Can a patient be treated if they are intoxicated?

Treatment of Intoxicated Patients

Yes, intoxicated patients should be treated, as withholding medical care could lead to increased morbidity and mortality. Treatment must be provided while addressing the unique challenges of intoxication.

Initial Assessment and Management

• Patients with alcohol or drug intoxication should be assessed and treated according to Advanced Trauma Life Support (ATLS) principles, with simultaneous evaluation for signs of specific toxidromes 1
• Securing airway, breathing, and circulation is the first priority in any intoxicated patient, regardless of the substance involved 2
• Personal protective equipment must be used when caring for patients with potential chemical exposures to prevent contamination of healthcare providers 2

Substance-Specific Considerations

Alcohol Intoxication

• For mild-moderate alcohol intoxication (blood alcohol concentration < 1 g/L), supportive care without medications is appropriate 3
• For severe intoxication (blood alcohol concentration > 1 g/L), provide intravenous fluids, treat hypoglycemia, hypotension, hypothermia, and electrolyte imbalances 3
• Metadoxine can be administered to increase ethanol metabolism and elimination in severe cases 4, 5

Benzodiazepine Intoxication

• Standard life support measures including airway management are the primary treatment 1
• Flumazenil can reverse CNS and respiratory depression but has significant risks including precipitating seizures in patients with benzodiazepine tolerance or preexisting seizure disorders 1
• Flumazenil should be avoided in patients with mixed overdoses, especially with cyclic antidepressants, due to risk of precipitating dysrhythmias 6

Organophosphate Intoxication

• Immediate decontamination is essential for external exposure by removing contaminated clothing and irrigation with soap and water 2
• Administer atropine immediately for severe poisoning manifestations (1-2 mg IV for adults, doubled every 5 minutes until atropinization) 2
• Early endotracheal intubation is recommended for life-threatening organophosphate poisoning 2
• Pralidoxime should be administered early to reactivate the acetylcholinesterase enzyme 2
• Avoid neuromuscular blockers metabolized by cholinesterase (succinylcholine and mivacurium) 2

Special Considerations

• The primary assessment of intoxicated trauma patients must follow ATLS principles while simultaneously evaluating for toxin-specific effects 1
• Patients with combined trauma and intoxication may have severe hypovolemia requiring judicious fluid administration and possibly vasopressors 1
• Traumatic cervical injury needs to be excluded in every patient before airway manipulation 1
• Patients should be considered to have a "full stomach," requiring awake intubation or rapid sequence induction using the Sellick maneuver 1

Disposition and Follow-up

• Many intoxicated patients can be managed in a temporary observation unit in the emergency department without requiring hospitalization 3, 7
• Clinical observation with vital signs monitoring is necessary to evaluate for possible development of withdrawal syndromes and potential complications 3
• Patients with alcohol use disorder should be referred to an alcohol addiction unit for follow-up to reduce the risk of relapse 4, 3

Common Pitfalls and Caveats

• Abdominal pain with nausea and vomiting can be due to intoxication but could also signal perforation or obstruction of a viscus 1
• Mixed overdoses are common and require careful assessment; benzodiazepine overdose should not preclude timely administration of naloxone when opioid overdose is suspected 1
• Delayed muscle weakness can follow the initial cholinergic crisis in organophosphate poisoning, even as late as 4 days after acute exposure 1, 2
• Intoxicated patients may have misleading mixed signs that can confound the clinical picture, requiring meticulous and repetitive examinations 1, 8