Treatment of Alcohol Intoxication
For mild-to-moderate acute alcohol intoxication (blood alcohol concentration < 1 g/L), supportive care with clinical observation is sufficient without pharmacological intervention, while severe intoxication (> 1 g/L) requires aggressive supportive measures including intravenous fluids, thiamine administration, correction of metabolic derangements, and consideration of metadoxine to accelerate alcohol elimination. 1
Severity-Based Treatment Algorithm
Mild-to-Moderate Intoxication (BAC < 1 g/L)
No medications are necessary for mild-to-moderate intoxication. 1 The cornerstone of management includes:
- Clinical observation with vital signs monitoring in a supportive environment, as most patients will resolve within 24 hours without requiring hospitalization 1
- Protection from secondary complications such as aspiration, hypothermia, and trauma 2
- Monitoring for development of alcohol withdrawal syndrome, which requires specific pharmacological treatment 1
Severe Intoxication (BAC > 1 g/L)
Aggressive supportive care is mandatory for severe intoxication. 1 Treatment priorities include:
- Intravenous fluid resuscitation to maintain hemodynamic stability 1
- Correction of hypoglycemia without delay—recent evidence suggests that treating hypoglycemia should not be delayed for thiamine administration, as the risk of precipitating Wernicke's encephalopathy with acute dextrose is extremely low 3
- Treatment of hypothermia and electrolyte imbalances, particularly magnesium replacement 1, 4
- Administration of thiamine (vitamin B1) 100-300 mg/day to prevent Wernicke's encephalopathy 5, 6
- Complex B and C vitamins as adjunctive therapy 1
- Metadoxine to accelerate alcohol elimination from blood 1
Thiamine Administration: Critical Considerations
All patients with acute alcohol intoxication should receive thiamine prophylaxis. 6 The evidence strongly supports:
- Oral thiamine is adequate for most patients presenting with acute intoxication 6
- Parenteral (IV or IM) thiamine is mandatory for high-risk patients: those who are malnourished, have severe withdrawal, or show suspected signs of Wernicke's encephalopathy 6, 7
- Dosing should be 25 mg four times daily rather than 50 mg twice daily based on pharmacokinetic properties 8
- Duration should be 2-3 months following resolution of acute symptoms 5
Addressing the "Thiamine Before Dextrose" Dogma
A common pitfall is delaying hypoglycemia treatment to administer thiamine first. Recent evidence from a national study of 120 veterans who received dextrose before thiamine found zero cases of Wernicke's encephalopathy. 3 While thiamine administration remains important and low-risk, hypoglycemia treatment should not be delayed for this intervention. 3
Management of Specific Symptoms
Nausea and Vomiting
- Metoclopramide for severe nausea 4
- Prochlorperazine for persistent nausea 4
- Ondansetron (serotonin receptor antagonist) for refractory cases 4
Agitation
Benzodiazepines are NOT indicated for acute alcohol intoxication itself—they are reserved for alcohol withdrawal syndrome. 6 For intoxication-related agitation, supportive care in a calm environment is preferred. 1
When Alcohol Withdrawal (Not Intoxication) Develops
If withdrawal symptoms emerge, benzodiazepines become first-line treatment. 6, 5 This is a critical distinction:
- Long-acting benzodiazepines (chlordiazepoxide 25-100 mg every 4-6 hours or diazepam 5-10 mg every 6-8 hours) for prevention of seizures and delirium 5, 9
- Lorazepam 1-4 mg every 4-8 hours for patients with hepatic insufficiency, advanced age, or respiratory compromise 5, 6
- Antipsychotics should never be used as monotherapy for withdrawal—only as adjunct to benzodiazepines for severe delirium unresponsive to adequate benzodiazepine doses 6
Setting of Care Determination
Most patients with acute alcohol intoxication can be managed in a Temporary Observation Unit within the Emergency Department, as clinical courses typically resolve within 24 hours with favorable outcomes. 1
Inpatient admission is required for: 5
- Serious medical or psychiatric complications
- History of withdrawal seizures or delirium tremens
- Hemodynamic instability
- Severe intoxication with altered mental status requiring intensive monitoring
Special Population: Adolescents
Adolescents are at higher risk for alcohol-related complications due to immature hepatic alcohol dehydrogenase activity, making them more susceptible to toxic effects. 1 The same treatment principles apply but with heightened vigilance for complications.
Critical Pitfalls to Avoid
- Do not confuse acute intoxication with withdrawal syndrome—they require fundamentally different pharmacological approaches 1
- Do not delay hypoglycemia treatment waiting for thiamine administration 3
- Do not use benzodiazepines for acute intoxication unless withdrawal symptoms develop 6
- Do not discharge without assessing for development of withdrawal syndrome, which may emerge as intoxication resolves 1
- Do not forget thiamine prophylaxis in all patients, as deficiency is present in 30-80% of alcohol-dependent individuals 6
Follow-Up and Long-Term Management
Patients with Alcohol Use Disorder must be referred to an Alcohol Addiction Unit for follow-up to reduce relapse risk and prevent future complications. 1 For relapse prevention in dependent patients, medications such as acamprosate, disulfiram, or naltrexone should be offered as part of comprehensive treatment. 6