Thyroid Problems Overview
The thyroid gland is located on the front part of the neck below the thyroid cartilage (Adam's apple). The gland produces thyroid hormones, which regulate body metabolism. Thyroid hormones are important in regulating body energy, the body's use of other hormones and vitamins, and the growth and maturation of body tissues.
Diseases of the thyroid gland can result in either production of too much (hyperthyroidism) or too little (hypothyroidism) hormone.
Production of thyroid hormones: The process of hormone synthesis begins in a part of the brain called the hypothalamus. The hypothalamus releases thyrotropin-releasing hormone (TRH). The TRH travels through the bloodstream to the pituitary gland, also in the brain. In response, the pituitary gland then releases thyroid-stimulating hormone (TSH) into the blood. The TSH then stimulates the thyroid to produce the two main thyroid hormones, L-thyroxine (T4) and triiodothyronine (T3). The thyroid gland also needs adequate amounts of dietary iodine to be able to produce T4 and T3.
Regulation of thyroid hormone production: To prevent the overproduction or underproduction of thyroid hormones, the pituitary gland can sense how much hormone is in the blood and adjust the production of hormones accordingly. For example, when there is too much thyroid hormone in the blood, the TRH does not work effectively to stimulate the pituitary gland. In addition, too much thyroid hormone will prevent the release of TSH from the pituitary gland. The sum effect of this is to decrease the amount of TSH released from the pituitary gland, resulting in less production of thyroid hormones in the thyroid gland. This then works to restore the amount of thyroid hormone in the blood to normal. Defects in these regulatory pathways may result in hypothyroidism or hyperthyroidism.
Hypothyroidism in pregnancy
Newly diagnosed hypothyroidism in pregnancy is rare because most women with untreated hypothyroidism have ovulatory problems, which make it difficult for them to conceive.
It is a difficult new diagnosis to make. Many of the symptoms of hypothyroidism (fatigue, poor attention, weight gain, numbness, and tingling of the hands or feet) are also prominent symptoms of a normal pregnancy.
Undiagnosed hypothyroidism during pregnancy increases the chance of stillbirth or growth retardation of the fetus. It also increases the chance that the mother may experience complications such as anemia, eclampsia, and placental abruption.
Probably the largest group of women who will have hypothyroidism during pregnancy are those who are currently on thyroid hormone replacement. The ideal thyroxine replacement dose during pregnancy may rise by 25-50% during pregnancy. It is important to have regular checks of T4 and TSH during pregnancy to make sure you are at the correct medication dose.
Hyperthyroidism in pregnancy
Newly diagnosed hyperthyroidism occurs in about 1 in 2,000 pregnancies. Graves disease accounts for 95% of hyperthyroidism newly diagnosed during pregnancy.
Like hypothyroidism, many symptoms of mild hyperthyroidism mimic those of normal pregnancy. However, anyone experiencing symptoms such as significant weight loss, vomiting, increased blood pressure, or persistently fast heart rate should have blood tests to look for hyperthyroidism.
Untreated hyperthyroidism does cause fetal and maternal complications similar to untreated hypothyroidism.
Treatment of hyperthyroidism during pregnancy is primarily medical. Propylthiouracil or methimazole are usual first-line agents to block the synthesis of thyroid hormone. They appear to be equally effective and have the same rate of side effects. The rate of side effects of each medication is not increased in pregnancy.
Iodine will cross the placenta, so its use in either a thyroid scan or in treatment with radioactive iodine is prohibited in pregnancy.
One positive note for women with hyperthyroidism is that those with Graves disease or Hashimoto thyroiditis may have improvement in their symptoms during pregnancy.
Postpartum thyroid disease
Some women may have thyroiditis that usually occurs within 3-6 months after birth. It also may occur after miscarriage. The classic clinical picture is a woman who will first have symptoms of hyperthyroidism, followed by hypothyroidism, culminating in normal thyroid function.
Women with insulin-dependent diabetes have a 25% risk of developing postpartum thyroid dysfunction.
Consult your doctor if you have symptoms of hypothyroidism or hyperthyroidism after pregnancy or miscarriage.
Thyroid Problems Causes
Hypothyroidism
Loss of tissue: Treatment of hyperthyroidism by radioactive destruction of thyroid tissue or surgical removal of thyroid tissue can result in hypothyroidism.
Antithyroid antibodies: These may be present in people who have diabetes, lupus, rheumatoid arthritis, chronic hepatitis, or Sjögren syndrome. These antibodies may cause decreased production of thyroid hormones.
Congenital: Hypothyroidism can be present from birth. This is commonly discovered early with nationwide newborn screening for this disease.
Defects in the production of thyroid hormone: Hashimoto thyroiditis occurs when there are defects in the production of thyroid hormone, resulting in an increased amount of TSH. The increased TSH results in a goiter (enlargement of the thyroid gland itself that can be seen as an obvious swelling in the front of the neck).
Medications: Some medications, particularly lithium, may cause a drug-induced hypothyroidism.
Hyperthyroidism
Graves disease: This thyroid condition results from abnormal stimulation of the thyroid gland by a material in the blood termed the long-acting thyroid stimulator (LATS). LATS overstimulates the thyroid causing a goiter. It also causes Graves eye disease, including a "bug-eyed" look and "frightened stare." This can progress to severe eye pain or eye muscle weakness. It also causes raised, thickened skin over the shins or tops of the feet.
Toxic multinodular goiter: This occurs when part of the thyroid gland produces thyroid hormones all by itself, without regard to TSH stimulation. It usually occurs in people with a long-standing goiter—usually in the elderly. Toxic multinodular goiter is different from Graves disease because of the general lack of eye complications and less severe signs of hyperthyroidism.
Thyroiditis: This inflammatory disorder of the thyroid gland includes such conditions as de Quervain thyroiditis or Hashimoto thyroiditis. In these conditions, you may have periods of increased thyroid hormone release due to the inflammation, causing a hyperthyroid state. As thyroid failure occurs due to the inflammatory response, hypothyroidism may occur.
Pituitary adenoma: This tumor of the pituitary gland causes independent TSH production leading to overstimulation of the thyroid gland.
Drug-induced hyperthyroidism: This is most commonly caused by a heart medication called amiodarone. It may be prevented by monitoring this possible side effect and weighing it against the benefits of using the heart medication.
Thyroid Problems Symptoms
Hypothyroidism
Infants
Constipation
Poor feeding
Jaundice (yellow discoloration of the skin and eyes)
Excessive tiredness
Children
Similar to adult symptoms
Poor school performance
Adults
Early symptoms
Easy fatigue, exhaustion
Poor tolerance to cold temperatures
Constipation
Carpal tunnel syndrome (pain at the wrists and numbness of the hands)
Later symptoms
Poor appetite
Weight increase
Dry skin
Hair falls out
Intellectual ability worsens
Deeper, hoarse voice
Puffiness around the eyes
Depression
Hyperthyroidism
Children
Similar to adult symptoms
Declining school performance
Behavior problems
Adults
Insomnia
Hand tremors
Nervousness
Feeling excessively hot in normal or cold temperatures
Frequent bowel movements
Losing weight despite normal or increased appetite
Excessive sweating
Menstrual period becomes scant, or ceases altogether
Joint pains
Difficulty concentrating
Eyes seem to be enlarging
Elderly
Worsening of angina (chest pain) in person with heart disease
Worsening of shortness of breath in person with heart failure
Muscle weakness, especially in the shoulders and thighs
When to Seek Medical Care
The signs and symptoms of hypothyroidism and hyperthyroidism typically develop slowly over a period of weeks to months. If you have prolonged symptoms or signs of either condition, call your doctor to be evaluated.
