What is the recommended treatment for alcohol intoxication?

Management of Acute Alcohol Intoxication

For mild-to-moderate acute alcohol intoxication (blood alcohol concentration <1 g/L), supportive care with clinical observation is sufficient without pharmacological intervention, while severe intoxication (>1 g/L) requires intravenous fluids, correction of metabolic derangements, thiamine supplementation, and consideration of metadoxine to accelerate alcohol elimination. 1, 2

Initial Assessment and Stabilization

Base management decisions on the patient's cognitive abilities, vital signs, and clinical presentation rather than waiting for specific blood alcohol levels. 1 Psychiatric evaluation can proceed immediately in alert, cooperative patients with normal vital signs, regardless of elevated alcohol levels. 1

Key Clinical Parameters to Assess:

• Vital signs stability (blood pressure, heart rate, respiratory rate, temperature) 2
• Cognitive state and level of consciousness 1, 3
• Hemodynamic stability 2
• Signs of alcohol-related complications (hypoglycemia, hypothermia, electrolyte imbalances) 2
• Concurrent substance use that may complicate the clinical picture 1

Treatment Based on Severity

Mild-to-Moderate Intoxication (BAC <1 g/L):

• Clinical observation only—no medications are necessary 2
• Monitor vital signs to detect progression or complications 2
• Observation period of up to 24 hours in a Temporary Observation Unit is often sufficient with favorable outcomes 2
• Thiamine supplementation (oral or parenteral) to prevent Wernicke's encephalopathy 1

Severe Intoxication (BAC >1 g/L):

• Intravenous fluid resuscitation for hemodynamic support 2
• Correct hypoglycemia immediately with dextrose administration 2
• Treat hypothermia with warming measures 2
• Correct electrolyte imbalances (particularly hypokalemia, hypomagnesemia) 2
• Administer B-complex and vitamin C 2
• Consider metadoxine to accelerate alcohol elimination from blood 2
• Parenteral thiamine for high-risk patients (malnourished, severe presentation, suspected Wernicke's encephalopathy) 1

Critical Pitfalls to Avoid

Do not order routine toxicologic screening in alert, cooperative patients with normal vital signs and noncontributory history/physical examination—studies show only 20% sensitivity for organic etiology and no justified change in management. 1

Do not delay psychiatric evaluation waiting for blood alcohol concentration results if the patient demonstrates adequate cognition, alertness, and normal vital signs. 1 Alcohol intoxication can mimic psychiatric symptoms, and suicidality often diminishes as blood alcohol concentration decreases. 1

Do not overlook concurrent substance use disorders that may complicate recovery and alter the clinical presentation. 1

Special Considerations for Adolescents

Adolescents are more vulnerable to alcohol's toxic effects due to immature hepatic alcohol dehydrogenase activity, making acute complications more frequent and dangerous than in adults. 2 Lower thresholds for intervention and closer monitoring are warranted in this population. 2

Disposition and Follow-up

Patients can be safely discharged when they have:

• Stable vital signs 1
• Resolution of withdrawal symptoms (CIWA-Ar score <8) 1
• No complications requiring inpatient care 1
• A comprehensive follow-up plan in place 1

Patients requiring inpatient management include those:

• At risk of severe withdrawal 1
• With concurrent serious physical or psychiatric disorders 1
• Lacking adequate social support 1

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

Transition to Alcohol Withdrawal Management

Monitor for development of alcohol withdrawal syndrome during observation, which requires specific treatment with benzodiazepines. 2 Withdrawal symptoms typically develop within 6-24 hours after the last drink. 4

If withdrawal develops, benzodiazepines are the gold standard treatment to reduce symptoms and prevent seizures and delirium tremens. 4, 1 Use symptom-triggered regimens rather than fixed-dose schedules to prevent drug accumulation. 4