From the Guidelines
A second ethanol (ETOH) level should be drawn in an intoxicated patient in the Emergency Department when the patient's cognitive abilities and clinical sobriety indicate it is necessary, rather than relying on a specific time frame or blood alcohol level. The decision to draw a second ETOH level should be based on the patient's individual response to alcohol metabolism and clearance, as well as their overall clinical presentation 1.
Factors to Consider
When deciding when to draw a second ETOH level, consider the following factors:
- The patient's cognitive abilities, such as their ability to respond to questions and follow commands
- The patient's clinical sobriety, including their coordination, balance, and ability to ambulate safely
- The patient's medical history, including any history of chronic alcohol use or liver disease
- The patient's current vital signs and physical examination findings
Clinical Assessment
Rather than relying solely on arbitrary cutoff values, such as a blood alcohol level below 80 mg/dL (0.08%), assess the patient's mental status, coordination, and ability to ambulate safely 1. Some facilities use a structured assessment tool like the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score to objectively document improvement.
Discharge Decision
The decision to discharge should ultimately be based on both laboratory values and clinical assessment of the patient's ability to safely care for themselves. The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis on which clinicians begin the psychiatric assessment and make discharge decisions 1.
From the Research
Timing of Second ETOH Level in Intoxicated Patients
- The provided studies do not directly address the timing of drawing a second ETOH level in intoxicated patients in the ED while awaiting levels to drop for discharge 2, 3, 4, 5, 6.
- However, the studies discuss the management of alcohol withdrawal syndrome and the use of benzodiazepines and phenobarbital in treating patients with alcohol withdrawal 2, 3, 5, 6.
- One study mentions the importance of repetitive examinations to properly determine the patient's condition, which may imply the need for regular monitoring of ETOH levels 4.
- Another study discusses the goal-directed management of severe alcohol withdrawal, which may involve monitoring ETOH levels as part of the treatment protocol 5.
Factors to Consider
- The clinical assessment of an acutely intoxicated patient should be performed with meticulous care and include repetitive examinations to properly determine the patient's condition 4.
- Multiple factors, such as trauma and concomitant use of other drugs, can confuse the diagnostic picture and affect the choice of therapy 4.
- The selection of a preferred benzodiazepine for treating alcohol withdrawal is limited due to a lack of comparative studies 5.
Treatment Protocols
- Benzodiazepines are the gold standard for treatment of alcohol withdrawal, and the selection of a preferred benzodiazepine is limited due to a lack of comparative studies 2, 3, 5.
- Phenobarbital has been shown to be an effective adjunctive therapy for severe alcohol withdrawal, reducing benzodiazepine use in the ED and ICU 3.
- The use of phenobarbital compared to benzodiazepines in alcohol withdrawal treatment has been evaluated, with mixed results regarding subsequent benzodiazepine use, alcohol recidivism, and mortality 6.