EM@3AM – Alcohol Intoxication

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 23-year-old male presents to the emergency department, escorted by law enforcement. According to an accompanying officer, the patient was apprehended thirty minutes prior to arrival following a physical altercation at a local drinking establishment.

VS: HR 119, BP 122/78, RR 12, T 99.5 Oral, SpO2 98% on room air

During your interview, the patient clings to the gurney for support, muttering profanities amidst appropriate responses to your line of questioning. After a physical examination, remarkable for a fight bite at the base of the right 5th metacarpal, the patient retches, unleashing nearly a pint of non-bloody, non-bilious emesis.

What do you suspect as a diagnosis? What’s the next step in your evaluation and treatment?


Answer: Alcohol Intoxication1-7

  • Definition: Although variable, state legislation typically defines alcohol intoxication as a blood alcohol concentration (BAC) of 80-100 mg/dL (0.08-1.0% BAC).1
  • Presentation:
    • Ethanol functions as CNS depressant (enhancing GABA inhibitory action and antagonizing NMDA glutamate receptors).As ethanol absorption and elimination depend on a number of factors including weight, gender, the presence or absence of gastric contents, the chronicity of alcohol use, etc., patients may present with with a variety of symptoms (e.g. loss of fine motor control, respiratory depression, altered mental status, coma, etc.).1
      • One specific presentation worth mentioning is Wernicke’s encephalopathy characterized by ocular abnormalities (nystagmus, CN palsies), ataxia, and altered mental status.
    • Ethanol consumption also stimulates the release of highly acidic, low pepsin gastric contents, which may result in GI upset. Concentrated ethanol (> 40% by volume) acts as a direct GI irritant often leading to gastritis.3
  • Evaluation:1
    • Address ABCs and intervene as appropriate.
    • Alcohol intoxication should be viewed as a diagnosis of exclusion. If and when able, perform a thorough history. Patients should be screened for alcohol abuse and questioned specifically regarding the time of most recent ingestion (anticipation of withdrawal). Physical examination should include a complete neurological exam.
      • Consider alternative etiologies of altered mental status: AEIOU TIPS => http://www.emdocs.net/em3am-altered-mental-status/
      • Laboratory Studies => Guided by the differential diagnosis.
        • Monitor blood glucose.
        • A BAC may be considered if the diagnosis is in doubt.
        • If suspicion of chronic alcohol use/abuse: consider CMP (electrolytes) +/- thiamine supplementation.
  • Treatment:
    • Supportive care: electrolyte repletion may be required. Fluid resuscitation if hypovolemic. Glucose supplementation if required. Anti-emetics.
      • For the majority of ED patients, alcohol will be eliminated at approximately 20 mg/dL/hr regardless of initial alcohol level or chronic alcohol use.4
      • IVF therapy has no effect on blood ethanol clearance.5,6
  • Disposition:
    • Patients who are not at risk of airway or breathing complications, and are ambulatory and clinically sober may be discharged (preferentially to the care of a sober adult).
  • Pearls:
    • Approximately 7.8 million annual ED visits are due to alcohol related diseases and diagnoses.1
    • Less than 10% of patients present with the Wernicke’s triad.7
    • If a BAC is drawn, a calculation of sober time may be performed as follows: (BAC (mg/dL) – legal limit) / 20 mg/dL/hr = time to sobriety in hours1

 

References:

  1. Lank P, Kusin S. Ethanol and Opiod Intoxication and Withdrawal. In: Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, Saunders Elsevier. 2013; 1314-1322.e1.
  2. Kumar S, Porcu P, Werner D, et al. The role of GABA(A) receptors in the acute and chronic effects of ethanol: a decade of progress. Psychopharmacology. 2009; 205: 529-564.
  3. Levine B. Physical and Chemical Injuries. In: Principles of Forensic Toxicology. Washington DC, AACC Press. 2003; 163.
  4. McDonald A, Wang N, Camargo C. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Arch Intern Med. 2004; 164: 531-537.
  5. Brennan D, Betzelos S, Reed R, et al. Ethanol elimination rates in an ED population. Am J Emerg Med. 1995; 13: 276-280.
  6. Li J, Mills T, Erato R. Intravenous saline has ne effect on blood ethanol clearance. J Emerg Med. 1999; 17(1):1-5.
  7. Perez S, Keijzers G, Steele M, Byrnes J, et al. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patient in the emergency department: a randomized controlled trial. Emerg Med Australas. 2013; 25(6): 527-534. 

For Additional Reading:

Review of Alcohol and Opiod Withdrawal:

Drug Withdrawal: Pearls and Pitfalls

 Documentation of a Neurologic Examination:

Emergency Medicine Documentation Pearls and Pitfalls: the Neuro Exam

One thought on “EM@3AM – Alcohol Intoxication”

  1. Reference 7 ( RCT of fluids vs observation) strongly suggest that IV fkuids have no effect on intoxication, symptoms, alcohol level or length of stay.

    Supportive care could be just observation until they are safe to go with another responsible adult.

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