Alcohol Intoxication

Background

• Alcohol intoxication usually describes the acute toxic effects following ingestion of a large amount of ethanol alcohol.
  • In adults and adolescents, alcohol intoxication is usually caused by ingesting multiple alcoholic beverages, including beer, wine, and spirits.
  • In some cases, particularly those involving children, alcohol intoxication can occur due to consumption of certain ethanol-containing medications or other products containing alcohol.
  • Alcohol intoxication in infants is rare but can occur due to accidental ingestion or absorption.
• In the United States, 20%-40% of persons admitted to emergency departments are reported to have alcohol-related disorders, of which acute alcohol intoxication is the most common.
• Binge drinking can increase the risk for alcohol intoxication, while lower body weight, higher percentage of alcohol in beverages, and large volume of alcohol consumed over a short period of time may increase the severity of alcohol intoxication.
• Acute alcohol intoxication can result in various respiratory, cardiac, gastrointestinal, and neurological complications.

Evaluation

• Patient may present to the emergency department due to alcohol related-trauma (such as, from a fall or car accident), violence, or complications requiring emergency treatment.
• Diagnostic criteria for acute alcohol intoxication from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) includes:
  • recent ingestion of alcohol
  • clinically significant maladaptive behavioral or mental status changes developing during or shortly after alcohol ingestion, including
    • sexual or aggressive behavior
    • unstable mood
    • impaired judgement
    • impaired social or occupational functioning
  • ≥ 1 of the following signs that develop during or shortly after alcohol use
    • slurred speech
    • lack of coordination
    • unsteady gait
    • nystagmus
    • impaired attention or memory
    • stupor or coma
  • symptoms not attributed to other medical conditions or mental disorders
• Elevated blood alcohol content (BAC) can confirm intoxication, and usually correlates with clinical findings.
  • National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as any pattern of drinking that brings BAC to ≥ 0.08% (≥ 80 mg/dL):
    • BAC level derived from the legal intoxication level for adults ≥ 21 years old in the United States
    • usually occurs after 4 drinks in women and 5 drinks in men in a 2-hour period
  • Common clinical findings based on BAC levels:
    • BAC < 50 mg/dL (< 10.9 mmol/L) - impairment in some tasks, increased talkativeness, and relaxation
    • BAC > 100 mg/dL (> 21.7 mmol/L) - altered perception of the environment, ataxia, hyper-reflexia, impaired judgement, impaired coordination, changes in mood/personality/behavior, nystagmus, prolonged reaction time, and slurred speech
    • BAC > 200 mg/dL (> 43.4 mmol/L) - amnesia, diplopia, dysarthria, hypothermia, nausea, and vomiting
    • BAC > 300 mg/dL (> 65.1 mmol/L) - respiratory depression and arrest
    • BAC > 400 mg/dL (> 86.8 mmol/L) - coma, respiratory arrest, death in some cases
    • BAC > 500 mg/dL (> 108.5 mmol/L) is when death typically occurs, though lethal dose can vary by tolerance level
• Assessment of BAC level can confirm intoxication if the diagnosis is not clinically obvious, and usually (but not always) correlates with clinical findings. If clinical findings do not correlate with blood alcohol levels, or if there is clinical suspicion for trauma or complications associated with alcohol toxicity, additional testing may be needed.
  • Perform chest x-ray and electrocardiography if there is suspected trauma or there are cardiac abnormalities.
  • Perform computed tomography (CT) of the brain if neurological symptoms are present or head trauma is suspected.
  • Consider additional blood tests to identify alcohol-related metabolic abnormalities or other conditions with similar presentations.

Management

• Stabilize the patient if there is a decreased level of consciousness or vomiting.
  • Perform an airway assessment and consider placing the patient in a lateral position to decrease the risk of aspiration in the event of vomiting.
  • Assess respiratory function to determine if there is a need for mechanical ventilation.
  • Administer IV crystalloid fluids for patients with evidence of volume depletion, dehydration, or shock.
  • Correct electrolytes and hypoglycemia.
• Consider patient sedation using medications (such as haloperidol) in agitated or violent patients.
• Follow-up:
  • Ensure patients are lucid and have the capacity to take care of themselves prior to discharge from the emergency department.
  • Patients with alcohol use disorder may experience alcohol withdrawal following detoxification, which can be life-threatening and present with delirium tremens and seizures.
  • Refer patients with suspected alcohol use disorder to an alcohol treatment center.