Treatment of Acute Alcohol Intoxication
For acute alcohol intoxication, provide supportive care with airway protection, IV fluids, and thiamine supplementation, as most patients metabolize ethanol rapidly without requiring specific pharmacological intervention. 1, 2
Immediate Stabilization
Airway management is the priority - ensure adequate ventilation and protect against aspiration, as respiratory depression and loss of protective reflexes are the primary life-threatening complications 1, 2
Administer thiamine 100-300 mg immediately (before any glucose-containing fluids) to prevent Wernicke's encephalopathy, which is a medical emergency requiring urgent treatment 3, 4
Provide IV fluid resuscitation to address dehydration and support renal function 2
Monitor vital signs continuously, particularly respiratory rate, blood pressure, and level of consciousness 3
Supportive Care Protocol
General supportive measures are the mainstay of treatment since hepatic metabolism of ethanol is usually rapid and most patients recover without specific interventions 1, 5
Maintain normoglycemia - check blood glucose and correct hypoglycemia if present 2
Monitor for and treat complications including hypothermia, electrolyte disturbances, and metabolic acidosis 1, 2
Consider metadoxine as an adjunctive agent to accelerate ethanol excretion in severe cases, though this is not widely available 2
Critical Assessment for Withdrawal Risk
Evaluate for alcohol dependence and withdrawal risk using patient history of chronic heavy use, as withdrawal syndrome can develop within hours and requires different management 6, 3, 7
If the patient has alcohol dependence, initiate benzodiazepines prophylactically - long-acting agents like chlordiazepoxide or diazepam are preferred (10 mg 3-4 times daily initially per FDA labeling) 6, 3, 8
Use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale to guide treatment intensity - scores >8 require pharmacological intervention 3
Special Populations
In patients with liver disease, switch to lorazepam or oxazepam (intermediate-acting benzodiazepines) rather than long-acting agents to avoid drug accumulation and encephalopathy 6, 3
For elderly patients or those with severe medical comorbidities, use lower initial benzodiazepine doses and intermediate-acting agents 3
Disposition and Follow-up
Admit to inpatient setting if: risk of severe withdrawal, concurrent serious medical/psychiatric conditions, inadequate social support, or inability to ensure reliable supervision 6, 3
Screen for alcohol use disorder using validated instruments (AUDIT, ASSIST) once the patient is medically stable 6
Provide brief intervention (5-30 minutes) with individualized feedback and advice on reducing/stopping alcohol consumption before discharge 6
Arrange psychiatric consultation and linkage to community alcohol services for patients with alcohol dependence to address long-term treatment needs 6, 4, 7
Common Pitfalls to Avoid
Never administer glucose before thiamine - this can precipitate acute Wernicke's encephalopathy 4
Do not discharge patients with suspected alcohol dependence without withdrawal prophylaxis, as delirium tremens and seizures can be fatal 6, 3
Avoid using antipsychotics as monotherapy for agitation - they lower seizure threshold and should only be used as adjuncts to benzodiazepines in severe cases 6
Do not assume all intoxicated patients are simply "sleeping it off" - assess for co-ingestions, trauma, hypoglycemia, and other medical emergencies 1, 2