What is the management for severe ethanol (ETOH) intoxication?

Management of Severe Ethanol Intoxication (ETOH 374 mg/dL)

At an ethanol level of 374 mg/dL (81 mmol/L), supportive care with airway protection, hemodynamic support, and close monitoring is the primary management approach, with hemodialysis reserved for life-threatening complications that fail conservative management.

Initial Stabilization and Supportive Care

The cornerstone of management for severe ethanol intoxication involves aggressive supportive measures targeting the most life-threatening complications 1, 2:

• Airway management: Intubation for airway protection in comatose patients or those with Glasgow Coma Scale ≤8 1
• Hemodynamic support: Intravenous fluids, vasopressors, and inotropic agents as needed for shock or hypotension 3, 1
• Mechanical ventilation: For respiratory failure or inadequate ventilation 1
• Continuous monitoring: Vital signs, cardiac rhythm, neurological status, and core temperature 1

Critical Assessments Required

Perform immediate evaluation for complications that significantly impact morbidity and mortality 1, 2:

• Neurological examination: Rule out cerebro-cranial trauma, assess for seizures, evaluate level of consciousness 1
• Metabolic monitoring: Check for hypoglycemia (administer dextrose if present), assess acid-base status, monitor electrolytes 1, 2
• Temperature control: Treat hypothermia with active rewarming measures 1
• Gastrointestinal assessment: Evaluate for severe gastric dysfunction, aspiration risk 1

Hemodialysis Considerations

While the provided guidelines focus on ethylene glycol poisoning rather than ethanol intoxication, the research evidence suggests hemodialysis may be considered in specific severe cases 3, 4, 5:

Potential indications for hemodialysis in severe ethanol intoxication:

• Refractory coma with minimal improvement after 4-9 hours of aggressive supportive care 3, 5
• Hemodynamic instability requiring high-dose vasopressors despite fluid resuscitation 3
• Intractable seizures not controlled with standard anticonvulsant therapy 5
• Extremely elevated ethanol levels (>500-600 mg/dL or >109-130 mmol/L) with severe clinical toxicity 4
• Osmole gap may serve as an indicator, though no validated cutoff exists for ethanol (unlike ethylene glycol) 4

Important caveat: At 374 mg/dL, this level alone does not mandate hemodialysis. The decision depends on clinical response to supportive care and presence of life-threatening complications 3, 4.

Pharmacological Adjuncts

• Metadoxine: May accelerate ethanol excretion and can be considered as adjunctive therapy 2
• Thiamine: Administer to prevent Wernicke encephalopathy in chronic alcohol users 1
• Dextrose: Only after thiamine administration if hypoglycemia present 1

Monitoring During Treatment

Track clinical improvement through 3, 5:

• Serial neurological assessments: Level of consciousness, Glasgow Coma Scale
• Ethanol level decline: Conservative management typically reduces levels by approximately 15-20 mg/dL/hour 3
• Hemodialysis clearance: If dialysis initiated, ethanol levels decline rapidly (much faster than conservative management) 3, 5

Common Pitfalls to Avoid

• Do not use receptor antagonists (opiate or benzodiazepine blockers) as they have proven ineffective in reducing ethanol toxicity 1
• Do not overlook co-ingestions: Assess for other substances that may complicate management 2
• Do not miss disulfiram interaction: If patient on disulfiram, immediately administer IV iron and vitamin C for "antabuse response" 1
• Do not delay intubation: Protect airway early in deeply comatose patients to prevent aspiration 1