Untreated hypothyroidism may have severe effects on the brain as well as cause intestinal obstruction and inability of the heart to beat effectively. An infection, exposure to cold, trauma, and certain medications may often cause a worsening of hypothyroidism.
Seek immediate attention at a hospital's emergency department if you have these signs and symptoms associated with thyroid problems.
Shortness of breath
Abdominal pain
Vomiting
Confusion
Coma
Severe hyperthyroidism, called thyrotoxic crisis, may be life threatening because of the effects it has on the heart and brain. It often occurs in people who are untreated or are receiving inadequate treatment for thyroid problems. A severe infection can also cause a thyrotoxic crisis.
Seek immediate attention at a hospital's emergency department if you have these signs and symptoms associated with thyroid problems.
Chest pain
Shortness of breath
Abdominal pain
Vomiting
Extreme agitation or irritability
Disorientation (person has no knowledge of the date or location)
Coma
Exams and Tests
The medical history and physical exam are important parts of the evaluation for thyroid problems. The doctor will focus on eye, skin, cardiac, and neurologic findings.
Blood tests
Thyroid-stimulating hormone (TSH): In most cases, this is the single most useful lab test in diagnosing thyroid disease. When there is an excess of thyroid hormone in the blood, as in hyperthyroidism, the TSH is low. When there is too little thyroid hormone, as in hypothyroidism, the TSH is high.
L-thyroxine (T4): T4 is one of the thyroid hormones. High T4 may indicate hyperthyroidism. Low T4 may indicate hypothyroidism.
Triiodothyronine (T3): T3 is another one of the thyroid hormones. High T3 may indicate hyperthyroidism. Low T3 may indicate hypothyroidism.
TSH receptor antibody: This antibody is present in Graves disease.
Antithyroid antibody: This antibody is present in Hashimoto disease.
Thyroid scan: For this test, a small amount of radioactive iodine is given into the blood, and then an x-ray image of the thyroid is taken. Increased uptake of the radioactive material in the thyroid gland indicates hyperthyroidism, while decreased uptake is present in hypothyroidism. This test should not be done on pregnant women.
Thyroid ultrasound: This exam helps to differentiate between different types of nodules of the thyroid gland.
Fine-needle aspiration: For this test, a small needle is inserted into the thyroid gland in order to get a sample of thyroid tissue, usually from a nodule. The tissue is then observed under a microscope to look for any signs of cancer.
Thyroid Problems Treatment
Medications
Medications for hyperthyroidism
Beta-blockers: This class of medications works by blocking many of the body’s responses to hyperthyroidism. It decreases tremor, nervousness, and agitation. It also reduces the fast heart rate. It is given as tablets to the person with mild to moderate symptoms, and as an IV preparation to the person with the severe form of hyperthyroidism (thyrotoxic crisis).
Propylthiouracil: This antithyroid drug works by blocking thyroid hormone synthesis. It takes about a week after starting the medication for full therapeutic effect. Common mild side effects include rash, itching, and mild fever. More rare, serious side effects include a decrease in white blood cell count, which can decrease the ability to fight off infection. Therefore, a high fever should prompt a call to the doctor.
Methimazole (Tapazole): This antithyroid drug also works by blocking thyroid hormone synthesis. It may take slightly longer than propylthiouracil to achieve full effect. It has similar side effects as propylthiouracil and may also cause a decreased white blood cell count.
Iodide (Lugol’s solution, Strong iodine): This medication works by inhibiting the release of thyroid hormone from the overfunctioning thyroid gland. It must be used in conjunction with an antithyroid drug because the iodine can be used to increase the amount of thyroid hormone and worsen the hyperthyroidism. Common side effects include nausea and a metallic taste in the mouth.
Medications for hypothyroidism
L-thyroxine: This medication is the mainstay of thyroid hormone replacement therapy in hypothyroidism. This is a synthetic form of thyroxine. The body tissues convert it to the active product L-triiodothyronine. Side effects are rare, and it has an excellent safety record.
L-triiodothyronine: This is rarely used alone as thyroid hormone replacement, because it has less uniform potency than L-thyroxine. Its use can cause rapid increases in L-triiodothyronine concentration, which can be dangerous in the elderly and in people with cardiac disease. It may be used in combination with L-thyroxine for people who have poor symptomatic relief with L-thyroxine alone.
Surgery
Surgery for hyperthyroidism may involve removal of much of the thyroid tissue, leaving some intact to continue to produce thyroid hormone. Risks in this procedure include damage to nerves that control the vocal cords, damage to the parathyroid glands, which lie just behind the thyroid gland, and bleeding causing breathing problems. Hypothyroidism may also occur, but occurs less frequently than in radioactive iodine treatment. Persistent hyperthyroidism may also occur. If so, the entire thyroid gland is removed. In general, in the hands of an experienced surgeon, this is considered an effective and relatively safe procedure.
Next Steps
Follow-up
Anyone diagnosed with Graves disease should stop smoking immediately because smoking increases the risk of progression to Graves eye disease.
Follow the medication schedule prescribed by your doctor. In addition, ask what side effects the medications may cause. Also discuss with your doctor the kinds of symptoms that would prompt a call to the doctor or a visit to the emergency department.
Prevention
There is no known way to prevent hyperthyroidism or hypothyroidism.
Outlook
Most people with either hypothyroidism or hyperthyroidism, with proper diagnosis and treatment, can control their condition with no long-term effects. However, those with undiagnosed disease may progress to coma or thyrotoxic crisis, with death rates approaching 50%.
Graves eye disease has been treated with corticosteroid medication, radiotherapy, and surgery with varying success.
Tuesday, November 6, 2007
Blood in Urine
Blood in Urine Overview
Blood in the urine is a common problem. The medical term for red blood cells in the urine is hematuria. Sometimes blood in the urine is a sign of a serious problem in the urinary tract, while other times it is not serious and requires no treatment. Only after a thorough evaluation by a healthcare provider should blood in the urine be attributed to a non-serious cause.
The urinary tract consists of the following structures:
Kidneys: You have two kidneys, located closer to your back than your front at about waist level. The kidneys filter the blood in your body and produce urine.
Ureters: These narrow, hollow tubes carry urine from the kidneys to the bladder.
Bladder: The bladder is a balloon-like organ that holds urine until it is convenient for you to empty your bladder (urinate).
Urethra: This narrow, hollow tube carries urine from the bladder to the outside of your body. The flow of urine is controlled by internal and external sphincter muscles, which tighten or relax around the urethra, holding or releasing urine.
In men, the genitals and prostate are considered part of the urinary system. The prostate surrounds the urethra in men. It is made up of glands that secrete a fluid that is part of semen. The prostate often becomes enlarged in older men.
Blood in the urine is not always visible. If the amount of blood is small, the urine looks normal. This is called microscopic hematuria because the blood cells are visible only under a microscope. Typically, this is discovered when the patient has a urine test for some other reason.
When there is enough blood to be visible, the urine may look pinkish, red, or smoky brown (like tea or cola). This is called gross or frank hematuria. It takes very little blood in urine to be visible —about one-fifth of a teaspoon in a half quart of urine.
A trace amount of blood in your urine is normal. The average person with a healthy urinary tract excretes about 1 million red blood cells (RBC) in the urine each day. This amount of blood is not visible. This is not considered to be hematuria.
