Management of Slightly Intoxicated Patients
For slightly intoxicated patients, prioritize airway protection and supportive care with observation, while avoiding routine intravenous fluids as they do not accelerate alcohol clearance or reduce emergency department length of stay. 1, 2, 3
Initial Assessment and Stabilization
Assess and stabilize using ATLS principles with simultaneous evaluation for specific toxidromes. 1
- Secure airway, breathing, and circulation as the first priority regardless of the intoxicating substance 1
- Evaluate for signs of respiratory depression, altered mental status, and loss of protective airway reflexes 1
- Monitor vital signs continuously including cardiac monitoring for dysrhythmias 4
- Consider the patient to have a "full stomach" with aspiration risk 1
Supportive Care Strategy
Observation alone is the preferred management approach for uncomplicated alcohol intoxication. 3
- Provide a safe environment with close monitoring until the patient achieves clinical sobriety 5
- Avoid routine intravenous fluid administration as it does not accelerate ethanol clearance (clearance rate remains 15 mg/dL/h regardless of IV fluids) 2
- IV normal saline does not reduce emergency department length of stay (mean difference only 13 minutes, not statistically significant) and adds unnecessary healthcare costs 3
Substance-Specific Considerations
Alcohol Intoxication
- Observation is sufficient for mild to moderate intoxication without complications 3
- Consider IV diazepam 10 mg initially, then 5-10 mg every 3-4 hours if signs of acute alcohol withdrawal develop (agitation, tremor, impending delirium tremens) 6
- Metadoxine may accelerate ethanol excretion in acute intoxication, though this is not standard practice 5
Benzodiazepine Intoxication
- Standard life support measures and airway management are primary treatment 1
- Avoid flumazenil in slightly intoxicated patients as it precipitates seizures in patients with benzodiazepine tolerance or preexisting seizure disorders, and can cause dysrhythmias 7, 1
Mixed Intoxication
- Mixed overdoses are common and require careful assessment 1
- Do not delay naloxone administration if opioid co-ingestion is suspected, even in presence of other substances 1
Critical Exclusions and Red Flags
Rule out life-threatening conditions that may mimic or coexist with intoxication. 1
- Exclude traumatic cervical injury before any airway manipulation 1
- Abdominal pain with nausea/vomiting may signal perforation or visceral obstruction rather than simple intoxication 1
- Assess for head injury, which may alter management approach (52% of physicians modify IV fluid use in this scenario) 8
- Perform meticulous and repetitive examinations as intoxicated patients may have misleading mixed signs 1
When to Escalate Care
Prepare for advanced interventions if the patient deteriorates. 1
- Administer benzodiazepines (diazepam or midazolam) for seizures or severe agitation 4
- Provide bag-mask ventilation or endotracheal intubation for CNS depression with loss of protective airway reflexes 4
- Use vasopressors (dopamine or vasopressin) for hypotension unresponsive to positioning 4
Common Pitfalls to Avoid
- Do not routinely administer IV fluids solely to expedite alcohol elimination—this practice lacks evidence and wastes resources 2, 3
- Do not assume all symptoms are due to intoxication; maintain high suspicion for trauma, infection, or metabolic derangements 1
- Avoid flumazenil in benzodiazepine intoxication unless you can definitively rule out tolerance, seizure history, and co-ingestion with proconvulsant drugs 7, 1
- Contact poison control (1-800-222-1222 in the US) for expert guidance on uncertain cases or mixed ingestions 4, 9