How should acute alcohol intoxication be managed in the emergency setting?

Emergency Management of Acute Alcohol Intoxication

Immediate Stabilization and Assessment

The primary management of acute alcohol intoxication is supportive care focused on airway protection, breathing support, and hemodynamic stabilization—no specific antidote is required for most cases. 1, 2

Initial Priorities

• Secure the airway immediately if the patient shows signs of respiratory depression, loss of protective airway reflexes, or altered mental status requiring bag-mask ventilation or endotracheal intubation. 3, 2
• Assess and support breathing with supplementary oxygen for hypoxemic patients (oxygen saturation <94%) or those with unknown oxygen saturation. 3
• Stabilize circulation by treating hypotension with judicious intravenous fluid administration and correcting any hemodynamic instability. 2, 4
• Monitor vital signs continuously including temperature, as hypothermia is a common complication requiring passive or active rewarming measures. 3, 4

Critical Differential Diagnosis

• Rule out co-ingestions and alternative diagnoses before attributing all symptoms to alcohol alone—hypoglycemia, head trauma, metabolic derangements, and other intoxications (particularly opioids) must be excluded. 2, 5
• Assess for traumatic injuries, particularly head and cervical spine injuries, especially in patients with a history of falls, altered consciousness, or diving into shallow water. 3, 2
• Check blood glucose immediately and treat hypoglycemia, which commonly coexists with alcohol intoxication and can mimic or worsen neurological symptoms. 4, 6

Severity-Based Treatment Approach

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

• Clinical observation alone is sufficient for alert, cooperative patients with stable vital signs and no complications—no pharmacologic intervention is necessary. 4, 6
• Provide a safe environment during the recovery phase with monitoring for deterioration or development of withdrawal symptoms. 2, 4
• Observation periods of up to 24 hours in a temporary observation unit are appropriate for uncomplicated cases, avoiding unnecessary hospitalization. 4

Severe Intoxication (BAC >1 g/L)

• Administer intravenous fluids to maintain hydration and support hemodynamic stability. 4, 6
• Correct electrolyte imbalances including hypokalemia, hypomagnesemia, and hypophosphatemia. 4, 6
• Administer thiamine (vitamin B1) 100 mg IV/IM before or concurrent with glucose administration to prevent Wernicke encephalopathy in chronic alcohol users. 4, 6
• Consider metadoxine (if available) to accelerate ethanol metabolism and elimination, though this is not standard practice in all regions. 1, 4, 6
• Treat hypothermia by removing wet clothing, providing insulation, and using warm humidified oxygen if available. 3

Psychiatric Evaluation Timing

Base the timing of psychiatric assessment on the patient's cognitive abilities and mental status rather than waiting for a specific blood alcohol concentration. 3

• Initiate psychiatric evaluation in alert, cooperative patients with normal vital signs and appropriate cognition, regardless of measured BAC. 3
• Use a period of observation to determine if psychiatric symptoms (particularly suicidality) resolve as intoxication clears, as many symptoms are transient and related to intoxication alone. 3
• Do not delay evaluation to obtain BAC results if the patient demonstrates adequate decision-making capacity on clinical assessment. 3

Critical Pitfalls to Avoid

• Never assume all symptoms are due to alcohol alone—failure to identify co-ingestions, head trauma, hypoglycemia, or other metabolic derangements is a common and dangerous error. 2, 5
• Do not perform gastric lavage or induce vomiting, as these interventions are contraindicated and increase aspiration risk. 3
• Avoid administering benzodiazepines for agitation until other causes of altered mental status are excluded, as they can worsen respiratory depression in severe intoxication. 3
• Do not discharge patients with suspected chronic alcohol use disorder without screening for alcohol withdrawal risk and providing appropriate prophylaxis or monitoring. 2, 6

Disposition and Follow-Up

• Admit to ICU or monitored setting any patient with severe intoxication (BAC >3-4 g/L), respiratory depression requiring intubation, hemodynamic instability, or significant co-morbidities. 4, 6
• Screen all patients for alcohol use disorder using validated tools and refer to addiction services for those meeting criteria, as acute intoxication represents a sentinel event for intervention. 1, 4, 6
• Provide brief intervention counseling in the emergency setting, which has demonstrated effectiveness in reducing future alcohol-related harm. 4, 6
• Ensure safe discharge only when the patient is alert, ambulatory, has normal vital signs, and has a responsible adult to accompany them home. 4