What is the immediate management for alcohol intoxication?

Management of Alcohol Intoxication

The immediate management of alcohol intoxication requires supportive care including intravenous fluids, correction of hypoglycemia, management of hypotension, warming if hypothermic, correction of electrolyte imbalances, and administration of thiamine to prevent Wernicke's encephalopathy. 1

Initial Assessment

A thorough assessment is critical for determining the appropriate management approach:

• Level of consciousness: Assess using Glasgow Coma Scale
• Vital signs: Monitor for hypotension, tachycardia, hypothermia
• Blood glucose: Check immediately as hypoglycemia is common
• Signs of trauma: Examine for injuries that may have occurred during intoxication
• Electrolytes: Assess for imbalances, particularly hypomagnesemia and hypokalemia
• Comorbid conditions: Identify any underlying medical or psychiatric conditions

Immediate Management Protocol

1. Airway and Breathing

• Ensure patent airway
• Position patient to prevent aspiration (recovery position if unconscious)
• Provide supplemental oxygen if needed

2. Circulation and Hydration

• Establish IV access
• Administer isotonic fluids (normal saline) for volume repletion 1, 2
• Monitor vital signs frequently

3. Metabolic Support

• Thiamine administration: Give 100-300 mg IV/IM before glucose to prevent precipitating Wernicke's encephalopathy 1
• Glucose: Administer 50% dextrose (D50W) if hypoglycemic
• Electrolyte correction: Replace magnesium, potassium, and phosphate as needed 2

4. Medication Considerations

• For severe agitation: Benzodiazepines are the preferred agents 3

  • Lorazepam 1-2 mg IV/IM is preferred in patients with hepatic dysfunction 1
  • Avoid antipsychotics as standalone treatment for alcohol-related agitation 1

• For severe intoxication: Consider metadoxine to accelerate ethanol excretion in countries where available 2, 4

Management Based on Severity

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

• Observation
• Supportive care
• No specific medications required 2

Severe Intoxication (BAC > 1 g/L)

• Intensive monitoring
• Aggressive supportive care
• Consider medications to accelerate alcohol elimination if available 2
• Monitor for development of withdrawal symptoms

Monitoring and Complications

Monitor for:

• Respiratory depression
• Hypotension
• Hypothermia
• Aspiration
• Development of withdrawal symptoms
• Wernicke's encephalopathy

Common Pitfalls to Avoid

• Delaying psychiatric evaluation based solely on blood alcohol concentration rather than cognitive function 1
• Using antipsychotics alone for management of alcohol-related agitation 1
• Failing to provide thiamine before administering glucose 1
• Inadequate dosing of benzodiazepines when treating concurrent withdrawal symptoms 1

Disposition Planning

Discharge Criteria

• Fully alert and oriented
• Stable vital signs
• Able to ambulate safely
• No signs of withdrawal
• Safe discharge plan

Referral to Treatment

• Screen for alcohol use disorder using validated tools (AUDIT, CAGE) 3
• Provide brief intervention for risky drinking 3
• Refer patients with alcohol use disorder to specialized addiction services 1
• Consider involvement of family members in treatment planning 1

Patients with alcohol intoxication often have mild-moderate transitory symptoms that resolve within 24 hours, making them good candidates for observation rather than inpatient admission 2. However, all patients should be assessed for alcohol use disorder and referred to appropriate follow-up care to reduce the risk of future alcohol-related complications.