Treatment of Acute Alcohol Intoxication
For mild-to-moderate acute alcohol intoxication (blood alcohol concentration <1 g/L or <100 mg/dL), supportive care with clinical observation is sufficient without medications, while severe intoxication (BAC >1 g/L) requires aggressive supportive treatment including IV fluids, correction of metabolic derangements, thiamine administration, and consideration of metadoxine to accelerate alcohol elimination. 1
Immediate Assessment and Triage
Determine blood alcohol concentration and assess for life-threatening complications:
- Measure vital signs, hemodynamic stability, cognitive state, and blood alcohol level to guide treatment intensity 1
- Check for respiratory depression, hypothermia, hypotension, and altered mental status requiring immediate intervention 2
- Screen for co-ingestion of recreational drugs, as polysubstance use dramatically increases mortality risk 3
- Evaluate for traumatic injuries, particularly head trauma and violent assault injuries, which occur in approximately 46% of intoxicated ED patients 4
Treatment Based on Severity
Mild-to-Moderate Intoxication (BAC <1 g/L)
No pharmacologic intervention is necessary:
- Clinical observation with serial vital sign monitoring is the primary management 1
- Most patients complete their clinical course within 24 hours with favorable outcomes 1
- Place in a Temporary Observation Unit rather than admitting to inpatient services, as hospitalization is rarely necessary 1
Severe Intoxication (BAC >1 g/L)
Aggressive supportive care is mandatory:
- Administer IV fluids for volume resuscitation and to support renal function 1
- Correct hypoglycemia immediately, as it is common and dangerous in severe intoxication 1
- Treat hypothermia and electrolyte imbalances (particularly hypokalemia and hypomagnesemia) 1
- Give thiamine 100-300 mg IV before any glucose-containing fluids to prevent Wernicke encephalopathy 5
- Administer B-complex and vitamin C supplementation 1
- Consider metadoxine to accelerate alcohol elimination from the bloodstream 1
Critical Pitfalls to Avoid
Do not miss these common complications:
- Adolescents are at higher risk for severe toxicity due to immature hepatic alcohol dehydrogenase activity, requiring more aggressive monitoring 1
- Respiratory depression can progress rapidly to death in severe cases 2
- Withdrawal syndrome may develop during observation, requiring benzodiazepine treatment 1
- Concurrent medical problems from chronic alcohol use (liver disease, cardiomyopathy, gastrointestinal bleeding) often coexist and need evaluation 6
Differential Diagnosis Considerations
Rule out other causes of altered mental status:
- Methanol or ethylene glycol poisoning presents similarly but causes metabolic acidosis, visual disturbances, and renal failure 3
- Head trauma, intracranial hemorrhage, and hypoglycemia from other causes must be excluded 2
- Concurrent drug intoxication or overdose significantly complicates the clinical picture 3
Disposition and Follow-Up
Address the underlying alcohol use disorder before discharge:
- Only 12.5% of intoxicated ED patients are screened for dangerous behaviors (suicide, homicide), and only 15% receive advice to stop drinking—this is inadequate 4
- Implement brief behavioral counseling using the FRAMES model (5-30 minutes) before discharge 5
- Refer all patients to alcohol addiction services or Alcoholics Anonymous for follow-up to prevent relapse 5, 1
- Schedule outpatient follow-up within 1-3 months to assess abstinence and provide ongoing support 5
Special Populations
Pregnant women require immediate specialized care:
- Alcohol during pregnancy causes fetal harm ranging from miscarriage to Fetal Alcohol Spectrum Disorder 2
- Consult obstetrics immediately for any pregnant patient with acute intoxication 2
Young adults and adolescents need age-specific counseling: