Is it safe to discharge a patient with a blood alcohol concentration (BAC) of 513 and significant laboratory abnormalities?

Management of Patient with BAC of 513 and Laboratory Abnormalities

A patient with a blood alcohol concentration (BAC) of 513 mg/dL should not be discharged from the emergency department due to the extremely high risk of respiratory depression, aspiration, and progression to severe alcohol withdrawal. 1, 2

Assessment of Severity

• A BAC of 513 mg/dL (0.513%) represents severe alcohol intoxication, which can cause respiratory depression, coma, and death, even in alcohol-tolerant individuals 3
• At BACs above 300 mg/dL, even chronic alcoholics demonstrate significant impairment, and levels above 250 mg/dL put patients at risk for coma 3
• Laboratory abnormalities may indicate alcohol-related organ damage or metabolic derangements that require monitoring and correction 1

Medical Risks

• Respiratory depression can worsen rapidly as alcohol continues to be absorbed, especially if the patient consumed alcohol shortly before presentation 2
• Risk of aspiration is significant due to impaired protective airway reflexes 2, 3
• Severe alcohol withdrawal can begin while blood alcohol levels are still elevated (>200 mg/dL) in dependent individuals 3
• Rhabdomyolysis may develop in patients with prolonged immobility or seizures 4

Monitoring Requirements

• Vital signs should be monitored frequently for signs of autonomic instability (tachycardia, hypertension, hyperthermia) that may indicate developing withdrawal 1
• Neurological status should be assessed regularly, as deterioration may indicate developing complications 1
• Laboratory abnormalities need to be corrected and reassessed 4

Treatment Approach

• Administer thiamine (100-300 mg) to prevent Wernicke encephalopathy 1
• Provide appropriate fluid resuscitation based on laboratory values 1
• Begin symptom-triggered benzodiazepine therapy using CIWA-Ar scores if withdrawal symptoms develop 1
• Consider prophylactic benzodiazepines if the patient has a history of severe withdrawal or seizures 1

Disposition Decision

• Inpatient admission is indicated for:
  • BAC >300 mg/dL (patient's level is significantly higher at 513 mg/dL) 2, 3
  • Presence of significant laboratory abnormalities 1
  • Risk of progression to severe withdrawal or delirium tremens 1
  • Inability to protect airway or maintain respiratory drive 2

Common Pitfalls to Avoid

• Underestimating withdrawal risk in chronic alcoholics with high tolerance 3
• Discharging before BAC has decreased to a safe level (<250 mg/dL) 3
• Failing to recognize early signs of withdrawal that can progress rapidly 5
• Neglecting to screen for and address underlying alcohol use disorder 2

Discharge Planning (When Appropriate)

• Discharge should only be considered when:
  • BAC has decreased to a safe level (<250 mg/dL) 3
  • Patient is fully alert and oriented 1
  • Laboratory abnormalities have been addressed 1
  • Patient has a responsible adult to monitor them 4
  • Follow-up for alcohol use disorder treatment has been arranged 1

Given the extremely high BAC of 513 mg/dL and the presence of significant laboratory abnormalities, this patient requires inpatient admission for monitoring and management until the BAC decreases to a safe level and laboratory abnormalities are addressed.