Treatment of Acute Ethanol Intoxication in the Emergency Department
The treatment of acute ethanol intoxication in the ED should focus on supportive care with close monitoring of vital signs, airway management, and observation until the patient's cognitive abilities return, rather than relying on a specific blood alcohol concentration threshold for intervention.
Initial Assessment and Stabilization
- Airway, Breathing, Circulation (ABC): First priority is to ensure patient stability
- Vital signs monitoring: Regular assessment of heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation
- Mental status evaluation: Using Glasgow Coma Scale or AVPU (Alert, Voice, Pain, Unresponsive) scale
Supportive Care Measures
Mild to Moderate Intoxication (patient alert but impaired)
- Observation in a safe environment
- Intravenous fluids if signs of dehydration present
- Position patient to prevent aspiration
- Monitor for clinical deterioration
Severe Intoxication (significantly altered mental status)
- Secure airway if GCS < 8 or inability to protect airway
- Intravenous fluid therapy to maintain hemodynamic stability
- Correct electrolyte imbalances if present
- Consider thiamine administration (100mg IV) before glucose to prevent Wernicke's encephalopathy 1
- Administer glucose if hypoglycemia is present
- Monitor for hypothermia and provide warming if needed
Important Clinical Considerations
Psychiatric Evaluation
- According to the American College of Emergency Physicians guidelines, cognitive abilities rather than specific blood alcohol level should determine when psychiatric evaluation can begin 2
- Consider a period of observation to determine if psychiatric symptoms resolve as intoxication clears 2
Pharmacologic Interventions
- Metadoxine: Can be considered to accelerate ethanol metabolism and elimination in severe cases 3, 1, 4
- Benzodiazepines: May be needed for management of alcohol withdrawal symptoms or agitation, not for intoxication itself
Monitoring and Disposition
- Continue observation until patient demonstrates:
- Improved mental status
- Ability to ambulate safely
- Resolution of significant symptoms
- No signs of withdrawal or other complications
When to Consider Additional Interventions
Indications for More Aggressive Management
- Severe acidemia (pH < 7.20)
- Persistent altered mental status despite observation
- Hemodynamic instability
- Respiratory depression
- Hypothermia
- Hypoglycemia unresponsive to glucose administration
- Suspected co-ingestion of other substances
Discharge Considerations
- Most patients with uncomplicated alcohol intoxication can be discharged after observation period (typically within 24 hours) 1
- Prior to discharge, ensure:
- Patient is alert and oriented
- Vital signs are stable
- Patient can ambulate safely
- Patient has a responsible adult to accompany them
Follow-up Recommendations
- Screen for underlying alcohol use disorder
- Consider referral to alcohol addiction services for patients with recurrent presentations or signs of alcohol dependence 3, 1
Common Pitfalls to Avoid
- Failing to consider other causes of altered mental status (head injury, hypoglycemia, other ingestions)
- Discharging patients before they are clinically sober
- Missing signs of alcohol withdrawal which may begin while still intoxicated
- Overlooking potential co-ingestions that may require specific treatments
The management of acute alcohol intoxication is primarily supportive, focusing on preventing complications while the body metabolizes the alcohol. Most patients recover completely with observation and basic supportive care.