An abnormal amount of blood in the urine can be acute (new, occurring suddenly) or chronic (ongoing, long term). Acute hematuria can occur just once, or it can occur many times.
Sometimes the urine can appear with a color indicating hematuria, but the urine actually does not contain red blood cells, but rather is discolored by medications or foods.
Up to 10% of people have hematuria. About 3% of people develop gross hematuria.
Women develop hematuria more than men because women are more likely to have urinary tract infections.
Older adults, especially men, have hematuria more often than younger people because they are more likely to take medications that can irritate the urinary tract, have enlargement of the prostate, or cancer.
Causes of Blood in Urine
Hematuria has many different causes.
Blood in the urine can come from any condition that results in infection, inflammation, or injury to the urinary system.
Typically, microscopic hematuria indicates damage to the upper urinary tract (kidneys), while visible blood indicates damage to the lower tract (ureters, bladder, or urethra). But this is not always the case.
The most common causes in people younger than 40 years of age are kidney stones or urinary tract infections.
These may also cause hematuria in older people, but cancers of the kidney, bladder, and prostate become a more common concern in people older than 40 years of age.
Several conditions causing hematuria may exist at the same time.
Some causes of hematuria are serious, others are not. Your healthcare provider will perform tests to help tell the difference.
The well-known causes of blood in the urine include the following:
Kidney stones
Infections of the urinary tract or genitals
Blockage of the urinary tract, usually the urethra - by a stone, a tumor, a narrowing of the opening (stricture), or a compression from surrounding structures
Cancer of the kidney, bladder, or prostate
Kidney disease
Blood clotting disorders
Injury to the upper or lower urinary tract, as in a car accident or a bad fall
Medications - Antibiotics [for example, rifampin (Rifadin)], analgesics such as aspirin, anticoagulants [blood thinners such as warfarin, (Coumadin)], phenytoin (Dilantin), quinine (Quinerva, Quinite, QM-260)
Benign (noncancerous) enlargement of the prostate - known as benign prostatic hypertrophy (BPH), a common condition in older men
Chronic diseases such as diabetes, hypertension, and sickle cell anemia
Viral infections
Inflammation of the kidney - usually of unknown cause
Strenuous exercise, especially running - results from repeated jarring of the bladder
Sometimes no cause is found for blood in the urine.
If serious conditions such as cancer, kidney disease, and other chronic diseases that cause kidney damage or bleeding are ruled out, the cause is usually not serious.
The hematuria will probably go away by itself or continue as a chronic condition without doing harm. Any changes should immediately trigger a return visit and evaluation by your healthcare provider.
Urine can be colored pink, red, or brown for reasons that have nothing to do with bleeding in the urinary tract:
Foods - beets, berries, rhubarb in large amounts
Food coloring
Medications - Certain laxatives and pain medications
Menstrual blood
Liver diseases - also can be very serious
Blood in Urine Symptoms
Blood in the urine is itself a symptom rather than a disease. The appearance of the urine is usually not a clue as to the cause.
In gross hematuria, the urine appears pinkish, red, or smoky brown (like cola or tea). There may be small blood clots. The amount of blood in the urine does not indicate the seriousness of the condition.
In microscopic hematuria, the urine appears normal.
Many people with hematuria have no other symptoms. Other symptoms are related to the underlying cause of the bleeding.
Pain in the flank (side of the body between the ribs and the hips), back, or lower belly (abdomen) or groin
Burning sensation or pain when urinating (dysuria)
Fever
Nausea or vomiting
Weight loss
Decreased appetite
Kidney stones: Not all people with kidney stones have all of these symptoms.
Pain, often severe, in the flank, back, or lower abdominal pain that may radiate to the groin area
Nausea and vomiting
Usually a normal temperature
Frequent urination
Burning sensation with urination
Restlessness - constant moving around (writhing) to find relief from pain
Urinary tract infection: Symptoms may be similar to those of kidney stones.
Pain in lower back, flank, lower abdomen, or groin - may be severe but not enough to cause writhing
Fever with or without chills
More frequent urination
Sensation of having to urinate but little urine produced (urgency)
Burning sensation or pain with urination
Cloudy urine - due to pus in the urine
When to Seek Medical Care
Any time you have blood in the urine or other symptoms of urinary tract disease call your healthcare provider. If you cannot get in touch with your provider or get an appointment that day, go to a hospital emergency department.
Any time you have the combination of blood in the urine, fever, and flank pain, you should seek emergency medical care, because this may represent a severe infection in your kidney.
Blood in Urine Treatment
Self-Care at Home
If you have visible blood in your urine, do not attempt to treat yourself with home remedies. See a medical professional without delay.
If you have a urinary tract infection, you will take antibiotics for 3-14 days, depending on what part of the urinary tract is infected.
If you have kidney stones, be sure to drink plenty of liquids to help pass the stones and prevent other stones from forming. You may need to take pain relievers.
Medical Treatment
Many conditions can cause blood in the urine. Some of these have no medical significance and do not require treatment. They usually go away by themselves. Others can be serious and require immediate treatment. Treatment depends on the underlying cause of the bleeding. Anytime you notice blood in the urine you need to consult a healthcare provider for an evaluation.
Kidney stones: For most cases of kidney stones, you will be told to drink plenty of water and other fluids and to take pain relievers.
Most stones will pass through urinary system by themselves. In certain instances, more extensive measures may be required.
One form of therapy, called extracorporeal shock wave lithotripsy, uses sound waves to crush the stones. The smaller pieces can then pass through more easily, though some pain will remain.
Another form of therapy uses cystoscopy to find the stone in the ureter and then to grab and remove it with a small scoop.
Urinary tract infection: Treatment seeks to get rid of the bacteria responsible for the infection. If you have no other significant illness, you will take a course of antibiotics for 3-14 days, depending on the source of the infection.
Benign prostate enlargement: Sometimes eliminating certain foods and medications that irritate the prostate can help shrink the prostate. Sometimes medication is necessary.
Medications: If a medication is causing hematuria, the medication should be stopped. Some medications only discolor the urine without actually causing hematuria. Your healthcare provider should determine if these can be continued. Do not stop a medication without talking it over with your healthcare provider.
Urinary tract blockage: A blockage usually requires surgery or other procedure to correct or remove the block.
Injury: These may heal over time, or you may need surgery or another procedure to repair the injury or remove the damaged tissue.
Next Steps
Follow-up
Follow-up is very important if you have blood in your urine.
Typically, you will go back to your health care provider in one to two weeks for a repeat analysis of your urine to make sure the hematuria has cleared up.
If bloody urine continues, you might need further testing or need to see a specialist (urologist).
You should drink plenty of water and take all medications as recommended if the hematuria is to go away.
Men older than 50 years of age for whom no definite cause is found should have yearly screening for prostate cancer.
Blood in the urine is a common problem. The medical term for red blood cells in the urine is hematuria. Sometimes blood in the urine is a sign of a serious problem in the urinary tract, while other times it is not serious and requires no treatment. Only after a thorough evaluation by a healthcare provider should blood in the urine be attributed to a non-serious cause.
The urinary tract consists of the following structures:
Kidneys: You have two kidneys, located closer to your back than your front at about waist level. The kidneys filter the blood in your body and produce urine.
Ureters: These narrow, hollow tubes carry urine from the kidneys to the bladder.
Bladder: The bladder is a balloon-like organ that holds urine until it is convenient for you to empty your bladder (urinate).
