A patient with a history of depression and alcohol use disorder (AUD) presents with slurred speech and drowsiness, what is the next best step in management?

Immediate Management of Acute Alcohol Intoxication with Slurred Speech

Administer IV thiamine (100 mg) immediately to prevent Wernicke's encephalopathy in this patient with alcohol use disorder presenting with altered mental status. 1

Critical First Action: Thiamine Administration

• Give thiamine 100 mg IV before any glucose administration to prevent precipitating or worsening Wernicke's encephalopathy in chronic alcohol users with acute intoxication 1
• This takes priority over diagnostic workup because Wernicke's encephalopathy can develop rapidly and cause permanent neurological damage if thiamine is not given prophylactically 1
• The American College of Emergency Physicians specifically recommends thiamine supplementation as part of initial stabilization for patients with high blood alcohol levels 1

Why Not the Other Options First

Urine drug screen (Option A) is not the immediate priority because:

• While marijuana use is mentioned, the clinical picture is consistent with acute alcohol intoxication (drowsy, slurred speech, smell of alcohol, stable vitals) 1
• Drug screening can be performed after thiamine administration and does not change immediate management 1

Liver function tests (Option B) are not urgent because:

• Vitals are stable, indicating no acute hepatic decompensation requiring emergent intervention 1
• LFTs can be obtained during the workup but do not guide immediate emergency management 1

Head CT (Option D) is not immediately indicated because:

• The patient has stable vitals and a clear history of alcohol intoxication with no mention of trauma, focal neurological deficits, or signs suggesting intracranial pathology 1
• CT should be considered if mental status does not improve with supportive care or if there are concerning neurological findings 1

Subsequent Management Steps

After thiamine administration:

• Provide supportive care with monitoring of vital functions, airway protection, and close observation for complications 1
• Assess for alcohol withdrawal using the CIWA-Ar scale, as benzodiazepines are first-line treatment if withdrawal symptoms develop 1
• Monitor cognitive abilities rather than focusing solely on blood alcohol level to guide further psychiatric evaluation 1
• Screen for complications including multi-organ failure, infection risk, and progression to delirium tremens or seizures 1

Addressing Comorbid Depression and Substance Use

Once acute intoxication resolves:

• Treat the depression concurrently with alcohol use disorder, as mental health disorders significantly worsen substance use outcomes 2
• Consider SSRI antidepressants as first-line treatment for comorbid depression in alcohol use disorder 2, 3
• Depression in alcohol use disorder shows large improvement within 3-6 weeks of treatment, even without antidepressants, though antidepressants provide modest additional benefit (effect size 0.25 for independent depression) 3
• Refer to mental health professionals for structured psychotherapy, particularly cognitive-behavioral therapy 2

Common Pitfalls to Avoid

• Never give glucose before thiamine in malnourished or chronic alcohol users, as this can precipitate Wernicke's encephalopathy 1
• Do not assume slurred speech is purely from intoxication without ensuring thiamine prophylaxis has been given 1
• Do not focus exclusively on substance use while ignoring the depression, as untreated depression leads to treatment failure and relapse 2
• Do not discharge without counseling for complete alcohol abstinence and nutritional supplementation assessment 1