Management of Severe Alcohol Intoxication with BAC of 386 mg/dL
For a patient with a blood alcohol concentration (BAC) of 386 mg/dL, immediate stabilization of airway, breathing, and circulation is essential, followed by supportive care including IV fluids, thiamine administration, and close monitoring for complications.
Initial Assessment and Stabilization
Airway and Breathing
- Ensure patent airway and adequate ventilation
- Position patient to prevent aspiration
- Consider intubation if GCS < 8 or inability to protect airway
- Monitor oxygen saturation continuously
Circulation
- Establish IV access immediately
- Administer normal saline IV fluids to correct dehydration and hypotension
- Monitor vital signs closely (heart rate, blood pressure, respiratory rate)
Neurological Assessment
- Perform regular neurological checks using Glasgow Coma Scale
- Monitor for signs of increased intracranial pressure
- Assess for focal neurological deficits that might indicate traumatic brain injury
Medical Management
Essential Medications
- Administer thiamine 100 mg IV before glucose to prevent Wernicke's encephalopathy 1
- Check blood glucose levels and administer D50W if hypoglycemic (after thiamine)
- Consider benzodiazepines for severe agitation:
- Lorazepam 2-4 mg IV for severe symptoms
- Diazepam 5-10 mg IV for severe agitation 1
Laboratory Monitoring
- Monitor electrolytes (particularly potassium, magnesium, phosphate)
- Check renal function (BUN, creatinine)
- Monitor acid-base status
- Consider toxicology screen for co-ingestions
Advanced Interventions
Consider Extracorporeal Treatment
- With BAC of 386 mg/dL (83.7 mmol/L), extracorporeal treatment should be strongly considered 2
- Hemodialysis is indicated when:
- BAC > 310 mg/dL (50 mmol/L) even when using ethanol or fomepizole 2
- Patient has severe metabolic acidosis
- Respiratory depression requiring mechanical ventilation
- Hemodynamic instability despite supportive care
Monitoring for Complications
- Assess for signs of alcohol withdrawal (may develop while still intoxicated)
- Monitor for aspiration pneumonia
- Watch for hypoglycemia, hypothermia, and electrolyte abnormalities
- Observe for rhabdomyolysis (check CPK levels)
- Monitor for hepatic dysfunction
Disposition Planning
- Continue supportive care until BAC decreases to a non-toxic level
- Ethanol is metabolized at approximately 15-20 mg/dL/hour in non-dependent adults 3
- Do not discharge until patient is clinically sober and can safely care for themselves 1
- Consider psychiatric evaluation only when patient is alert with appropriate cognition, not based on specific BAC 2
- Refer to addiction services for ongoing care and treatment of potential alcohol use disorder
Pitfalls and Caveats
- Do not administer glucose before thiamine as it may precipitate Wernicke's encephalopathy
- Avoid antipsychotics as standalone treatment as they may lower seizure threshold 1
- Do not rely solely on BAC to determine clinical management; individual response to alcohol varies
- Remember that severe alcohol intoxication (BAC > 250 mg/dL) can be life-threatening due to respiratory depression 3
- BAC of 386 mg/dL is potentially lethal, especially in non-tolerant individuals
- Do not delay hemodialysis in severely intoxicated patients with metabolic complications
This patient requires immediate intensive care management due to the extremely high BAC, which poses significant risk for respiratory depression, cardiovascular collapse, and death.