Urethra: This narrow, hollow tube carries urine from the bladder to the outside of your body. The flow of urine is controlled by internal and external sphincter muscles, which tighten or relax around the urethra, holding or releasing urine.
In men, the genitals and prostate are considered part of the urinary system. The prostate surrounds the urethra in men. It is made up of glands that secrete a fluid that is part of semen. The prostate often becomes enlarged in older men.
Blood in the urine is not always visible. If the amount of blood is small, the urine looks normal. This is called microscopic hematuria because the blood cells are visible only under a microscope. Typically, this is discovered when the patient has a urine test for some other reason.
When there is enough blood to be visible, the urine may look pinkish, red, or smoky brown (like tea or cola). This is called gross or frank hematuria. It takes very little blood in urine to be visible —about one-fifth of a teaspoon in a half quart of urine.
A trace amount of blood in your urine is normal. The average person with a healthy urinary tract excretes about 1 million red blood cells (RBC) in the urine each day. This amount of blood is not visible. This is not considered to be hematuria.
An abnormal amount of blood in the urine can be acute (new, occurring suddenly) or chronic (ongoing, long term). Acute hematuria can occur just once, or it can occur many times.
Sometimes the urine can appear with a color indicating hematuria, but the urine actually does not contain red blood cells, but rather is discolored by medications or foods.
Up to 10% of people have hematuria. About 3% of people develop gross hematuria.
Women develop hematuria more than men because women are more likely to have urinary tract infections.
Older adults, especially men, have hematuria more often than younger people because they are more likely to take medications that can irritate the urinary tract, have enlargement of the prostate, or cancer.
Causes of Blood in Urine
Hematuria has many different causes.
Blood in the urine can come from any condition that results in infection, inflammation, or injury to the urinary system.
Typically, microscopic hematuria indicates damage to the upper urinary tract (kidneys), while visible blood indicates damage to the lower tract (ureters, bladder, or urethra). But this is not always the case.
The most common causes in people younger than 40 years of age are kidney stones or urinary tract infections.
These may also cause hematuria in older people, but cancers of the kidney, bladder, and prostate become a more common concern in people older than 40 years of age.
Several conditions causing hematuria may exist at the same time.
Some causes of hematuria are serious, others are not. Your healthcare provider will perform tests to help tell the difference.
The well-known causes of blood in the urine include the following:
Kidney stones
Infections of the urinary tract or genitals
Blockage of the urinary tract, usually the urethra - by a stone, a tumor, a narrowing of the opening (stricture), or a compression from surrounding structures
Cancer of the kidney, bladder, or prostate
Kidney disease
Blood clotting disorders
Injury to the upper or lower urinary tract, as in a car accident or a bad fall
Medications - Antibiotics [for example, rifampin (Rifadin)], analgesics such as aspirin, anticoagulants [blood thinners such as warfarin, (Coumadin)], phenytoin (Dilantin), quinine (Quinerva, Quinite, QM-260)
Benign (noncancerous) enlargement of the prostate - known as benign prostatic hypertrophy (BPH), a common condition in older men
Chronic diseases such as diabetes, hypertension, and sickle cell anemia
Viral infections
Inflammation of the kidney - usually of unknown cause
Strenuous exercise, especially running - results from repeated jarring of the bladder
Sometimes no cause is found for blood in the urine.
If serious conditions such as cancer, kidney disease, and other chronic diseases that cause kidney damage or bleeding are ruled out, the cause is usually not serious.
The hematuria will probably go away by itself or continue as a chronic condition without doing harm. Any changes should immediately trigger a return visit and evaluation by your healthcare provider.
Urine can be colored pink, red, or brown for reasons that have nothing to do with bleeding in the urinary tract:
Foods - beets, berries, rhubarb in large amounts
Food coloring
Medications - Certain laxatives and pain medications
Menstrual blood
Liver diseases - also can be very serious
Blood in Urine Symptoms
Blood in the urine is itself a symptom rather than a disease. The appearance of the urine is usually not a clue as to the cause.
In gross hematuria, the urine appears pinkish, red, or smoky brown (like cola or tea). There may be small blood clots. The amount of blood in the urine does not indicate the seriousness of the condition.
In microscopic hematuria, the urine appears normal.
Many people with hematuria have no other symptoms. Other symptoms are related to the underlying cause of the bleeding.
Pain in the flank (side of the body between the ribs and the hips), back, or lower belly (abdomen) or groin
Burning sensation or pain when urinating (dysuria)
Fever
Nausea or vomiting
Weight loss
Decreased appetite
Kidney stones: Not all people with kidney stones have all of these symptoms.
Pain, often severe, in the flank, back, or lower abdominal pain that may radiate to the groin area
Nausea and vomiting
Usually a normal temperature
Frequent urination
Burning sensation with urination
Restlessness - constant moving around (writhing) to find relief from pain
Urinary tract infection: Symptoms may be similar to those of kidney stones.
Pain in lower back, flank, lower abdomen, or groin - may be severe but not enough to cause writhing
Fever with or without chills
More frequent urination
Sensation of having to urinate but little urine produced (urgency)
Burning sensation or pain with urination
Cloudy urine - due to pus in the urine
When to Seek Medical Care
Any time you have blood in the urine or other symptoms of urinary tract disease call your healthcare provider. If you cannot get in touch with your provider or get an appointment that day, go to a hospital emergency department.
Any time you have the combination of blood in the urine, fever, and flank pain, you should seek emergency medical care, because this may represent a severe infection in your kidney.
Blood in Urine Treatment
Self-Care at Home
If you have visible blood in your urine, do not attempt to treat yourself with home remedies. See a medical professional without delay.
If you have a urinary tract infection, you will take antibiotics for 3-14 days, depending on what part of the urinary tract is infected.
If you have kidney stones, be sure to drink plenty of liquids to help pass the stones and prevent other stones from forming. You may need to take pain relievers.
Medical Treatment
Many conditions can cause blood in the urine. Some of these have no medical significance and do not require treatment. They usually go away by themselves. Others can be serious and require immediate treatment. Treatment depends on the underlying cause of the bleeding. Anytime you notice blood in the urine you need to consult a healthcare provider for an evaluation.
Kidney stones: For most cases of kidney stones, you will be told to drink plenty of water and other fluids and to take pain relievers.
Most stones will pass through urinary system by themselves. In certain instances, more extensive measures may be required.
One form of therapy, called extracorporeal shock wave lithotripsy, uses sound waves to crush the stones. The smaller pieces can then pass through more easily, though some pain will remain.
Another form of therapy uses cystoscopy to find the stone in the ureter and then to grab and remove it with a small scoop.
Urinary tract infection: Treatment seeks to get rid of the bacteria responsible for the infection. If you have no other significant illness, you will take a course of antibiotics for 3-14 days, depending on the source of the infection.
Benign prostate enlargement: Sometimes eliminating certain foods and medications that irritate the prostate can help shrink the prostate. Sometimes medication is necessary.
Medications: If a medication is causing hematuria, the medication should be stopped. Some medications only discolor the urine without actually causing hematuria. Your healthcare provider should determine if these can be continued. Do not stop a medication without talking it over with your healthcare provider.
Urinary tract blockage: A blockage usually requires surgery or other procedure to correct or remove the block.
Injury: These may heal over time, or you may need surgery or another procedure to repair the injury or remove the damaged tissue.
Next Steps
Follow-up
Follow-up is very important if you have blood in your urine.
