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. 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

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