Medical Management of Alcohol Intoxication
The medical management of alcohol intoxication requires supportive care as the cornerstone of treatment, 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 and Monitoring
- Assess level of consciousness using Glasgow Coma Scale
- Monitor vital signs for:
- Hypotension
- Tachycardia
- Hypothermia
- Respiratory depression
- Check blood glucose immediately (hypoglycemia is common)
- Perform basic laboratory tests:
- Complete blood count
- Electrolytes
- Liver function tests
- Blood alcohol concentration (BAC)
Treatment Protocol
Mild-Moderate Intoxication (BAC < 1 g/L)
- Clinical observation with vital signs monitoring
- No specific medications required
- Oral hydration if patient can safely swallow
Severe Intoxication (BAC > 1 g/L)
Airway management:
- Position patient to prevent aspiration
- Consider intubation for severely decreased consciousness
Nutritional support:
- Administer thiamine (100 mg IV) BEFORE glucose to prevent precipitating Wernicke's encephalopathy 1
- Administer complex B and C vitamins
Fluid management:
- IV fluid resuscitation with isotonic solutions (typically 0.9% saline)
- Correct hypoglycemia with IV glucose after thiamine administration
Temperature management:
- Warming measures if hypothermic
Pharmacological interventions:
- Consider metadoxine to accelerate ethanol excretion in countries where available 2, 3
- For agitation or withdrawal symptoms, benzodiazepines are the preferred agents 1, 4
- Diazepam is specifically indicated for acute alcohol withdrawal, including symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis 4
Management of Complications
Alcohol Withdrawal Syndrome (AWS)
- Use Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to assess severity
- CIWA-Ar score >8 indicates moderate AWS; score ≥15 indicates severe AWS 5
- Benzodiazepines are the gold standard treatment 5, 6:
- Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide better protection against seizures and delirium
- Short-acting benzodiazepines (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction
Seizures
- Benzodiazepines are the treatment of choice for alcohol withdrawal seizures 6
- Avoid using antiepileptics alone as they are less effective than benzodiazepines 6
Delirium Tremens
- Requires intensive monitoring and aggressive treatment
- Benzodiazepines are more effective than neuroleptics in preventing delirium-related mortality 6
- Continuous monitoring of vital signs and respiratory support if necessary
Common Pitfalls to Avoid
- Failing to provide thiamine supplementation before glucose administration
- Using antipsychotics alone for withdrawal management
- Inadequate dosing of benzodiazepines
- Administering IV ethanol (not recommended due to questionable efficacy, inconsistent pharmacokinetics, and narrow therapeutic index) 7
- Delaying psychiatric evaluation based solely on blood alcohol concentration rather than cognitive function 1
Discharge Criteria
Patients can be discharged when they are:
- Fully alert and oriented
- Have stable vital signs
- Able to ambulate safely
- Show no signs of withdrawal
- Have a safe discharge plan in place 1
Follow-up Care
- Refer patients with alcohol use disorder to specialized addiction services
- Encourage engagement with mutual help groups like Alcoholics Anonymous
- Consider medications for maintaining abstinence in dependent patients (acamprosate, naltrexone, disulfiram) 1
The medical management of alcohol intoxication requires prompt assessment and appropriate interventions based on severity. While mild-moderate cases often resolve with supportive care, severe intoxication requires more intensive management to prevent complications and reduce mortality.