Typically, you will go back to your health care provider in one to two weeks for a repeat analysis of your urine to make sure the hematuria has cleared up.
If bloody urine continues, you might need further testing or need to see a specialist (urologist).
You should drink plenty of water and take all medications as recommended if the hematuria is to go away.
Men older than 50 years of age for whom no definite cause is found should have yearly screening for prostate cancer.
Monday, November 5, 2007
Alcohol Intoxication
Alcohol Intoxication Definition and Causes
Definition: A person is said to suffer from alcohol intoxication when the quantity of alcohol the person consumes exceeds the individual's tolerance for alcohol and produces behavioral or physical abnormalities. In other words, the person's mental and physical abilities are impaired. The person can't function and certainly should not be operating a motor vehicle.
Causes: Alcohol is a generic term for ethanol, which is a particular type of alcohol produced by the fermentation of many foodstuffs—most commonly barley, hops, and grapes. Other types of alcohol commonly available such as methanol (common in glass cleaners), isopropyl alcohol (rubbing alcohol), and ethylene glycol (automobile antifreeze solution) are highly poisonous when swallowed, even in small quantities. Ethanol produces intoxication because of its depressive effects on various areas of the brain causing these impairments in a progressive order as the person gets more and more drunk:
Disinhibition of normal social functioning (excessive talking, showing off)
Loss of memory
Confusion
Disorientation
Movement not coordinated
Progressive lethargy
Coma
Ultimately the shutdown of the respiratory centers (death)
What happens in the brain: Alcohol increases the effect of the body's naturally occurring neurotransmitter GABA (gamma amino butyric acid). Neurotransmitters are substances that chemically connect the signals from one nerve to the next allowing a signal to flow along a neural pathway. An inhibitory neurotransmitter (alcohol) reduces this signal flow in the brain. This explains how alcohol depresses both a person's mental and physical activities. By way of comparison, cocaine does the opposite by producing a general excitatory effect on the nervous system.
Available forms and measurement: A standard "drink" of ethanol consists of 10 grams. This amount is equal to 10 ounces (300 cc) of regular beer (5% alcohol content); 3-4 ounces of wine (12% alcohol content); or 1 ounce of hard liquor (40% alcohol content, 80 "proof").
Absorption: Approximately 20% of ethanol is absorbed into the bloodstream directly from the stomach, and 80% from the small intestine. Consequently, the longer the ethanol/alcohol remains in the stomach, the slower it will be absorbed and the lower will be the peak in the blood alcohol concentration (known as BAC).
This explains the apparent sobering effect of food, which slows the process of emptying the stomach contents, slows the absorption of alcohol, and reduces the peak BAC reached.
When alcohol is taken with food, absorption generally is complete in 1-3 hours during which time the BAC will peak. If no further alcohol is consumed, sobering up will follow this peak level of BAC.
Distribution: Ethanol is highly soluble in water and is absorbed much less in fat. So alcohol tends to distribute itself mostly in tissues rich in water (muscle) instead of those rich in fat.
Two people may weigh the same, yet their bodies may have different proportions of tissue containing water and fat. Think of a tall, thin person and a short, fat person who both weigh 150 pounds. The short, fat person will have more fat and less water making up his body than the tall, thin person. If both people, in this example, consume the same amount of alcohol, the short, fat person will end up with a higher BAC. This is because the alcohol he drank was spread into a smaller water "space."
Women's bodies, on average, have more fat and less water than men's bodies. Using the same logic, this means that a woman will reach a higher BAC than a man of the same weight when both drink the same amount of alcohol.
Metabolism (elimination): Metabolism is the method by which the body processes alcohol (and everything else you eat). Some of the alcohol is converted to other substances (such as fat, as in "beer belly"). Some is burned as energy (and converted to water and carbon dioxide). A small amount is excreted unchanged (in your breath and urine). The liver metabolizes about 90% of the ethanol. The lungs excrete about 5% during exhalation (breathing out). Alcohol excretion by the lungs forms the basis for Breathalyzer testing. Another 5% is excreted into the urine.
The average person metabolizes about 1 standard drink (10 grams) per hour.
Heavy drinkers have more active livers and may be able to metabolize up to 3 drinks per hour.
People with liver diseases will metabolize less than 1 drink per hour. In many chronic alcoholics, the liver gets burned out and can no longer metabolize alcohol, or anything else, efficiently. This is known as alcoholic cirrhosis.
In alcoholic cirrhosis, the liver cells become badly scarred. This scarring has the effect of blocking blood flow through the liver, impeding exchange of metabolic chemicals into and out of the liver cells and damaging the cells' ability to function.
Alcohol Intoxication Signs and Symptoms
The effects of alcohol vary widely from person to person. Several factors can account for obvious differences in how certain amounts of alcohol can affect one person more than another. These factors also affect the particular signs and symptoms the person may have to indicate alcohol intoxication.
Major factors account for this variation in signs and symptoms:
Prior experience with alcohol. A longtime, heavy drinker may achieve blood alcohol concentration levels that would kill the average casual drinker. Conversely, a college student (typically a freshman) who is a novice drinker may get knocked out by a 6-pack of beer. As a person's drinking increases, his or her liver will increase its capacity to metabolize alcohol. Put simply, a heavy drinker will be able to burn off drinks much faster. In addition, a heavy drinker's brain gets used to frequent, even constant, high blood alcohol concentrations (BAC). This habituation in a heavy drinker can backfire if this person suddenly stops drinking. The person may go into withdrawal and develop seizures or a condition called delirium tremens (DTs).
Taking drugs. The effects of alcohol are enhanced if someone may be taking other drugs, especially those of the sedative class such as sleeping pills or antianxiety medications. A person who is not habituated to either alcohol or sedatives may cause serious harm, or death, in taking sub-lethal doses of each. Together, they can be a deadly combination. The person may be taking medications prescribed by a doctor or over-the-counter drugs and may not intend for the drugs to enhance the effects of the alcohol.
Medical conditions. The presence of a wide variety of medical conditions may affect how someone reacts to alcohol.
Smell of alcohol on the breath. There is a very poor correlation between the strength of the smell of alcohol on the breath and the BAC. Pure alcohol has very little smell. It is the metabolism of other substances in alcoholic beverages that produces most of the smell. This explains why a person who drinks large amounts of high-proof vodka (a more pure form of alcohol) may have only a faint smell of alcohol on the breath. On the other hand, a person who drinks a modest amount of beer may have a strong smell of alcohol on the breath.
Scale of effects. In the average social drinker (defined as someone who drinks no more than 2 standard drinks per day), there is a rough correlation between blood alcohol concentration (BAC) and how the person acts.
Blood alcohol concentration. BAC commonly is expressed in milligrams per deciliter (mg/dL). Using this measure, 100 mg/dL roughly is equal to 1 part alcohol in 1000 parts of water (or blood). Consequently, 100 mg/dL would be equal to a 0.1% concentration. In most states, 100 mg/dL represents the threshold concentration above which a person is legally drunk when operating a motor vehicle.
To find out more about BAC and how it affects you, go to the Blood Alcohol Educator Web site of the Century Council and the University of Illinois for some startling interactive activities.
