased breathing rate and a slowing pulse, and, eventually, death.  Exposure to an extremely high concentration can cause rapid collapse and death within a few minutes. Heavy cigarette smokers are at a higher risk than non-smokers.  ACETAMINOPHEN A disorderTOXICITY characterized by hepatic necrosis following large ingestions of acetaminophen. Symptoms may vary from initial nausea, vomiting, diaphoresis, and malaise to jaundice, confusion, somnolence, coma, and death. The clinical hallmark is the onset of symptoms within 24 hours of ingestion of acetaminophen-only or combination products.  Acetaminophen poisoning  is most often encountered following large single ingestions of acetaminophen-containing medications. Usual toxic doses are > 7.5 g in adults and 150 mg/kg in children. However, poisoning also occurs following acute and chronic ingestions of lesser amounts in susceptible individuals including those who regularly abuse alcohol, are chronically malnourished, or take medications which affect hepatic metabolism of acetaminophen  Rumack Nomogram The best indicator of acetaminophen toxicity is to measure the drug half-life by analyzing a blood level taken six hours postingestion, then a second level three to four hours later. At normal levels half-life is one to three hours. Half-lives exceeding four hours are consistent with hepatic necrosis. The Rumack nomogram is available for estimating toxicity from serum level at six hours or later after ingestion.  Overdose Treatment  TREATMENT Gastric decontamination N-acetylcysteine (MUCO-MYST) SALICYLATES (ASA)  CLINICAL PRESENTATION  Mixed acid-base disturbances  GI: N/V, abdominal pain  CNS: tinnitus, lethargy seizures, cerebral edema, irritability  Resp: pulmonary edema  Coagulation abnormalities Digoxin (Lanoxin)  Exerts direct and indirect effects on SA and AV nodal fibers  At toxic levels, can halt impulses in the SA node, depress conduction through the AV node, and increase sensitivity of the SA and AV nodes to catecholamines  Can produce most any dysrhythmia or conduction block DIGOXIN  CLINICAL PRESENTATION  Nausea/vomiting  Mental status changes  Cardiovascular symptoms  Visual changes (often yellow or green)  TREATMENT  Gastric decontamination  Fab fragments Barbiturates  General CNS depressants that inhibit impulse conduction in the ascending reticular activating system  Were once widely used to treat anxiety and insomnia  Signs and symptoms of sedative– hypnotic overdose chiefly are related to the central nervous and cardiovascular systems  Emergency care Amphetamines  Frequently used to produce general mood elevation, improve task performance, suppress appetite, and prevent sleepiness  Structurally similar to endogenous catecholamines (epinephrine and norepinephrine) but differ in their more pronounced effects on the CNS  Signs and symptoms  Emergency care CLINICAL SCENARIO 1  A 48 year old unconscious mermaid is brought to the hospital. She is convulsing and has an odor of garlic on her breath. She is incontinent for urine and stool. On exam her VS: T99, HR50, RR24, BP146/88. Skin is diaphoretic. She is drooling. Pupils are constricted. Lungs diffuse wheezing. CLINICAL SCENARIO 1  Recognize: Cholinergic poisoning  Treatment:  Gastric lavage  Respiratory support  Cardiac monitoring  Atropine followed by pralidoxime  Treat seizures with benzodiazepine CLINICAL SCENARIO 2  17 year old male brought by paramedics to the hospital. He presents somnolent, with slurred speech, and combative behavior. His younger sister said he showed her a handful of small seeds that he was going to eat. On exam his VS: T100, HR120, BP100/60, RR22. Skin is warm and dry. Mucous membranes are dry. Pupils are dilated and not reactive. CLINICAL SCENARIO 2  Recognize: Anticholinergic poisoning  Treatment  Supportive care  Watch for:  Coma  Arrythmias  Severe HTN  Seizures  CLINICAL SCENARIO 3  21 y/o male student presents unresponsive. His young friend accompanies him and states he took a handful of pills because he was in pain. On exam his VS: T96, HR40, RR6, BP50/30. Pupils are 3mm. CLINICAL SCENARIO 3  Recognize: Opioid poisoning  Treatment  Narcan  Oxygen  Cardiac Monitor Alcohol Dependence  In 2002, an estimated 641,000 people, or about 2.6% of the population aged 15 or older, reported symptoms suggesting that they were dependent on alcohol, according to a new study.  Young people were most at risk of dependence. While 9% of 20- to 24- year-olds were dependent on alcohol, the figure at age 55 or older was less than 1%.  The proportion of men who were alcohol-dependent was about three times the proportion of women: 3.9% versus 1.3%. Alcohol Dependence Alcohol dependence is a disorder characterized by chronic, excessive consumption of alcohol that results in injury to health or in inadequate social function and the development of withdrawal symptoms when the patient stops drinking suddenly Acute Alcohol Intoxication  Alcohol ingestion can cause acute poisoning if consumed in sufficiently large amounts over a relatively short period  Signs and symptoms  Management Alcohol Withdrawal Syndrome  A period of relative or absolute abstinence from alcohol may cause withdrawal in an alcoholic  Alcohol withdrawal syndromes can be divided into four general categories:  Minor reactions  Hallucinations  Alcohol withdrawal seizures  Delirium tremens Minor Reactions  Begin about 6 to 8 hours after cessation or reduction of alcohol intake  Symptoms peak within 24 to 36 hours and may persist for 10 to 14 days  When alcohol withdrawal is confined to minor reactions, the prognosis for full recovery is excellent with appropriate management Alcohol Withdrawal Seizures Usually occur 7 to 48 hours after ethanol cessation, with a peak incidence between 13 and 24 hours  Seizures may occur singly or in groups of two to six  Are most often grand mal and of short duration (status seizures are rare) Delirium Tremens (DTs)  The most dramatic and serious form of alcohol withdrawal  Usually occurs 72 to 96 hours after cessation of alcohol but may be delayed up to 14 days Disulfiram–Ethanol Reaction  Disulfiram (Antabuse) is a medication prescribed to some alcoholic patients to help them abstain  Patients who take disulfiram and then ingest ethanol experience an unpleasant and potentially life–threatening physiological response  The reaction begins 15 to 30 minutes after ingestion of 2 to 5 alcoholic drinks and continues for 1 to 2 hours Any Questions ?