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 to alcohol alone. 1

Immediate Stabilization and Assessment

Airway, Breathing, and Circulation

• Secure the airway and assess respiratory function immediately, as severe alcohol intoxication can produce global neurological impairment leading to autonomic dysfunction, respiratory depression, and cardiac arrest 2
• Monitor vital signs continuously, including oxygen saturation and cardiac rhythm
• Establish IV access for fluid resuscitation and medication administration 2

Cervical Spine Precautions

• Maintain full cervical spine immobilization until spinal cord injury is definitively excluded with imaging, regardless of the patient's claim of "no head trauma" 1
• The mechanism of fall during intoxication makes cervical spine injury a critical consideration in any patient presenting with acute quadriplegia

Neurological Emergency Workup

• Obtain emergent CT head and cervical spine imaging immediately to evaluate for:
  • Intracranial hemorrhage (subdural, epidural, subarachnoid)
  • Ischemic stroke (particularly bilateral anterior cerebral artery territory, which can present with quadriplegia) 1
  • Cervical spine fracture or cord compression
• If CT is negative but clinical suspicion remains high, proceed to MRI brain and cervical spine to detect subtle infarcts or cord pathology 1
• Check blood alcohol concentration (BAC) for both clinical management and documentation 2

Cardiac Management of PACs

Rate and Rhythm Assessment

• The presence of PACs on ECG in this clinical context is likely incidental and does not require specific treatment, as isolated PACs are generally benign and common in the setting of acute alcohol intoxication 3, 4
• Monitor for progression to more serious arrhythmias including atrial fibrillation or higher-degree AV block, both of which can occur with acute alcohol intoxication ("holiday heart syndrome") 3
• Continuous cardiac monitoring is warranted given that alcohol can cause AV conduction disturbances, though this typically occurs at very high BAC levels 3

When PACs Require Intervention

• If PACs are non-conducted and occurring in bigeminal pattern causing symptomatic bradycardia, consider beta-blockers for rate control only after hemodynamic stability is confirmed 4
• In this acute setting with quadriplegia and altered mental status, do not treat asymptomatic PACs pharmacologically 5

Alcohol Intoxication Management

Supportive Care

• Administer IV thiamine 100mg, folate, and multivitamins immediately to prevent Wernicke encephalopathy in this chronic alcohol user
• Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which can exacerbate cardiac arrhythmias 2
• Maintain normothermia, as mild hypothermia can occur with intoxication and may contribute to conduction abnormalities 3

Pharmacological Treatment

• Consider metadoxine to accelerate ethanol metabolism and elimination if available, as this is the only specific drug useful for acute alcohol intoxication 2, 6
• If agitation develops during evaluation, use diazepam 10mg IV/PO as indicated for symptomatic relief in acute alcohol withdrawal 7

Differential Diagnosis Considerations

Critical Neurological Causes

The quadriplegia in this patient could represent:

• Bilateral anterior cerebral artery infarct (can present with quadriplegia, particularly with azygous ACA anatomy) 1
• High cervical cord injury (C1-C4 level)
• Basilar artery thrombosis with brainstem infarction
• Central pontine myelinolysis (if chronic alcoholic with recent electrolyte shifts)
• Acute disseminated encephalomyelitis or other inflammatory myelopathy

Alcohol-Related Mimics

• Severe alcohol intoxication alone can cause profound neurological depression but typically does not cause isolated quadriplegia with preserved consciousness level 2
• The combination of "unable to move fully all extremities" with alcoholic breath should not be assumed to be purely intoxication-related

Disposition and Follow-Up

Immediate Actions

• Admit to ICU or stroke unit depending on imaging findings
• Neurology and/or neurosurgery consultation emergently based on imaging results
• Do not attribute quadriplegia to alcohol intoxication alone without excluding structural pathology 1

Screening for Alcohol Use Disorder

• Once medically stable, screen for underlying alcohol use disorder and refer to addiction services, as acute intoxication represents a sentinel event for chronic alcohol abuse 2, 6
• Initiate multidisciplinary treatment planning for long-term alcohol abstinence 2

Critical Pitfalls to Avoid

• Never assume quadriplegia is due to intoxication alone—this is a neurological emergency requiring immediate imaging 1
• Do not delay cervical spine imaging based on patient's self-report of mechanism
• Avoid treating PACs aggressively in the acute setting unless they are causing hemodynamic compromise or symptomatic bradycardia 4
• Do not use AV nodal blocking agents (beta-blockers, calcium channel blockers, digoxin) if there is any concern for high-grade AV block, which can rarely occur with acute alcohol intoxication 3
• Remember that normal body temperature does not exclude alcohol-related conduction abnormalities 3