The following scale details the expected effects of alcohol at various BACs. There is a tremendous variation from person to person, and not all people exhibit all the effects. This scale would apply to a typical social drinker:
50 mg/dL: Loss of emotional restraint, vivaciousness, feeling of warmth, flushing of skin, mild impairment of judgment
100 mg/dL: Slight slurring of speech, loss of control of fine motor movements (such as writing), confusion when faced with tasks requiring thinking, emotionally unstable, inappropriate laughter
200 mg/dL: Very slurred speech, staggering gait, double vision, lethargic but able to be aroused by voice, difficulty sitting upright in a chair, memory loss
300 mg/dL: Stuporous, able to be aroused only briefly by strong physical stimulus (such as a face slap or deep pinch), deep snoring
400 mg/dL: Comatose, not able to be aroused, incontinent (wets self), low blood pressure, irregular breathing
500 mg/dL: Death possible, either from cessation of breathing, excessively low blood pressure, or vomit entering the lungs without the presence of the protective reflex to cough it out
Other conditions that look like alcohol intoxication. It is important to recognize the symptoms of alcohol intoxication not only to confirm the presence and severity of the alcohol effect, but also to be able to differentiate the symptoms from other conditions that may coexist, mimic, or mask the symptoms of alcohol intoxication. Admittedly, such a distinction can be exceedingly difficult for a lay person (such as a police officer) and equally difficult for inexperienced doctors. See, in particular, Advice to Law Enforcement Personnel.
Home Care
The majority of people with simple alcohol intoxication can be cared for by a friend or relative at home.
Remove the person from all sources of alcohol. Remove the person from the bar or party. If in a home environment, get rid of all the liquor.
Provide a safe environment (prevent falls, keep away from dangerous machines and objects, keep from driving vehicles).
Find out if only ethanol has been ingested. Determine if the person has taken any medications, illegal drugs, or nonethanol alcohols.
See if the person is easy to arouse when spoken to or with a slight shake of a shoulder.
Make sure that the person’s condition is not due to an underlying medical cause or injury. Ask about other conditions and look for any evidence of a head injury.
Have someone in constant attendance to ensure that the person is improving and to obtain medical assistance as needed. If the care-taking person does not feel comfortable monitoring the condition of the intoxicated person, then it would be best to take the person to the hospital.
No medications will speed up the sobering process. Caffeine (by drinking coffee) and cold showers have a minimal and very temporary effect.
NOTE: It is extremely common for an intoxicated person to vomit once. However, vomiting more than once may be a sign of head injury or other cause of serious illness. If a drunken person vomits more than once and is not completely coherent, then he or she should be taken to the hospital's emergency department for evaluation.
When to Seek Medical Care
If all Home Care conditions cannot be assured, if a care-taking person feels uncomfortable monitoring the intoxicated person, or if there is doubt about the person’s condition, then bring the person to a hospital's emergency department. In addition, the person may need attention to chronic medical conditions unrelated to the alcohol intoxication. These could be such conditions as diabetes, renal (kidney) failure, or epilepsy (seizures).
NOTE: It is extremely common for an intoxicated person to vomit once. However, vomiting more than once may be a sign of head injury or other cause of serious illness. If a drunken person vomits more than once and is not completely coherent, then he or she should be taken to the hospital's emergency department for evaluation.
Physician Diagnosis
The doctor will assess the person suspected of alcohol intoxication to answer the following medical questions and provide the appropriate care. Friends or family who accompany a drunken person (or person suspected to be intoxicated) to the hospital can provide invaluable information regarding recent events as well as past medical history.
Does the blood alcohol concentration (BAC) correspond to the physical exam and the person’s apparent degree of intoxication?
Most importantly, in a lethargic, drunken person, a doctor may be more interested in how low the BAC is rather than how high it is. This is because the lower the BAC, the less likely that alcohol explains the abnormal drowsiness.
The dilemma: If the BAC is found to be inappropriately low for the apparent degree of intoxication (for example, a BAC of 150 in a person who is deeply lethargic), then the doctor must look elsewhere for an explanation. Conversely, a BAC of 300 may perfectly explain a stuporous state while masking a coexisting, serious, life-threatening condition.
Is there any evidence of serious physical injury?
In people with mild-to-moderate intoxication, the physical exam alone may often be sufficient to exclude serious physical injuries or at least permit a later reassessment.
The existence or extent of a head injury may be difficult or impossible to assess in a lethargic, intoxicated person. Important information about the person's medical history and recent activities is often lacking, and the person usually is in no condition to talk coherently.
It is entirely possible to have a serious, life-threatening, internal head injury (from a fall, car accident, baseball bat) with no cuts or bleeding in the head. So, deeply lethargic or comatose, intoxicated people should undergo CT scans of their head. A plain skull x-ray is of little value and may actually do harm if the absence of a skull fracture lulls the doctor into thinking there is no head injury. A plain skull x-ray only assesses for a cracked skull. CT scans visualize bleeding in the brain.
Are any medical conditions contributing to the person’s condition?
The assessment of medical conditions in an intoxicated person can be quite complex, as the two often coexist. The doctor will need to assess the status of the person's chronic medical illnesses plus any acute illnesses and injuries. Diagnosis and further investigation of these possibilities are guided by available medical history, physical exam, and results of standard blood tests.
The doctor will check (to rule out) common conditions that mimic those of alcohol intoxication, such as head injuries (usually with internal bleeding), hypoglycemia (low blood sugar), seizure disorders, and the influence of illicit drugs (marijuana, cocaine, amphetamines, and opiates). Common opiates are heroin and codeine. In addition, psychiatric conditions, especially depression and alcohol abuse, frequently coexist. Until the alcohol wears off, it can be exceedingly difficult for the doctor to separate the effects of each.
The doctor will look for specific conditions. For example, if there is fever, the doctor might consider meningitis, pneumonia, or some other serious infection that might be causing a change of mental status. If the blood pressure is extremely low, the doctor will look for internal bleeding.
In addition, the doctor will be looking for evidence of chronic alcohol abuse, such as red spots on the skin (called spider angiomas), an enlarged liver, or yellow eyes or skin (jaundice, caused by damage to the liver).
Alcohol Intoxication, Physician Treatment and Follow-up
Treatment: No specific treatment can reverse the effects of alcohol intoxication.
Intoxicated people often receive IV fluids and B complex vitamins for dehydration (alcohol is a diuretic and increases urine output) as a precaution or treatment for vitamin deficiency.
In severe cases—those of severe stupor and coma—the person should be intubated (breathing tube placed in airway) to support respirations (which may stop spontaneously) and to protect the lungs from filling with vomit.
Intubation involves placing a short, flexible plastic tube into the windpipe to just below the vocal cords and connecting the tube to a respirator machine. The tip of the tube has a small donut-shaped balloon around it, which is inflated to seal the end of the tube to the inside of the windpipe. This accomplishes two things:
It prevents the air from the respirator from leaking out into the mouth instead of going into the lungs.
It provides a protective seal so that a large amount of vomit in the mouth would be prevented from entering the lungs where it would cause a great deal of damage and possibly suffocation.
Follow-up: Barring any major complications, most intoxicated people may go home from the hospital's Emergency Department. For some medical and many legal reasons, most hospitals prefer to keep people suspected of alcohol intoxication under observation until their blood alcohol concentration (BAC) falls to below 100 mg/dL.
In most people, the liver metabolizes about 10 grams of ethanol per hour. This corresponds to a BAC fall of about 20 mg/dL per hour. Thus, the length of time a person (and family) will need to wait until discharge may be expressed by the formula (BAC-100)/20 = the wait in hours. Example: The BAC from a blood sample drawn at midnight is 280. (280-100)/20 = 9. The BAC should fall to 100 mg/dL by 9 am (midnight plus 9 hours).
