What is the approach to managing alcohol intoxication in the Emergency Department (ED)?

Management of Alcohol Intoxication in the Emergency Department

The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis for clinical assessment and management of alcohol intoxication in the Emergency Department. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABCs): First priority is to ensure patient stability

  • Assess for respiratory depression, which can occur in severe intoxication
  • Monitor vital signs closely, with particular attention to:
    • Hypotension (increases odds of critical illness by 3.8)
    • Tachycardia (increases odds by 1.8)
    • Hypoxia (increases odds by 3.8)
    • Hypothermia (increases odds by 4.2)
    • Fever (increases odds by 7.6) 2

• Blood glucose measurement: Immediate priority

  • Hypoglycemia increases odds of critical illness by 9.2 2
  • Treat hypoglycemia promptly with IV dextrose if present

• Clinical assessment of intoxication level:

  • Mild: Euphoria, mild impairment in coordination
  • Moderate: Emotional lability, slurred speech, ataxia
  • Severe: Marked ataxia, vomiting, confusion, stupor
  • Life-threatening: Respiratory depression, hypothermia, coma 1, 3

Medical Management

Pharmacological Interventions

• For severe agitation: Benzodiazepines are the treatment of choice

  • Diazepam IV: Indicated for acute alcohol withdrawal and acute agitation 4
  • Administration considerations:
    • Inject slowly (at least one minute per 5 mg)
    • Avoid small veins
    • Have resuscitation equipment readily available
    • Reduce dosage of any concomitant narcotic analgesics by at least one-third 4

• Important caution: Diazepam should not be administered to patients in shock, coma, or acute alcoholic intoxication with depression of vital signs 4

• Supportive care:

  • IV fluids for hydration and to correct electrolyte imbalances
  • Administration of B and C vitamins (particularly thiamine)
  • Treatment of hypoglycemia, hypotension, hypothermia as needed 5

Non-Pharmacological Management

• Observation period: Consider using a period of observation to determine if psychiatric symptoms resolve as intoxication resolves 1

  • Many patients can be managed in an observation unit with clinical course completed within 24 hours 5

• Monitoring for complications:

  • Approximately 1% of patients initially assessed as low-risk develop critical illness requiring intensive care 2
  • Most common complications: acute hypoxic respiratory failure, alcohol withdrawal, sepsis/infection, and intracranial hemorrhage 2

Special Considerations

• Psychiatric evaluation:

  • Cognitive function should be assessed individually rather than using a predetermined blood alcohol concentration cutoff 1
  • Psychiatric facilities generally will not accept transfers of inebriated patients 1
  • As blood alcohol concentration decreases, psychiatric symptoms may clear, particularly suicidality 1

• Differential diagnosis:

  • Rule out other causes of altered mental status (Table 6 features mimicking stroke):
    • Hypoglycemia
    • Seizures
    • Wernicke's encephalopathy
    • Drug toxicity
    • CNS infection or tumor 1

Disposition Planning

• Discharge criteria:

  • Return to baseline mental status
  • Ability to ambulate safely
  • Absence of suicidal ideation or other psychiatric emergencies
  • Stable vital signs

• Referral for alcohol use disorder:

  • Screen for underlying alcohol use disorder
  • Refer to alcohol addiction unit for multidisciplinary treatment 3, 5
  • Brief motivational interventions should be routinely used 1

Pitfalls and Caveats

• Do not rely solely on blood alcohol concentration for clinical decision-making; cognitive function is more important 1

• Never underestimate intoxicated patients: 1% of patients initially assessed as low-risk develop critical illness 2

• Watch for withdrawal: Monitor for development of alcohol withdrawal syndrome, which requires specific treatment 5

• Consider occult trauma: Intoxicated patients may have unrecognized injuries due to decreased pain perception

• Avoid premature psychiatric evaluation: Alcohol intoxication can mimic or alter psychiatric symptoms 1