What is the treatment for acute alcohol intoxication in the Emergency Department (ED)?

From the Guidelines

The treatment of acute alcohol intoxication in the emergency department should focus on supportive care, including ensuring airway protection, maintaining breathing, and stabilizing circulation, as well as administering thiamine and intravenous fluids to prevent complications such as Wernicke's encephalopathy and dehydration, as recommended by the most recent guidelines 1.

Initial Management

The initial management of acute alcohol intoxication includes:

• Ensuring airway protection, maintaining breathing, and stabilizing circulation
• Placing patients in a lateral position to prevent aspiration if vomiting occurs
• Administering intravenous fluids, typically normal saline, to correct dehydration and electrolyte imbalances
• Giving thiamine 100mg IV before glucose administration to prevent precipitating Wernicke's encephalopathy
• Administering 50mL of 50% dextrose (D50W) if hypoglycemia is present

Pharmacological Treatment

For severe agitation, benzodiazepines such as lorazepam 1-2mg IV or diazepam 5-10mg IV may be used, as recommended by recent guidelines 1.

• Long-acting benzodiazepines (e.g., chlordiazepoxide and diazepam) are recommended for the prevention of seizures
• Lorazepam, an intermediate-acting benzodiazepine, is recommended for patients with severe AWS, advanced age, recent head trauma, liver failure, respiratory failure, or other serious medical comorbidities

Monitoring and Laboratory Tests

Continuous monitoring of vital signs, oxygen saturation, and mental status is essential.

• Laboratory tests should include blood alcohol level, electrolytes, glucose, and liver function tests
• Patients should only be discharged when clinically sober with a responsible adult to accompany them

Ongoing Care

For patients with alcohol use disorder, the ED visit presents an opportunity to discuss treatment options and provide referrals for ongoing care, as recommended by recent guidelines 1.

• The physiological basis for this approach is that alcohol acts as a central nervous system depressant, and management focuses on preventing complications while allowing natural metabolism of alcohol at approximately one standard drink per hour.

From the FDA Drug Label

In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis. 10 mg, intramuscular or intravenous initially, then 5 mg to 10 mg in 3 to 4 hours, if necessary.

The treatment of acute alcohol intoxication in the ED with diazepam (IV) is not directly addressed in the provided drug labels. However, diazepam is indicated for the management of acute alcohol withdrawal, which may be a related condition.

• The recommended dose for acute alcohol withdrawal is 10 mg, intramuscular or intravenous initially, then 5 mg to 10 mg in 3 to 4 hours, if necessary 2.
• It is essential to note that diazepam should be used with caution in patients with acute alcohol intoxication, as it may exacerbate respiratory depression and other adverse effects.
• The decision to use diazepam in this setting should be made on a case-by-case basis, taking into account the patient's overall clinical condition and medical history 2.

From the Research

Treatment of Acute Alcohol Intoxication in ED

• The treatment of acute alcohol intoxication depends on the general clinical conditions of the patient, vital signs, hemodynamic stability, cognitive state, alcohol-related complications, and blood alcohol concentration 3.
• In cases of mild-moderate intoxication (blood alcohol concentration < 1 g/L), no drugs are necessary, and patients can benefit from clinical observation with vital signs control 3.
• In cases of severe intoxication (blood alcohol concentration > 1 g/L), it is necessary to support with intravenous fluids, treat hypoglycemia, hypotension, hypothermia, and electrolyte imbalance, administer complex B and C vitamins, and accelerate alcohol elimination from blood with metadoxine 3, 4.
• Metadoxine is a specific drug that is useful in the treatment of acute alcohol intoxication, as it is able to accelerate ethanol excretion 4.
• Patients affected by acute alcohol intoxication are the best candidates to apply the rules of the Temporary Observation Unit in the Emergency Department, due to a clinical course often completed within 24 hours and a favorable outcome without the need for hospitalization 3.

Medical Needs of Patients with Acute Alcohol Intoxication

• Patients with acute alcohol intoxication often have underlying acute medical needs, including the need for medical interventions such as medications, diagnostic testing, procedures, and airway interventions 5.
• A substantial proportion of patients with acute alcohol intoxication receive medical interventions, including sedating medications, physical restraints, imaging studies, laboratory testing, and airway interventions 5.
• Some patients may require hospital admission, and it is essential to identify those who need further medical attention 5.

Wernicke's Encephalopathy

• Wernicke's encephalopathy (WE) is a neurologic emergency that requires immediate attention to prevent permanent neurological morbidity and mortality 6, 7.
• WE is caused by thiamine deficiency, often related to alcohol abuse, and presents with confusion, ophthalmoplegia, and gait ataxia 6, 7.
• Thiamine replacement therapy can rapidly reverse neurologic symptoms and MRI findings in patients with WE 7.
• Routine administration of large doses of intravenous thiamine to all patients admitted with alcohol withdrawal symptoms should be considered to avoid insufficient treatment 6.