**8. Acute care**

224 Complementary Pediatrics

The clustering of social problems and alcohol intoxication was a particular observation of interest in a project carried out at the Reinier de Graaf Hospital in Delft, The Netherlands (see Protocol chapter). The rate of self-reported social problems was high among the adolescents admitted for alcohol intoxication. Among them were family histories of addiction (35.3%), divorce or a deceased parent (19.1% and 11,3% respectively); parent-child interaction was aberrant in many cases (44.6%), as were school problems (34.3%) and sexual abuse (4.4%) or life-events (e.g. severe illness, emotional problems (41.2%). Also common were underlying psychiatric disorders (40%) (autism, attention deficit hyperactivity

These percentages show that the clustering of personal and social issues during puberty

It is important to realize on the long term, that alcohol and substance abuse tend to track on into early adulthood and that alcohol use at a young age is a predictor for future alcohol use

Adolescent drinkers are more likely than their non-drinking or experimenting peers to have school problems, drugs or engage in criminal activities such as stealing. In a follow up study carried out 10 years later, adolescents who had consumed alcohol were still more often involved in problem behaviors including unreliable work attendance, substance use problems, violent behavior and illegal activities during early adulthood. Early experimenters were also at higher risk than non-drinkers to have problems with substance

Heavy drinking has been shown to affect neuropsychological performance and could impair the growth and integrity of the brain structures. During adolescence, the part of the brain that is developing in particular is the frontal lobe. Here, the higher cognitive functions such

Research with functional magnetic resonance imaging (fMRI) demonstrates that memory, attention and visuospatial abilities are negatively affected by alcohol. Alcohol and drug abusers perform worse than their peers (35). Increased vulnerability for these neurologic effects is seen in women, patients with a family history of alcohol use disorders, heavy episodic drinkers and alcohol use combined with drug use. The co-occurrence of psychiatric disorders is an important factor to consider in the evaluation of neurocognitive functioning in patients with alcohol abuse. As was mentioned before causality is not clear. The role of time of abstinence and age of first drink seem to be less related to neurologic damage (36). Importantly, as young adulthood is a period when most people make important educational, occupational and social decisions, an impaired cognitive function could

Alcohol use increases the risk of high-risk sexual intercourse. Young adolescents report that alcohol has caused them to engage in unplanned sex (27). Girls in particular are prone to participate in sexual relationships more readily, and even against their will, during intoxication. Afterwards, they often regret the incident and it is not uncommon that they are

disorder, depression or eating disorders).

use and criminal and violent behavior (32).

significantly affect their futures.

traumatized.

as cognitive processing and executive functions are located (33;34).

makes this group vulnerable.

**7. Consequences** 

(31).

The acute care of an adolescent presenting with alcohol intoxication is being done conform the Advanced Pediatric Life Support protocol (APLS). Most hospitalizations occur during the evening or night (93%), (see Epidemiology section). The announcement of an adolescent having become unwell at a party or an unconscious youngster smelling of ethanol usually gives away the diagnosis. However, as the presentation is often severe, especially the level of consciousness, ABCD-assessment should always be done. Reports of reduced consciousness vary from a couple of minutes up to 48 hours (!), with an average of 2 hours and 11 minutes. According to Dutch research, average time of unconsciousness has risen during the past years from 2,2 hours in 2007 to 3,1 hours in 2010 (7). Other presentations include traffic accidents, aggression and violence and even suicide attempts (1%). These type of symptoms of alcohol intoxication (Table 3) usually appear at a blood alcohol concentration of 20-50 mg/dl (0.2-0.5%).


Table 3. Symptoms of alcohol intoxication

At admission of a patient with alcohol intoxication, the following assessments should be done:


A New Approach in Adolescent Alcohol Intoxication –

Mild intoxication

Child psychologist screening talk

Evaluation talk potent. by phone

Neuropsychological examination

PHASE 1 \*

PHASE 2 \*\*

PHASE 3 \*\*

On indication

12 wks after D

Advisory talk

NSCK: Dutch Pediatric Surveillance System

CBCL: Child Behaviour Checklist

**10. Hospital admittance** 

outpatient department.

TRF: Teacher Report Form YSR: Youth Self Report

Final talk using standardised interview

Fig. 3. Flowchart alcohol treatment policlinic alcohol and youth

Nurse

Clinical Pediatric Experience and Research Combined 227

Pediatrician Pedagogic worker/

**Youth and Alcohol Outpatient Clinic**

Discharge

CBCL TRF YSR 1 CBCL TRF YSR 1

CBCL YSR 2 CBCL YSR 2

After acute care, the focus shifts towards treatment and education. By informing the patients and their parents about the dangers of alcohol consumption, the effect of hospitalization is broadened towards prevention and intervention. This will be of use during follow up at the

Most patients are admitted in the evening or at night (40). The next morning, they are woken on time to start a short program before being discharged from hospital. First, the pediatrician speaks both to the patient and the parents, explaining the reason for admittance and emphasizing the seriousness of the event. The patient's medical and social histories are checked and questions are asked about further alcohol use. The dangers of alcohol use are explained. This is seen as an important moment for intervention and education. Patient and parents pay more attention shortly after the incident occurred. Later on, a pedagogic

6-8 months 4-8 months

Pediatric Consult 1

NSCK\*\*\* NSCK\*\*\*

< 6 wks of D Start point: referral from regional hospital

Moderate/severe intoxication

External referral (ADHD, addiction, etc.)

> Multidiscip. Meeting 1

Multidiscip. Meeting 2

Final consult 2

Admission to Pediatric ward

Arrival at General Hospital Emergency Department

The amount of alcohol consumed can be estimated by using the formula, based on the Widmark equation, in figure 2 (39). This can be of use in conversations with parents and patients about alcohol consumption.


Fig. 2. Formula to calculate amount of alcohol consumed

In general, acute medical complications are serious but mild. The complications seen most frequently are reduced consciousness (45%) and hypothermia (43.1%). Electrolyte disturbances are most often hypercloremia (31.1%) and low bicarbonate (22%), but hypokalemia (11.9%) and hypernatremia (7.7%) are also seen. Hypoglycaemia is not often reported, however hyperglycaemia can be seen in some patients (13.6%). Mild acidosis, more often metabolic but also respiratory, was observed in 28.8% of patients (2).

After admittance patients are directly monitored. Treatment mostly consists of administering intravenous fluids to rehydrate. Metabolic acidosis, hypoglycaemia and hypothermia are corrected. Gastric lavage and activated charcoal are not recommended since they are ineffective due to the rapid resorption of ethanol and because they possibly enhance the risk of aspiration.
