Management of Alcohol Intoxication
For acute alcohol intoxication, management should be stratified by severity based on blood alcohol concentration and clinical presentation, with supportive care and thiamine supplementation as the cornerstone, reserving metadoxine for severe cases to accelerate alcohol elimination. 1, 2
Initial Assessment and Stabilization
Base your management decisions on the patient's cognitive abilities and clinical presentation rather than waiting for a specific blood alcohol level. 3 The psychiatric evaluation can proceed in alert, cooperative patients with normal vital signs and noncontributory history/physical examination, regardless of elevated alcohol levels. 3
Severity Stratification
Mild-to-moderate intoxication (BAC < 1 g/L):
- No pharmacologic treatment is necessary 2
- Clinical observation with vital sign monitoring is sufficient 2
- Most patients complete their clinical course within 24 hours with favorable outcomes 2
Severe intoxication (BAC > 1 g/L):
- Administer intravenous fluids for hydration 2, 4
- Treat hypoglycemia, hypotension, hypothermia, and electrolyte imbalances 2, 4
- Administer complex B and C vitamins 2
- Consider metadoxine to accelerate alcohol elimination from blood 2, 5, 4
Thiamine Administration
All patients with severe alcohol intoxication should receive thiamine supplementation to prevent Wernicke's encephalopathy. 1
- Oral thiamine is appropriate for most patients 1, 6
- Parenteral thiamine is indicated for high-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy 1, 6
Observation Period and Disposition
Use a period of observation to determine if psychiatric symptoms resolve as intoxication resolves. 3 This approach is particularly important because alcohol intoxication can mimic or alter psychiatric symptoms, and suicidality often diminishes as blood alcohol concentration decreases. 3
Patients are appropriate for Temporary Observation Unit management because they typically have a clinical course completed within 24 hours with favorable outcomes and often do not require hospitalization. 2
Critical Pitfalls to Avoid
Do not routinely order toxicologic screening in alert, cooperative patients with noncontributory history/physical examination and normal vital signs, as studies show no justified change in management plans and only 20% sensitivity for organic etiology. 3
Do not delay psychiatric evaluation waiting for blood alcohol concentration results if the patient demonstrates adequate cognition, alertness, and normal vital signs. 3
Recognize that adolescents are more vulnerable to toxic effects of alcohol due to immature hepatic alcohol dehydrogenase activity, making acute complications more frequent and dangerous in young people. 2
Transition to Alcohol Withdrawal Management
Monitor for development of alcohol withdrawal syndrome during observation, which requires specific treatment with benzodiazepines as the gold standard. 1, 6 Benzodiazepines alleviate withdrawal discomfort and prevent seizures and delirium. 1, 6
Antipsychotics should never be used as standalone medications but may serve as adjuncts to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses. 1, 6
Long-Term Follow-Up
Patients with acute alcohol intoxication are candidates for referral to an Alcohol Addiction Unit to reduce relapse risk and complications related to alcohol abuse. 2, 4 This is critical because acute intoxication may represent a sentinel event of underlying alcohol use disorder. 4
For relapse prevention, offer acamprosate, disulfiram, or naltrexone to alcohol-dependent patients after complete detoxification. 1, 6 Naltrexone should only be started after complete detoxification, not during active withdrawal. 6
Psychosocial support should be routinely offered alongside any pharmacologic interventions, including structured psychological interventions and engagement with mutual help groups like Alcoholics Anonymous. 1, 6