What are the appropriate treatment and management steps for a patient with a blood alcohol level (BAL) of 114, indicating severe alcohol intoxication?

Management of Blood Alcohol Level of 114 mg/dL

A patient with a BAL of 114 mg/dL requires immediate supportive care with airway protection, thiamine supplementation, and close monitoring for complications, while the specific blood alcohol number itself should not dictate clinical decision-making—instead, assess the patient's cognitive function and clinical stability to guide psychiatric evaluation and disposition. 1, 2

Initial Stabilization and Supportive Care

Immediate interventions:

• Stabilize airway, breathing, and circulation as the first priority 2
• Administer thiamine 100 mg IV immediately to prevent Wernicke's encephalopathy, particularly critical in chronic alcohol users 2
• Monitor vital signs continuously for hemodynamic instability 2
• Assess for co-ingestions, as 44% of intentional poisoning patients have multiple substances on board, with 66% involving ethanol plus other agents 2

Clinical Assessment Over Arbitrary BAL Thresholds

The cognitive abilities of the patient, rather than the specific blood alcohol level of 114 mg/dL, should determine your clinical approach. 1

• No evidence-based data supports a specific BAL threshold at which psychiatric evaluation can accurately commence 1
• If the patient is alert, cooperative, has normal vital signs, appropriate cognition, and a noncontributory history and physical examination, you can proceed with psychiatric assessment regardless of the elevated BAL 1
• Consider a period of observation to determine if psychiatric symptoms resolve as intoxication clears 1

Alcohol Withdrawal Assessment and Prevention

Use the CIWA-Ar scale to assess for early signs of alcohol withdrawal syndrome, which can progress from mild symptoms to life-threatening delirium tremens, seizures, and cardiac arrest. 2, 3

Benzodiazepines are the gold standard for treating alcohol withdrawal:

• Long-acting benzodiazepines like diazepam or chlordiazepoxide provide superior protection against seizures and delirium 2, 3
• Mild AWS may not require treatment, but moderate and severe AWS need pharmacologic intervention 3
• Outpatient treatment is appropriate for mild-to-moderate AWS; severe AWS requires inpatient management 3

Special Populations and Medication Considerations

In patients with chronic alcohol use or suspected liver disease, carefully adjust medication selection and dosing to prevent adverse outcomes. 2, 4

• Avoid nephrotoxic drugs and use diuretics sparingly, as acute kidney injury is an early manifestation of multi-organ failure in alcoholic liver disease 4
• Do not administer iodinated contrast dye for imaging, as this significantly increases AKI risk in cirrhotic patients 4
• Monitor for infections with high clinical suspicion—fever and elevated WBC are unreliable indicators in alcoholic hepatitis, yet infections occur in 20-30% of severe cases 2, 4

Monitoring for Complications

Watch for development of:

• Multi-organ failure, which carries extremely high mortality 2, 4
• Respiratory depression and autonomic dysfunction in severe intoxication 5
• Traumatic injuries, as alcohol is directly responsible for more than half of traffic accidents 6
• Gastrointestinal bleeding from varices or erosive gastritis in chronic users 4

Nutritional Support and Metabolic Considerations

Evaluate nutritional status and provide supplementation, as malnutrition is common in chronic alcohol users. 2, 4

• Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day if alcoholic liver disease is present 4
• Metadoxine can accelerate ethanol metabolism and elimination, though supportive care remains the primary therapy 7, 5

Disposition and Follow-Up

All patients with alcohol intoxication should be:

• Counseled to completely abstain from alcohol 2, 4
• Screened for underlying alcohol use disorder using validated criteria (2 or more symptoms indicates AUD: mild 2-3, moderate 4-5, severe 6+ symptoms) 1
• Referred to alcohol addiction services for multidisciplinary treatment, as brief intervention during hospitalization reduces future alcohol consumption by approximately 41 g/week 4
• Provided extended alcohol counseling after discharge to maintain abstinence 4

Common Pitfalls to Avoid

• Do not delay psychiatric evaluation solely based on the BAL number if the patient demonstrates adequate cognitive function 1
• Do not assume the absence of fever rules out infection in patients with chronic alcohol use or liver disease 4
• Do not overlook thiamine administration—this is critical to prevent irreversible neurological damage 2
• Do not discharge without screening for AUD, as acute intoxication represents a sentinel event for chronic alcohol abuse 5