From the Guidelines
For an agitated patient due to alcohol intoxication, benzodiazepines are the first-line treatment. I recommend starting with lorazepam (Ativan) 1-2 mg IV or IM every 1-2 hours as needed for agitation, based on the Level B recommendations from the Annals of Emergency Medicine study 1. These medications work by enhancing the effect of GABA, an inhibitory neurotransmitter in the brain, which helps reduce agitation and prevents progression to alcohol withdrawal.
Key Considerations
- Monitor vital signs closely, especially respiratory rate, as benzodiazepines can cause respiratory depression.
- Ensure the patient is in a safe environment to prevent injury.
- Maintain adequate hydration with IV fluids if needed.
- Consider thiamine 100 mg IV/IM to prevent Wernicke's encephalopathy.
Alternative Treatments
- Avoid antipsychotics like haloperidol as first-line treatment as they can lower the seizure threshold and potentially worsen outcomes in alcohol intoxication, although they may be considered in certain cases as noted in the study 1.
Post-Acute Management
- Once the acute agitation is controlled, assess for underlying conditions and develop a plan for alcohol detoxification if appropriate. Some key points from the study 1 include the use of benzodiazepines or conventional antipsychotics as effective monotherapy for the initial drug treatment of the acutely agitated patient, and the consideration of droperidol instead of haloperidol if rapid sedation is required. However, benzodiazepines remain the preferred choice for alcohol intoxication-related agitation due to their efficacy and safety profile in this context.
From the FDA Drug Label
Acute Alcohol Withdrawal: As an aid in symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis. 10 mg, intramuscular or intravenous initially, then 5 mg to 10 mg in 3 to 4 hours, if necessary. The recommended treatment for a patient experiencing agitation due to alcohol (ethanol) intoxication is diazepam (IV), with an initial dose of 10 mg and a possible repeat dose of 5 mg to 10 mg in 3 to 4 hours, if necessary 2.
From the Research
Treatment Options for Agitation due to Alcohol Intoxication
- Benzodiazepines, such as diazepam, lorazepam, and midazolam, are commonly used to treat agitation due to alcohol intoxication 3, 4, 5
- Diazepam is recommended for the treatment of moderate to severe alcohol withdrawal, which can include agitation, due to its rapid onset of action and long elimination half-life 3
- Other treatment options for acute agitation include antipsychotics, such as haloperidol, olanzapine, and risperidone, which can be used alone or in combination with benzodiazepines 4, 6, 5, 7
- The choice of treatment should be based on the patient's specific needs and medical history, as well as the potential risks and benefits of each medication 4, 6, 5, 7
Considerations for Treatment
- The use of benzodiazepines, such as diazepam, may be preferred in patients with alcohol intoxication due to their efficacy in reducing agitation and preventing seizures 3, 4, 5
- Antipsychotics, such as haloperidol and olanzapine, may be associated with a longer emergency department length of stay compared to benzodiazepines or other antipsychotics, such as droperidol 7
- Risperidone may be a safe option for acute agitation in patients presenting to the emergency department with alcohol intoxication, although more research is needed to confirm its efficacy and safety in this population 6