A social worker may talk with the intoxicated person prior to discharge from the hospital. The social worker may advise the person to go to an alcohol treatment center. This is an extremely difficult situation because many people either don't recognize their problem, if they are chronic drinkers, or don't have any desire to correct the situation.
Definition: A person is said to suffer from alcohol intoxication when the quantity of alcohol the person consumes exceeds the individual's tolerance for alcohol and produces behavioral or physical abnormalities. In other words, the person's mental and physical abilities are impaired. The person can't function and certainly should not be operating a motor vehicle.
Causes: Alcohol is a generic term for ethanol, which is a particular type of alcohol produced by the fermentation of many foodstuffs—most commonly barley, hops, and grapes. Other types of alcohol commonly available such as methanol (common in glass cleaners), isopropyl alcohol (rubbing alcohol), and ethylene glycol (automobile antifreeze solution) are highly poisonous when swallowed, even in small quantities. Ethanol produces intoxication because of its depressive effects on various areas of the brain causing these impairments in a progressive order as the person gets more and more drunk:
Disinhibition of normal social functioning (excessive talking, showing off)
Loss of memory
Confusion
Disorientation
Movement not coordinated
Progressive lethargy
Coma
Ultimately the shutdown of the respiratory centers (death)
What happens in the brain: Alcohol increases the effect of the body's naturally occurring neurotransmitter GABA (gamma amino butyric acid). Neurotransmitters are substances that chemically connect the signals from one nerve to the next allowing a signal to flow along a neural pathway. An inhibitory neurotransmitter (alcohol) reduces this signal flow in the brain. This explains how alcohol depresses both a person's mental and physical activities. By way of comparison, cocaine does the opposite by producing a general excitatory effect on the nervous system.
Available forms and measurement: A standard "drink" of ethanol consists of 10 grams. This amount is equal to 10 ounces (300 cc) of regular beer (5% alcohol content); 3-4 ounces of wine (12% alcohol content); or 1 ounce of hard liquor (40% alcohol content, 80 "proof").
Absorption: Approximately 20% of ethanol is absorbed into the bloodstream directly from the stomach, and 80% from the small intestine. Consequently, the longer the ethanol/alcohol remains in the stomach, the slower it will be absorbed and the lower will be the peak in the blood alcohol concentration (known as BAC).
This explains the apparent sobering effect of food, which slows the process of emptying the stomach contents, slows the absorption of alcohol, and reduces the peak BAC reached.
When alcohol is taken with food, absorption generally is complete in 1-3 hours during which time the BAC will peak. If no further alcohol is consumed, sobering up will follow this peak level of BAC.
Distribution: Ethanol is highly soluble in water and is absorbed much less in fat. So alcohol tends to distribute itself mostly in tissues rich in water (muscle) instead of those rich in fat.
Two people may weigh the same, yet their bodies may have different proportions of tissue containing water and fat. Think of a tall, thin person and a short, fat person who both weigh 150 pounds. The short, fat person will have more fat and less water making up his body than the tall, thin person. If both people, in this example, consume the same amount of alcohol, the short, fat person will end up with a higher BAC. This is because the alcohol he drank was spread into a smaller water "space."
Women's bodies, on average, have more fat and less water than men's bodies. Using the same logic, this means that a woman will reach a higher BAC than a man of the same weight when both drink the same amount of alcohol.
Metabolism (elimination): Metabolism is the method by which the body processes alcohol (and everything else you eat). Some of the alcohol is converted to other substances (such as fat, as in "beer belly"). Some is burned as energy (and converted to water and carbon dioxide). A small amount is excreted unchanged (in your breath and urine). The liver metabolizes about 90% of the ethanol. The lungs excrete about 5% during exhalation (breathing out). Alcohol excretion by the lungs forms the basis for Breathalyzer testing. Another 5% is excreted into the urine.
The average person metabolizes about 1 standard drink (10 grams) per hour.
Heavy drinkers have more active livers and may be able to metabolize up to 3 drinks per hour.
People with liver diseases will metabolize less than 1 drink per hour. In many chronic alcoholics, the liver gets burned out and can no longer metabolize alcohol, or anything else, efficiently. This is known as alcoholic cirrhosis.
In alcoholic cirrhosis, the liver cells become badly scarred. This scarring has the effect of blocking blood flow through the liver, impeding exchange of metabolic chemicals into and out of the liver cells and damaging the cells' ability to function.
Alcohol Intoxication Signs and Symptoms
The effects of alcohol vary widely from person to person. Several factors can account for obvious differences in how certain amounts of alcohol can affect one person more than another. These factors also affect the particular signs and symptoms the person may have to indicate alcohol intoxication.
Major factors account for this variation in signs and symptoms:
Prior experience with alcohol. A longtime, heavy drinker may achieve blood alcohol concentration levels that would kill the average casual drinker. Conversely, a college student (typically a freshman) who is a novice drinker may get knocked out by a 6-pack of beer. As a person's drinking increases, his or her liver will increase its capacity to metabolize alcohol. Put simply, a heavy drinker will be able to burn off drinks much faster. In addition, a heavy drinker's brain gets used to frequent, even constant, high blood alcohol concentrations (BAC). This habituation in a heavy drinker can backfire if this person suddenly stops drinking. The person may go into withdrawal and develop seizures or a condition called delirium tremens (DTs).
Taking drugs. The effects of alcohol are enhanced if someone may be taking other drugs, especially those of the sedative class such as sleeping pills or antianxiety medications. A person who is not habituated to either alcohol or sedatives may cause serious harm, or death, in taking sub-lethal doses of each. Together, they can be a deadly combination. The person may be taking medications prescribed by a doctor or over-the-counter drugs and may not intend for the drugs to enhance the effects of the alcohol.
Medical conditions. The presence of a wide variety of medical conditions may affect how someone reacts to alcohol.
Smell of alcohol on the breath. There is a very poor correlation between the strength of the smell of alcohol on the breath and the BAC. Pure alcohol has very little smell. It is the metabolism of other substances in alcoholic beverages that produces most of the smell. This explains why a person who drinks large amounts of high-proof vodka (a more pure form of alcohol) may have only a faint smell of alcohol on the breath. On the other hand, a person who drinks a modest amount of beer may have a strong smell of alcohol on the breath.
Scale of effects. In the average social drinker (defined as someone who drinks no more than 2 standard drinks per day), there is a rough correlation between blood alcohol concentration (BAC) and how the person acts.
Blood alcohol concentration. BAC commonly is expressed in milligrams per deciliter (mg/dL). Using this measure, 100 mg/dL roughly is equal to 1 part alcohol in 1000 parts of water (or blood). Consequently, 100 mg/dL would be equal to a 0.1% concentration. In most states, 100 mg/dL represents the threshold concentration above which a person is legally drunk when operating a motor vehicle.
To find out more about BAC and how it affects you, go to the Blood Alcohol Educator Web site of the Century Council and the University of Illinois for some startling interactive activities.
