What is the treatment for alcohol intoxication?

Treatment for Acute Alcohol Intoxication

For acute alcohol intoxication, treatment is primarily supportive care with observation, thiamine supplementation to prevent Wernicke's encephalopathy, and management based on clinical presentation rather than waiting for specific blood alcohol levels. 1

Initial Assessment and Stabilization

Base management decisions on the patient's cognitive abilities and clinical presentation, not blood alcohol concentration. 1 Alert, cooperative patients with normal vital signs and noncontributory history/physical examination can proceed directly to psychiatric evaluation if needed, regardless of elevated alcohol levels. 1

Key Clinical Approach:

• Do not routinely order toxicologic screening in alert, cooperative patients with normal vital signs—studies show only 20% sensitivity for organic etiology and no justified change in management plans. 1
• Assess for concurrent medical complications including hypoglycemia, hypotension, hypothermia, and electrolyte imbalances. 2
• Monitor vital signs and hemodynamic stability continuously. 2

Severity-Based Treatment Protocol

Mild-to-Moderate Intoxication (Blood Alcohol Concentration < 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 (Blood Alcohol Concentration > 1 g/L):

• Administer intravenous fluids for hydration and hemodynamic support. 2
• Treat hypoglycemia immediately if present. 2
• Correct hypothermia and electrolyte imbalances. 2
• Administer thiamine (B complex) and vitamin C to prevent Wernicke's encephalopathy. 1, 2
• Consider metadoxine to accelerate ethanol elimination from blood. 3, 2

Critical Thiamine Administration

All patients with severe intoxication require thiamine supplementation (oral or parenteral) to prevent Wernicke's encephalopathy. 1 This is particularly crucial in malnourished patients or those with suspected Wernicke's encephalopathy, who should receive parenteral thiamine. 1

Observation Period and Disposition

Use a period of observation to determine if psychiatric symptoms resolve as intoxication resolves. 1 Alcohol intoxication can mimic or alter psychiatric symptoms, and suicidality often diminishes as blood alcohol concentration decreases. 1

Discharge Criteria:

Patients can be safely discharged when they demonstrate:

• Stable vital signs 1
• Resolution of withdrawal symptoms (CIWA-Ar score <8) 1
• No complications requiring inpatient care 1
• Adequate cognition and alertness 1
• Comprehensive follow-up plan in place 1

Special Considerations for Adolescents

Adolescents are more exposed to toxic effects of alcohol due to immature hepatic alcohol dehydrogenase activity, making acute complications more frequent and dangerous than in adults. 2 Monitor young patients more closely for severe complications.

Alcohol Withdrawal Management

If withdrawal syndrome develops during observation:

Benzodiazepines are the front-line medication for alcohol withdrawal to prevent seizures and delirium tremens. 1, 4 Diazepam is specifically FDA-approved for symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis in acute alcohol withdrawal. 4

• Do not use antipsychotics as stand-alone medications—they may only be used as adjuncts to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses. 1
• Avoid prescribing benzodiazepines beyond 7-14 days to prevent dependence. 1

Inpatient vs. Outpatient Decision

Admit patients to inpatient settings if they have:

• Risk of severe withdrawal 1
• Concurrent serious physical or psychiatric disorders 1
• Lack of adequate social support 1
• Unstable vital signs or ongoing complications 1

Temporary Observation Units in Emergency Departments are ideal for uncomplicated acute alcohol intoxication cases, as clinical courses are often completed within 24 hours with favorable outcomes, avoiding unnecessary hospitalization costs. 2

Post-Intoxication Follow-Up

All patients with Alcohol Use Disorder must be referred to an Alcohol Addiction Unit for follow-up to reduce relapse risk and alcohol-related complications. 2 For long-term relapse prevention, offer acamprosate, disulfiram, or naltrexone combined with psychosocial support. 1

Common Pitfalls to Avoid

• Never delay psychiatric evaluation waiting for blood alcohol results if the patient demonstrates adequate cognition and normal vital signs. 1
• Do not overlook concurrent substance use disorders that may complicate recovery. 1
• Avoid missing alcohol withdrawal syndrome development during observation—this requires specific benzodiazepine treatment. 2
• Do not discharge without assessing for chronic alcohol-related complications including liver damage, as patients seeking treatment for acute intoxication likely have additional medical problems from chronic consumption. 5