What are the key considerations when admitting a patient with alcohol overdose?

Key Considerations When Admitting a Patient with Alcohol Overdose

When admitting a patient with alcohol overdose, immediate assessment and management of withdrawal symptoms, nutritional deficiencies, and potential complications are essential to prevent morbidity and mortality.

Initial Assessment and Stabilization

Vital Signs and Neurological Status

• Monitor vital signs frequently (pulse, blood pressure, respiratory rate, temperature)
• Assess level of consciousness using Glasgow Coma Scale
• Evaluate for focal neurological deficits that may indicate traumatic brain injury
• Consider CT scan for patients with first alcohol withdrawal seizure, focal deficits, persistent altered mental status, or history of head trauma 1

Laboratory Evaluation

• Complete blood count (CBC)
• Comprehensive metabolic panel (including liver function tests)
• Blood alcohol concentration (BAC)
• Serum electrolytes (particularly magnesium, potassium, phosphate)
• Glucose level (to rule out hypoglycemia)
• Consider toxicology screen for polysubstance use

Withdrawal Risk Assessment

Withdrawal Severity Measurement

• Use Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to guide treatment 1
  • Mild withdrawal: CIWA-Ar score <8
  • Moderate withdrawal: CIWA-Ar score 8-14
  • Severe withdrawal: CIWA-Ar score ≥15

Alcohol Use History

• Document pattern of alcohol consumption using standardized tools:
  • AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) 2
  • Timeline Followback (TLFB) to track recent drinking patterns 2
• Assess for history of previous withdrawal episodes, seizures, or delirium tremens

Pharmacological Management

Benzodiazepine Protocol

• Benzodiazepines are the standard pharmacological treatment for alcohol withdrawal syndrome 1
• For patients without liver disease: Diazepam 10mg IV initially for acute agitation/tremor, then 5-10mg IV every 3-4 hours as needed
• For patients with hepatic dysfunction: Lorazepam (shorter half-life, less hepatic metabolism) 2
• Consider symptom-triggered approach based on CIWA-Ar scores rather than fixed schedule 1

Nutritional Support

• Administer thiamine 100-300 mg IV daily before glucose administration to prevent Wernicke encephalopathy 1
• Correct electrolyte abnormalities, particularly magnesium, potassium, and phosphate 1
• Ensure adequate hydration with IV fluids

Adjunctive Therapies for Refractory Cases

• For benzodiazepine-resistant withdrawal: Consider phenobarbital, propofol, or dexmedetomidine 1, 3
• For hallucinations/agitation not controlled by benzodiazepines: Haloperidol 0.5-5 mg PO/IM every 8-12 hours (not as standalone treatment) 1

Monitoring for Complications

Hepatic Assessment

• Monitor for signs of alcoholic hepatitis or cirrhosis
• Evaluate for jaundice, ascites, encephalopathy
• Consider hepatic dosing of medications in patients with liver dysfunction 2

Cardiovascular Monitoring

• Watch for arrhythmias, particularly in chronic heavy drinkers
• Monitor for hypertension during withdrawal phase
• Assess for cardiomyopathy in chronic alcoholics

Metabolic Complications

• Monitor for hypoglycemia, particularly in malnourished patients
• Watch for acid-base disturbances
• Assess for pancreatitis (abdominal pain, elevated lipase/amylase)

Discharge Planning and Follow-up

Alcohol Cessation Counseling

• Complete and permanent cessation of alcohol consumption is recommended for patients with alcohol-related liver disease 2
• Provide education about risks of continued alcohol use
• Consider psychiatric consultation for evaluation and treatment planning 1

Medication for Relapse Prevention

• Consider medications to prevent relapse after successful withdrawal:
  • Acamprosate, naltrexone, or disulfiram (with caution in liver disease) 2, 1
• Note that naltrexone and disulfiram are contraindicated in severe hepatic insufficiency 2

Referrals

• Arrange follow-up with addiction services
• Provide information about mutual help groups (e.g., Alcoholics Anonymous)
• Consider outpatient hepatology referral for patients with liver disease

Common Pitfalls to Avoid

1. Failing to recognize Wernicke encephalopathy - Always administer thiamine before glucose
2. Overlooking traumatic injuries - Thoroughly examine for trauma, especially head injuries
3. Missing polysubstance use - Screen for other substances that may complicate withdrawal
4. Inadequate benzodiazepine dosing - Underdosing can lead to progression to delirium tremens
5. Neglecting nutritional status - Malnutrition is common and requires aggressive correction
6. Discharging too early - Ensure withdrawal symptoms are adequately controlled before discharge

By following this comprehensive approach to alcohol overdose admission, clinicians can effectively manage acute intoxication, prevent withdrawal complications, and initiate appropriate long-term care planning.