What is the appropriate management for a patient presenting with ethanol intoxication?

Management of Ethanol Intoxication

For acute ethanol intoxication, management is primarily supportive care focused on stabilizing vital functions, monitoring for complications, and allowing time for natural ethanol elimination—no specific antidote exists and intravenous fluids do not accelerate ethanol clearance.

Initial Stabilization and Monitoring

Supportive care is the cornerstone of management, as there is no effective pharmacologic intervention to reverse ethanol's CNS effects 1, 2. The priority is maintaining vital functions through:

• Airway protection and respiratory support: Mechanical ventilation may be required for severe CNS depression with respiratory failure 1, 3
• Hemodynamic monitoring: Administer vasopressors and inotropics for shock states 3
• Continuous vital signs monitoring: Track respiratory rate, heart rate, blood pressure, and temperature 1

Critical Complications to Assess

Every patient requires neurological examination to exclude traumatic brain injury, as cerebro-cranial trauma commonly accompanies intoxication 1. Specifically evaluate for:

• Hypoglycemia: Check blood glucose immediately and treat if present 1
• Hypothermia: Monitor core temperature and rewarm as needed 1
• Seizures: Manage with benzodiazepines if they occur 1
• Acid-base disturbances: Monitor and correct metabolic abnormalities 1, 3
• Electrolyte imbalances: Maintain water-electrolyte balance 1
• Severe gastric dysfunction: Address nausea, vomiting, and abdominal pain 1

What Does NOT Work

Intravenous saline does not accelerate ethanol clearance (clearance rate remains 15 mg/dL/h regardless of IV fluids) and should not be initiated solely to expedite elimination 4. While IV fluids may be justified for dehydration or hypotension, they have no effect on ethanol metabolism 4.

Receptor antagonists are ineffective: Despite ethanol's effects on opiate, benzodiazepine receptors, and neurotransmitters, attempts to block these receptors have proven unsuccessful in reducing CNS toxicity 1.

Pharmacologic Consideration

Metadoxine may accelerate ethanol excretion in some clinical settings, though evidence is limited 2. This represents the only medication with potential benefit specifically for ethanol intoxication 2.

Hemodialysis for Severe Cases

Hemodialysis should be considered for life-threatening ethanol intoxication when conservative management fails 3. Specific indications include:

• Profound coma with markedly elevated blood ethanol levels (e.g., >136 mM or ~630 mg/dL) 3
• Refractory shock requiring vasopressors despite aggressive supportive care 3
• Inadequate ethanol clearance after 4 hours of conservative treatment 3

Hemodialysis rapidly reduces blood ethanol concentrations and can restore consciousness when standard measures fail 3.

Disposition and Follow-up

Screen all patients for alcohol use disorder to facilitate referral to specialized alcohol treatment programs where personalized interventions can be established 2. This represents a critical opportunity for secondary prevention 2.

Common Pitfalls

• Do not rely on IV fluids to "flush out" alcohol—this is physiologically ineffective 4
• Do not miss concurrent trauma—always perform thorough neurological examination 1
• Do not overlook hypoglycemia—check glucose in all intoxicated patients 1
• Do not delay hemodialysis in severe cases—it may be life-saving when blood alcohol remains dangerously elevated despite supportive care 3