How to manage and reverse alcohol intoxication in a patient?

Management of Alcohol Intoxication

The most effective approach to reverse alcohol intoxication is supportive care while allowing time for the body to metabolize the alcohol naturally, with benzodiazepines used only when withdrawal symptoms develop. 1, 2

Assessment of Alcohol Intoxication

• Cognitive assessment is more important than blood alcohol level when determining management approach 3
• Evaluate for:
  • Level of consciousness and orientation
  • Vital signs (particularly for hypotension, hypothermia)
  • Signs of trauma or other injuries
  • Blood glucose (to rule out hypoglycemia)
  • Electrolyte imbalances
  • Comorbid conditions requiring immediate attention

Management Algorithm for Alcohol Intoxication

1. Mild-Moderate Intoxication (BAC < 1 g/L)

• Supportive care only - no medications needed 2
• Intravenous fluids if signs of dehydration
• Monitor vital signs
• Observe until cognitive function improves

2. Severe Intoxication (BAC > 1 g/L)

• Supportive care with:
  • Intravenous fluids
  • Correction of hypoglycemia if present
  • Management of hypotension
  • Warming if hypothermic
  • Correction of electrolyte imbalances
  • Administration of thiamine (vitamin B1) 3, 1
  • Consider metadoxine to accelerate alcohol elimination in severe cases 2

3. For Patients Developing Withdrawal Symptoms

• Benzodiazepines are the gold standard for alcohol withdrawal management 3, 1
• Dosing options:
  • Diazepam: 5-10 mg orally/IV/IM every 6-8 hours 1, 4
  • Lorazepam: 1-4 mg orally/IV/IM every 4-8 hours (preferred in elderly or those with hepatic dysfunction) 3, 1
  • Chlordiazepoxide: 25-100 mg orally every 4-6 hours 1

Special Considerations

Thiamine Administration

• All patients with alcohol intoxication should receive thiamine supplementation (100-300 mg/day) 3, 1
• High-risk patients (malnourished, severe withdrawal) should receive parenteral thiamine to prevent Wernicke's encephalopathy 3, 1

Inpatient vs. Outpatient Management

• Outpatient observation is appropriate for:

  • Patients with mild-moderate symptoms
  • Normal vital signs
  • No comorbidities requiring hospitalization
  • Adequate social support 2

• Inpatient management is recommended for:

  • Severe intoxication with complications
  • Risk of severe withdrawal
  • Concurrent serious physical or psychiatric disorders
  • Inadequate social support 3

Common Pitfalls to Avoid

• Using antipsychotic medications as stand-alone treatment for alcohol withdrawal (should only be used as adjuncts to benzodiazepines in severe withdrawal delirium) 3, 1
• Failing to provide thiamine supplementation 1
• Delaying psychiatric evaluation based solely on blood alcohol concentration rather than cognitive function 3
• Inadequate dosing of benzodiazepines when withdrawal symptoms are present 1
• Neglecting to screen for and address underlying alcohol use disorder 1, 5

Follow-up Recommendations

• Patients with alcohol use disorder should be referred to specialized addiction services 2
• Consider pharmacological options for maintaining abstinence in dependent patients (acamprosate, naltrexone, disulfiram) 3, 1
• Encourage engagement with mutual help groups like Alcoholics Anonymous 3, 1
• Family members should be involved in treatment when appropriate 3, 1

Remember that while acute alcohol intoxication typically resolves within 24 hours with supportive care 2, addressing the underlying alcohol use disorder is crucial for preventing recurrence and improving long-term outcomes.