What is the management for a patient with an alcohol overdose?

Management of Alcohol Overdose (Acute Alcohol Intoxication)

For acute alcohol intoxication, stabilize the patient with supportive care focused on airway protection, IV fluids, thiamine administration, and monitoring for complications—no specific antidote exists for ethanol itself, and most patients with mild-to-moderate intoxication (blood alcohol concentration <1 g/L) require only clinical observation without pharmacological intervention. 1, 2

Immediate Stabilization and Assessment

Airway and Vital Signs

• Secure the airway immediately if the patient has altered mental status, as respiratory depression is the primary cause of death in severe alcohol intoxication. 2, 3
• Monitor vital signs continuously for autonomic instability including tachycardia, hypotension, hypothermia, and respiratory depression. 4, 2
• Assess blood alcohol concentration (BAC) to confirm intoxication and guide management: BAC <1 g/L indicates mild-moderate intoxication; BAC >1 g/L indicates severe intoxication requiring aggressive supportive care. 1, 2

Critical Initial Interventions

• Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating Wernicke encephalopathy. 4, 5
• Check fingerstick glucose and treat hypoglycemia if present, but only after thiamine administration. 1, 2
• Establish IV access and begin fluid resuscitation with normal saline to treat dehydration and support hemodynamics. 1, 3

Severity-Based Management Algorithm

Mild-to-Moderate Intoxication (BAC <1 g/L)

• No pharmacological treatment is necessary for most patients with mild-moderate intoxication. 1
• Place patient in clinical observation unit with vital signs monitoring every 2-4 hours. 1
• Ensure patient is positioned to prevent aspiration (recovery position if vomiting). 2
• Clinical course typically resolves within 24 hours with favorable outcome. 1

Severe Intoxication (BAC >1 g/L)

• Aggressive supportive care is mandatory, including IV fluid resuscitation, correction of electrolyte imbalances (particularly magnesium and potassium), and treatment of hypothermia. 1, 2
• Administer thiamine 100-300 mg/day IV or IM, plus B-complex vitamins and vitamin C. 1, 3
• Consider metadoxine 300-900 mg IV to accelerate ethanol metabolism and elimination (available in some countries). 1, 2, 3
• Monitor for and treat complications: aspiration pneumonia, rhabdomyolysis, acute kidney injury, cardiac arrhythmias. 2, 6

Critical Differential Diagnoses to Exclude

Rule Out Toxic Alcohol Ingestion

• Check anion gap metabolic acidosis—values >27 mmol/L suggest toxic alcohol poisoning (methanol, ethylene glycol) requiring fomepizole as antidote. 7
• Toxic alcohols present with severe metabolic acidosis, visual disturbances (methanol), or acute kidney injury (ethylene glycol), unlike pure ethanol intoxication. 7

Assess for Co-Ingestions

• Obtain acetaminophen level in all patients, as acetaminophen overdose is common in alcohol users and has synergistic hepatotoxicity. 5, 8
• Treat alcoholic patients for acetaminophen toxicity even with levels in the "non-toxic" range on standard nomograms, as chronic alcohol use lowers the toxic threshold. 8
• Screen for benzodiazepines, opioids, and other sedatives that potentiate CNS depression. 2, 6

Evaluate for Traumatic Injury

• Perform thorough physical examination for head trauma, intracranial hemorrhage, and occult injuries—alcohol intoxication masks pain and neurological findings. 2, 6
• Obtain CT head if there is any history of fall, assault, or unexplained altered mental status beyond expected for BAC. 6

Monitoring and Observation Protocol

Duration of Observation

• Monitor patients for minimum 4-6 hours after presentation, or until BAC decreases and clinical improvement is evident. 1, 2
• Most patients complete clinical course within 24 hours and can be discharged without hospitalization. 1

Indications for Hospital Admission

• Persistent altered mental status despite decreasing BAC (suggests alternative diagnosis). 2, 6
• Severe metabolic derangements (profound acidosis, severe electrolyte abnormalities, acute kidney injury). 2
• Complications requiring inpatient management (aspiration pneumonia, rhabdomyolysis, GI bleeding). 1, 2
• Concern for alcohol withdrawal syndrome in chronic alcohol users. 1, 3

Assessment for Alcohol Withdrawal Risk

Identify High-Risk Patients

• Patients with history of chronic heavy drinking (>80 g/day for ≥10 years) are at high risk for severe withdrawal and require close monitoring. 4
• Assess for prior history of withdrawal seizures or delirium tremens, which predict severe withdrawal. 4
• Alcohol withdrawal symptoms typically begin 6-24 hours after last drink, peak at 3-5 days. 4

Prophylactic Withdrawal Management

• Do NOT routinely administer benzodiazepines prophylactically—over 70% of patients, including those with cirrhosis, do not require pharmacological withdrawal treatment. 5, 4
• If withdrawal symptoms develop (tremor, tachycardia, hypertension, diaphoresis), initiate symptom-triggered benzodiazepine therapy with chlordiazepoxide 50-100 mg orally or diazepam 10 mg orally. 4
• Continue thiamine 100-300 mg/day for 2-3 months following resolution of acute intoxication. 5, 4

Special Populations

Adolescents and Young Adults

• Adolescents are more vulnerable to toxic effects of alcohol due to immature hepatic alcohol dehydrogenase activity, making acute complications more frequent and dangerous than in adults. 1
• Lower threshold for admission and prolonged observation in adolescent patients. 1

Patients with Chronic Liver Disease

• Assess for hepatic encephalopathy, which can be triggered by acute intoxication, dehydration, or electrolyte imbalances. 4
• Avoid hepatotoxic medications and use short-acting benzodiazepines (lorazepam, oxazepam) if withdrawal treatment becomes necessary. 5, 4

Post-Acute Management and Referral

Screening for Alcohol Use Disorder

• Every patient presenting with acute alcohol intoxication should be screened for underlying alcohol use disorder using validated tools (AUDIT questionnaire). 5, 1
• Acute intoxication represents a sentinel event and opportunity for intervention. 1, 2, 3

Mandatory Referral

• Refer all patients with suspected alcohol use disorder to an alcohol addiction unit for multidisciplinary treatment and long-term abstinence planning. 1, 2, 3
• Psychiatric consultation is essential for evaluation of alcohol use disorder severity and relapse prevention strategies. 4
• Consider pharmacological aids for maintaining abstinence (acamprosate, naltrexone, baclofen) after acute stabilization. 5

Common Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine—this precipitates acute Wernicke encephalopathy. 4, 5
• Do not assume altered mental status is solely due to alcohol—always exclude hypoglycemia, head trauma, toxic alcohol ingestion, and co-ingestions. 2, 6
• Do not discharge patients with BAC >0.08% or persistent altered mental status—they cannot safely care for themselves. 2
• Do not use anticonvulsants for alcohol withdrawal seizures—benzodiazepines are the only proven treatment. 4
• Avoid acetaminophen for symptom management in alcoholic patients due to synergistic hepatotoxicity—use ibuprofen instead. 8