• Critical conditions include:
  • Wernicke’s disease (mental confusion, ataxia, ophthalmoplegia of CN VI)
  • Trauma – any but NB head
  • Simultaneous drug intoxication
  • Alcohol induced ketoacidosis
  • Infections – various

• 6% of all death worldwide and is the leading risk factor for disability in individuals aged 25-49 years.
• The incidence of alcohol intoxication in trauma patients admitted to the emergency department is between 24-47%.

• Acute Alcohol Intoxication (AAI):
  • Changes in behaviour – disinhibition, lethargy, aggression, euphoria, dysphoria, stupor.
  • Confusion and altered mood.
  • Memory deficits and impaired coordination.
  • Metabolic changes – hypoglycemia, hypokalemia, hypomagnesaemia, hypoalbuminemia, hypocalcemia, hypophosphatemia, lactic acidosis.
  • Muscle pain, muscle weakness, rhabdomyolysis.
  • Tachycardia, volume depletion, hypotension, hypothermia, arrhythmias.
  • Nausea, vomiting, diarrhea, abdominal pain, peptic ulcer disease.
  • Respiratory depression, cirrhosis, alcoholic hepatitis, cardiac arrest, coma, and death.
• Blood alcohol concentration that leads to these symptoms can vary depending on the individual and their rate of alcohol metabolism.
• Mimics to consider:
  • Substance use (e.g., methanol, cocaine, carbon monoxide, barbiturates, benzodiazepines).
  • Metabolic changes (e.g., elevated or decreased thyroid, glucose, calcium, sodium).
  • Seizures, trauma, stroke.
  • Infections (e.g., sepsis, meningitis, encephalitis).
  • Diabetic or alcoholic ketoacidosis.
  • Hypoxia.
• Diagnostic steps
  • Monitor vitals, hydration, nutritional status.
  • Perform neurological exam – looking for Wernicke’s.
  • Check for signs of trauma and other other toxidromes.
  • Lab studies may obtain blood alcohol levels, glucose, electrolytes.
• AAI strongly associated with an underlying alcohol use disorder, mental health disorders, domestic violence and trauma, suicide attempts (more details can be found under the in-depth review section on how to navigate this).

• Treatment is primarily supportive for AAI.
• Continue to monitor vitals, airway, breathing, circulation.
  • If patients present with severe intoxication (BAC > 0.2-0.3) and coma, they should have their airway carefully monitored and stabilization should be considered.
• Place the patient in the lateral safety position to prevent aspiration.
• Obtain IV access and administer fluids if the patient is dehydrated, hypotensive, or malnourished.
  • Anyone at risk of a nutritional deficiency should be given thiamine 100mg before glucose as Wernicke’s encephalopathy onset may be accelerated otherwise.
  • If patient is severely hypoglycemic, do not delay administration of dextrose to prepare for thiamine infusion.
  • For patients that are presenting with coma secondary to AAI, dextrose and 100 mg thiamine should be administered.
• Consider giving antidotes in the case of simultaneous drug use (e.g., naloxone for opioid use).
• Monitor for withdrawal symptoms:
  • Increased hand tremor
  • Seizures
  • Agitation
  • Nausea / vomiting
  • Insomnia
  • Hallucinations
  • Autonomic hyperactivity
• If there is a history of head trauma or mental status does not improve after examinations, obtain head CT scan.
• In cases of repeated vomiting, administer antiemetic drugs (e.g., metoclopramide).
• If patient is agitated, consider using sedatives such as haloperidol or benzodiazepines but carefully monitor due to synergistic effect that can lead to respiratory depression.
• Encourage patients to rest and hydrate.
• Consider referral for possible alcohol use disorder (see in-depth resources).
• Consider admitting patient if they present with coma or significant complications of ethanol intoxication.

In-Depth Resources

• https://emergencycarebc.ca/clinical_resource/alcohol-use-disorder-aud/
• https://emergencycarebc.ca/clinical_resource/suicide-risk-assessment/
• https://equiphealthcare.ca/files/2019/12/Top-things-support-people-Jan-15-2018-1.pdf
• http://www.bcmhsus.ca/health-professionals/clinical-professional-resources

1. Caputo F, Agabio R, Vignoli T, Patussi V, Fanucchi T, Cimarosti P, et al. Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: Position Paper of the Italian society on alcohol. Internal and Emergency Medicine. 2018 Sept 5;14(1):143–60. doi:10.1007/s11739-018-1933-8

   
   

2. Cowan E, Su MK. Ethanol intoxication in adults [Internet]. 2024 [cited 2024 Apr 16]. Available from: https://www.uptodate.com/contents/ethanol-intoxication-in-adults?search=acute+alcohol+intoxication

   
   

3. Mirijello A, Sestito L, Antonelli M, Gasbarrini A, Addolorato G. Identification and management of acute alcohol intoxication. European Journal of Internal Medicine. 2023 Feb;108:1–8. doi:10.1016/j.ejim.2022.08.013

   
   

4. Vonghia L, Leggio L, Ferrulli A, Bertini M, Gasbarrini G, Addolorato G. Acute alcohol intoxication. European Journal of Internal Medicine. 2008 Dec;19(8):561–7. doi:10.1016/j.ejim.2007.06.033