The following scale details the expected effects of alcohol at various BACs. There is a tremendous variation from person to person, and not all people exhibit all the effects. This scale would apply to a typical social drinker:
50 mg/dL: Loss of emotional restraint, vivaciousness, feeling of warmth, flushing of skin, mild impairment of judgment
100 mg/dL: Slight slurring of speech, loss of control of fine motor movements (such as writing), confusion when faced with tasks requiring thinking, emotionally unstable, inappropriate laughter
200 mg/dL: Very slurred speech, staggering gait, double vision, lethargic but able to be aroused by voice, difficulty sitting upright in a chair, memory loss
300 mg/dL: Stuporous, able to be aroused only briefly by strong physical stimulus (such as a face slap or deep pinch), deep snoring
400 mg/dL: Comatose, not able to be aroused, incontinent (wets self), low blood pressure, irregular breathing
500 mg/dL: Death possible, either from cessation of breathing, excessively low blood pressure, or vomit entering the lungs without the presence of the protective reflex to cough it out
Other conditions that look like alcohol intoxication. It is important to recognize the symptoms of alcohol intoxication not only to confirm the presence and severity of the alcohol effect, but also to be able to differentiate the symptoms from other conditions that may coexist, mimic, or mask the symptoms of alcohol intoxication. Admittedly, such a distinction can be exceedingly difficult for a lay person (such as a police officer) and equally difficult for inexperienced doctors. See, in particular, Advice to Law Enforcement Personnel.
Home Care
The majority of people with simple alcohol intoxication can be cared for by a friend or relative at home.
Remove the person from all sources of alcohol. Remove the person from the bar or party. If in a home environment, get rid of all the liquor.
Provide a safe environment (prevent falls, keep away from dangerous machines and objects, keep from driving vehicles).
Find out if only ethanol has been ingested. Determine if the person has taken any medications, illegal drugs, or nonethanol alcohols.
See if the person is easy to arouse when spoken to or with a slight shake of a shoulder.
Make sure that the person’s condition is not due to an underlying medical cause or injury. Ask about other conditions and look for any evidence of a head injury.
Have someone in constant attendance to ensure that the person is improving and to obtain medical assistance as needed. If the care-taking person does not feel comfortable monitoring the condition of the intoxicated person, then it would be best to take the person to the hospital.
No medications will speed up the sobering process. Caffeine (by drinking coffee) and cold showers have a minimal and very temporary effect.
NOTE: It is extremely common for an intoxicated person to vomit once. However, vomiting more than once may be a sign of head injury or other cause of serious illness. If a drunken person vomits more than once and is not completely coherent, then he or she should be taken to the hospital's emergency department for evaluation.
When to Seek Medical Care
If all Home Care conditions cannot be assured, if a care-taking person feels uncomfortable monitoring the intoxicated person, or if there is doubt about the person’s condition, then bring the person to a hospital's emergency department. In addition, the person may need attention to chronic medical conditions unrelated to the alcohol intoxication. These could be such conditions as diabetes, renal (kidney) failure, or epilepsy (seizures).
NOTE: It is extremely common for an intoxicated person to vomit once. However, vomiting more than once may be a sign of head injury or other cause of serious illness. If a drunken person vomits more than once and is not completely coherent, then he or she should be taken to the hospital's emergency department for evaluation.
Physician Diagnosis
The doctor will assess the person suspected of alcohol intoxication to answer the following medical questions and provide the appropriate care. Friends or family who accompany a drunken person (or person suspected to be intoxicated) to the hospital can provide invaluable information regarding recent events as well as past medical history.
Does the blood alcohol concentration (BAC) correspond to the physical exam and the person’s apparent degree of intoxication?
Most importantly, in a lethargic, drunken person, a doctor may be more interested in how low the BAC is rather than how high it is. This is because the lower the BAC, the less likely that alcohol explains the abnormal drowsiness.
The dilemma: If the BAC is found to be inappropriately low for the apparent degree of intoxication (for example, a BAC of 150 in a person who is deeply lethargic), then the doctor must look elsewhere for an explanation. Conversely, a BAC of 300 may perfectly explain a stuporous state while masking a coexisting, serious, life-threatening condition.
Is there any evidence of serious physical injury?
In people with mild-to-moderate intoxication, the physical exam alone may often be sufficient to exclude serious physical injuries or at least permit a later reassessment.
The existence or extent of a head injury may be difficult or impossible to assess in a lethargic, intoxicated person. Important information about the person's medical history and recent activities is often lacking, and the person usually is in no condition to talk coherently.
It is entirely possible to have a serious, life-threatening, internal head injury (from a fall, car accident, baseball bat) with no cuts or bleeding in the head. So, deeply lethargic or comatose, intoxicated people should undergo CT scans of their head. A plain skull x-ray is of little value and may actually do harm if the absence of a skull fracture lulls the doctor into thinking there is no head injury. A plain skull x-ray only assesses for a cracked skull. CT scans visualize bleeding in the brain.
Are any medical conditions contributing to the person’s condition?
The assessment of medical conditions in an intoxicated person can be quite complex, as the two often coexist. The doctor will need to assess the status of the person's chronic medical illnesses plus any acute illnesses and injuries. Diagnosis and further investigation of these possibilities are guided by available medical history, physical exam, and results of standard blood tests.
The doctor will check (to rule out) common conditions that mimic those of alcohol intoxication, such as head injuries (usually with internal bleeding), hypoglycemia (low blood sugar), seizure disorders, and the influence of illicit drugs (marijuana, cocaine, amphetamines, and opiates). Common opiates are heroin and codeine. In addition, psychiatric conditions, especially depression and alcohol abuse, frequently coexist. Until the alcohol wears off, it can be exceedingly difficult for the doctor to separate the effects of each.
The doctor will look for specific conditions. For example, if there is fever, the doctor might consider meningitis, pneumonia, or some other serious infection that might be causing a change of mental status. If the blood pressure is extremely low, the doctor will look for internal bleeding.
In addition, the doctor will be looking for evidence of chronic alcohol abuse, such as red spots on the skin (called spider angiomas), an enlarged liver, or yellow eyes or skin (jaundice, caused by damage to the liver).
Alcohol Intoxication, Physician Treatment and Follow-up
Treatment: No specific treatment can reverse the effects of alcohol intoxication.
Intoxicated people often receive IV fluids and B complex vitamins for dehydration (alcohol is a diuretic and increases urine output) as a precaution or treatment for vitamin deficiency.
In severe cases—those of severe stupor and coma—the person should be intubated (breathing tube placed in airway) to support respirations (which may stop spontaneously) and to protect the lungs from filling with vomit.
Intubation involves placing a short, flexible plastic tube into the windpipe to just below the vocal cords and connecting the tube to a respirator machine. The tip of the tube has a small donut-shaped balloon around it, which is inflated to seal the end of the tube to the inside of the windpipe. This accomplishes two things:
It prevents the air from the respirator from leaking out into the mouth instead of going into the lungs.
It provides a protective seal so that a large amount of vomit in the mouth would be prevented from entering the lungs where it would cause a great deal of damage and possibly suffocation.
Follow-up: Barring any major complications, most intoxicated people may go home from the hospital's Emergency Department. For some medical and many legal reasons, most hospitals prefer to keep people suspected of alcohol intoxication under observation until their blood alcohol concentration (BAC) falls to below 100 mg/dL.
In most people, the liver metabolizes about 10 grams of ethanol per hour. This corresponds to a BAC fall of about 20 mg/dL per hour. Thus, the length of time a person (and family) will need to wait until discharge may be expressed by the formula (BAC-100)/20 = the wait in hours. Example: The BAC from a blood sample drawn at midnight is 280. (280-100)/20 = 9. The BAC should fall to 100 mg/dL by 9 am (midnight plus 9 hours).
A social worker may talk with the intoxicated person prior to discharge from the hospital. The social worker may advise the person to go to an alcohol treatment center. This is an extremely difficult situation because many people either don't recognize their problem, if they are chronic drinkers, or don't have any desire to correct the situation.
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