What is the management for a 56-year-old male with sudden onset quadriplegia, sinus rhythm with PACs (premature atrial contractions), and acute alcohol intoxication after a fall?

Management of Acute Quadriplegia with Alcohol Intoxication and PACs

This patient requires immediate neuroimaging (CT/MRI) to rule out catastrophic central nervous system pathology causing the quadriplegia, as the acute inability to move all extremities after a fall—even without reported head trauma—demands urgent exclusion of cervical spine injury, stroke, or intracranial hemorrhage before attributing symptoms solely to alcohol intoxication. 1, 2

Immediate Stabilization and Assessment

Airway, Breathing, and Circulation Priority

• Secure the airway immediately if the patient shows signs of respiratory depression or inability to protect airway, as severe alcohol intoxication can produce global neurological impairment leading to autonomic dysfunction, respiratory depression, and cardiac arrest 1
• Monitor vital signs continuously, including oxygen saturation, as acute alcohol intoxication affects multiple organ systems 3
• Establish IV access for fluid resuscitation and medication administration 1

Critical Neurological Evaluation

• Obtain emergent CT head and cervical spine imaging to exclude traumatic injury, intracranial hemorrhage, or acute stroke as the cause of quadriplegia 2
• The case report of a 50-year-old chronic alcohol user presenting with quadriplegia revealed bilateral anterior cerebral artery infarct, demonstrating that stroke can present as quadriplegia in intoxicated patients 2
• Assess for cervical spine injury with immobilization until cleared, as falls can cause spinal cord injury even without obvious head trauma 1
• Consider MRI brain and spinal cord if CT is non-diagnostic but clinical suspicion remains high 2

Alcohol Intoxication Management

Supportive Care

• Administer IV thiamine (100 mg) before any glucose-containing fluids to prevent Wernicke encephalopathy in chronic alcohol users 1
• Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which are common in alcohol intoxication 3
• Monitor blood alcohol concentration (BAC) for both clinical and legal documentation 1

Pharmacological Treatment

• Consider metadoxine administration to accelerate ethanol metabolism and elimination, as this represents a useful drug to increase ethanol clearance 1, 3
• Diazepam 10 mg IV/PO 3-4 times in first 24 hours for symptomatic relief of acute agitation, tremor, or impending delirium tremens if withdrawal symptoms develop 4
• Reduce diazepam to 5 mg 3-4 times daily as needed after initial 24 hours 4

Cardiac Rhythm Management

PACs in Context of Alcohol Intoxication

• The PACs are likely related to acute alcohol intoxication ("holiday heart syndrome"), which commonly causes atrial arrhythmias including premature atrial contractions 5
• Monitor continuously with telemetry, as acute alcohol intoxication can cause AV conduction disturbances ranging from first-degree to complete heart block, though this is rare 5
• Blood alcohol levels as low as 90 mg/dL have been associated with AV block in otherwise healthy individuals 5

Rate Control Strategy (if needed)

• PACs with sinus rhythm typically do not require acute treatment unless causing symptomatic bradycardia from non-conducted beats 6
• If PACs are frequent and non-conducted causing symptomatic bradycardia, beta-blockers are first-line for rate control in patients with preserved left ventricular function 7
• Avoid AV nodal blocking agents initially in this patient until alcohol-induced conduction abnormalities are excluded, as ethanol can inhibit calcium and sodium currents in conductive tissue 5

Monitoring Parameters

• Continuous ECG monitoring for progression to higher-degree AV block or other arrhythmias 5
• Body temperature monitoring, as mild hypothermia (around 36°C) can occur with alcohol intoxication but is not typically the primary cause of conduction abnormalities 5
• Rhythm typically normalizes upon sobriety in alcohol-induced arrhythmias 5

Common Pitfalls to Avoid

• Do not attribute quadriplegia solely to alcohol intoxication without excluding structural neurological causes—this is a critical diagnostic error 2
• Do not administer glucose before thiamine in chronic alcohol users, as this precipitates Wernicke encephalopathy 1
• Avoid aggressive cardioversion or antiarrhythmic drugs for isolated PACs in sinus rhythm, as these are typically benign and self-limited with alcohol clearance 5, 6
• Do not discharge the patient until neurological examination normalizes and alternative causes of quadriplegia are definitively excluded 2

Disposition and Follow-up

• Screen for alcohol use disorder using validated tools, as acute intoxication represents a sentinel event for underlying chronic alcohol abuse 1, 3
• Refer to alcohol addiction unit for multidisciplinary treatment to achieve long-term abstinence 1, 3
• Neurology consultation if any neurological deficits persist after alcohol clearance 2
• Cardiology follow-up only if arrhythmias persist beyond intoxication period 5