What is the treatment for acute alcohol intoxication?

Treatment of Acute Alcohol Intoxication

Base management decisions on the patient's cognitive abilities and clinical presentation rather than waiting for a specific blood alcohol level, and proceed with psychiatric evaluation in alert, cooperative patients with normal vital signs regardless of elevated alcohol levels. 1, 2

Initial Assessment and Stabilization

Assess cognitive function individually rather than relying on predetermined blood alcohol concentrations. 1, 2 The American College of Emergency Physicians emphasizes that cognitive abilities—not a specific blood alcohol level—should determine when to begin psychiatric assessment and disposition planning. 1

Key Clinical Parameters to Evaluate:

• Mental status: Alertness, orientation, memory, judgment, and decision-making capacity 1, 2
• Vital signs: Blood pressure, heart rate, respiratory rate, and temperature 2, 3
• Physical examination: Look for signs of trauma, aspiration risk, and stigmata of chronic liver disease (spider angiomata, palmar erythema, jaundice, ascites) 3
• Neurological examination: Assess for focal deficits, nystagmus, ataxia, and signs of Wernicke's encephalopathy 2, 4

Treatment Based on Severity

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

No pharmacologic treatment is necessary for most patients with mild-to-moderate intoxication. 5 Management consists of:

• Clinical observation with serial vital sign monitoring 5, 4
• Supportive care: Maintain airway, ensure adequate hydration 4, 6
• Thiamine supplementation (oral or parenteral) to prevent Wernicke's encephalopathy, particularly in patients with suspected chronic alcohol use or malnutrition 2, 3
• Observation period to determine if psychiatric symptoms (particularly suicidality) resolve as intoxication clears 1, 2

Most patients complete their clinical course within 24 hours with favorable outcomes and can be managed in a Temporary Observation Unit without requiring hospitalization. 5

Severe Intoxication (Blood Alcohol Concentration > 1 g/L):

Aggressive supportive care is required for severe intoxication. 5, 4 Treatment includes:

• Intravenous fluid resuscitation to maintain hemodynamic stability 5, 4
• Correct hypoglycemia with dextrose administration 5, 4
• Treat hypothermia with warming measures 5
• Correct electrolyte imbalances (particularly hypokalemia, hypomagnesemia, hypophosphatemia) 5, 4
• Administer B-complex and vitamin C 5
• Consider metadoxine to accelerate alcohol elimination from blood 5, 4, 6
• Thiamine supplementation (parenteral preferred in severe cases) before glucose administration to prevent precipitating Wernicke's encephalopathy 2, 3

Management of Acute Alcohol Withdrawal

If withdrawal symptoms develop during observation, benzodiazepines are the front-line medication. 2, 7

Benzodiazepine Dosing for Acute Withdrawal:

• Diazepam 10 mg orally 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 7
• Benzodiazepines prevent seizures, delirium tremens, and alleviate discomfort 2
• Antipsychotics should not be used as stand-alone medications but may be adjuncts to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses 2

Critical Pitfalls to Avoid

Do not delay psychiatric evaluation waiting for blood alcohol results if the patient demonstrates adequate cognition, alertness, and normal vital signs. 1, 2 There is no evidence-based blood alcohol concentration threshold at which psychiatric evaluation can accurately commence. 1

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. 2

Recognize that alcohol intoxication can mimic or alter psychiatric symptoms, and suicidality often diminishes as blood alcohol concentration decreases. 1, 2 Use an observation period to reassess as intoxication resolves. 1, 2

Be aware that adolescents are more vulnerable to alcohol's toxic effects due to immature hepatic alcohol dehydrogenase activity, making acute complications more frequent and dangerous in young people. 5

Disposition and Follow-Up

Discharge Criteria:

• Stable vital signs 2
• Resolution of withdrawal symptoms (CIWA-Ar score <8) 2
• No complications requiring inpatient care 2
• Comprehensive follow-up plan established 2

Indications for Inpatient Management:

• Risk of severe withdrawal 2
• Concurrent serious physical or psychiatric disorders 2
• Lack of adequate social support 2

All patients presenting with acute alcohol intoxication should be screened for underlying alcohol use disorder and referred to an alcohol addiction unit for multidisciplinary treatment to achieve long-term abstinence. 5, 4, 6 Acute intoxication represents a sentinel event for chronic alcohol abuse. 4