What's the management for a patient with a high Blood Alcohol Concentration (BAC)?

Management of High Blood Alcohol Concentration (BAC)

For patients with high BAC, prioritize airway protection and supportive care over any specific BAC threshold, as cognitive function—not a numerical value—should guide clinical decision-making. 1

Initial Stabilization and Assessment

Immediate Priorities

• Secure the airway and ensure adequate ventilation in patients with respiratory depression, as this is life-saving and prevents death from ethanol-induced respiratory depression or aspiration of gastric contents 2
• Assess cardiovascular and respiratory stability as the first step in management 3
• Administer thiamine 100 mg IV first, followed by dextrose to prevent Wernicke-Korsakoff syndrome, particularly in patients with chronic alcohol use or marginal thiamine status 4
  • Note: Thiamine must be given before dextrose to avoid precipitating acute Wernicke's encephalopathy 4
  • Be prepared to treat potential anaphylactic reactions to thiamine with epinephrine, oxygen, vasopressors, steroids, and antihistamines 4

Clinical Evaluation Based on BAC and Presentation

• At BAC >250 mg/dL (0.25%), patients are typically at risk of coma, though alcohol-naive individuals may experience severe toxicity at <100 mg/dL while chronic users may show impairment only at >300 mg/dL 3
• Cognitive function assessment takes precedence over specific BAC levels when determining medical stability and readiness for psychiatric evaluation 1
• Monitor vital signs closely as symptoms can be extremely variable due to individual differences in alcohol metabolism 5

Treatment Strategies by Severity

Mild-to-Moderate Intoxication (BAC <1 g/L or <100 mg/dL)

• Clinical observation with vital signs monitoring is sufficient—no specific pharmacologic treatment is necessary 5
• Observe for 24 hours to monitor for alcohol withdrawal syndrome development and evaluate for pathological complications 5
• Consider Temporary Observation Unit placement as these patients often have favorable outcomes within 24 hours without requiring hospitalization 5

Severe Intoxication (BAC >1 g/L or >100 mg/dL)

• Provide supportive care with IV fluids to maintain hemodynamic stability 5, 6
• Treat specific complications aggressively:
  • Hypoglycemia with dextrose (after thiamine) 5
  • Hypotension with fluids and vasopressors as needed 5
  • Hypothermia with rewarming measures 5
  • Electrolyte imbalances with appropriate replacement 5
• Administer B-complex and C vitamins to address nutritional deficiencies common in alcohol intoxication 5
• Consider metadoxine to accelerate ethanol metabolism and elimination from blood 7, 5, 6

Critical Intoxication with Respiratory Depression

• Intubate and ventilate immediately as this is life-saving and prevents consequential damage even at extremely high BAC levels (>8 g/L documented survival) 2
• Haemodialysis may be considered in severely ill children or comatose adults, though this is rarely necessary 3
• Expect ethanol metabolism at approximately 15 mg%/hour in non-dependent adults for planning observation duration 3

Important Clinical Pitfalls

Avoid These Common Errors

• Do not delay psychiatric evaluation solely to wait for BAC results in alert patients with appropriate cognition, normal vital signs, and noncontributory history/physical examination 1
• Do not use a predetermined BAC threshold to determine when psychiatric evaluation can commence—there is no evidence-based specific level 1
• Do not administer dextrose before thiamine in patients with suspected chronic alcohol use, as this can precipitate Wernicke-Korsakoff syndrome 4
• Do not routinely order toxicology screens as they rarely change management in isolated alcohol intoxication 1

Special Considerations for Adolescents

• Adolescents are more vulnerable to alcohol's toxic effects due to immature hepatic alcohol dehydrogenase activity 5
• Acute complications are more frequent and dangerous in young people compared to adults 5
• Lower thresholds for aggressive intervention should be maintained in pediatric patients 3

Screening for Alcohol Use Disorder

• Screen all patients with acute alcohol intoxication for underlying alcohol use disorder as AAI often represents a sentinel event of chronic abuse 7, 6
• Refer to alcohol addiction unit for multidisciplinary treatment to achieve long-term abstinence and reduce risk of relapse 5, 6
• Use observation period to assess if psychiatric symptoms resolve as intoxication clears, particularly suicidality 1

Monitoring for Withdrawal

• Observe for ethanol withdrawal syndrome which may begin within 8 hours of last drink, even with BAC >200 mg/dL in dependent patients 3
• Withdrawal symptoms include tremor, nausea/vomiting, increased blood pressure and heart rate, paroxysmal sweats, depression, and anxiety 3
• Benzodiazepines are first-line for managing agitation related to alcohol withdrawal if it develops 1