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Emergency and Acute Medicine – Alcohol Poisoning
BASICS DESCRIPTION
Alcohol is the most commonly abused recreational agent among emergency department patients. Alcohol is frequently associated with traumatic injuries.
ETIOLOGY
Alcohol intoxication: Directly depresses CNS function. Blood alcohol levels drop by 15–40 mg/dL/hr depending on individual variables and chronicity of alcohol use.
Alcohol withdrawal: Occurs in chronic alcohol abusers after partial or complete alcohol abstinence. May occur despite a serum alcohol level >100 mg/dL (e.g., “intoxicated”). Primarily due to loss of chronic CNS inhibition: profound CNS excitation with increased catecholamine release and adrenergic tone.
DIAGNOSIS SIGNS AND SYMPTOMS
Acute alcohol intoxication: CNS effects occur on a spectrum including relaxation, euphoria, sedation, memory loss, impaired judgment, ataxia, slurred speech, obtundation, or coma. May also cause GI upset.
Alcohol withdrawal syndrome:
Early or minor withdrawal: <8 hr after last drink—symptoms of hangover, headache, nausea />omiting. At 12 hr—mild tremors/anxiety, anorexia, nausea, vomiting, weakness, myalgias, vivid dreams/nightmares.
12–36 hr after last drink—irritability/agitation, tachycardia/HTN, tremors in hands and tongue.
24–48 hr—alcoholic hallucinosis with visual hallucinations most common (bug crawling) and auditory hallucinations (buzzing, clicks).
Alcohol withdrawal seizures: 8–12 hr after last drink; brief, spontaneously abating tonic–clonic activity; often precede delirium tremens (DTs).
Late or major withdrawal: ≥48 hr after last drink—DTs characterized by clouded consciousness, confusion, agitation/combativeness, tachycardia/HTN, hyperpyrexia, and diaphoresis.
History is often provided by EMS, family, or friends. Beware the “frequent flyer” in the ED, as other causes of AMS may coexist, including hepatic encephalopathy, postictal state, hypoglycemia, head injury, or intracranial bleeding.
Physical exam: Vital signs—acute intoxication usually normal or depressed; withdrawal usually elevated. Mental status—acute intoxication presents with somnolence or coma; withdrawal presents with hyperalert agitation. Signs of hepatic injury include jaundice, icterus, spider angiomata, asterixis, and hepatomegaly. Signs of malnutrition include alopecia, poor dentition, poor muscle mass, abdominal wasting, and temporal wasting.
ESSENTIAL WORKUP
Obtain accurate alcohol ingestion and abstinence history. Investigate life-threatening causes of seizures including hypoglycemia (rapid bedside glucose), intracranial hemorrhage, CNS infection, and electrolyte abnormalities. Evaluate for occult trauma. Monitor vital signs frequently; hyperthermia predicts poorer outcomes.
DIAGNOSTIC TESTS & INTERPRETATION
Labs: Alcohol level if abnormal mental status; urine toxicology for coingestants; electrolytes, BUN, creatinine, glucose; CBC; magnesium, calcium, phosphate; PT/INR if coagulopathy suspected; LFTs if liver disease suspected; ammonia if hepatic encephalopathy suspected; urinary ketones or serum acetone if alcoholic ketoacidosis suspected.
Imaging: CT head if mental status is disproportionate to alcohol level, head trauma suspected, focal neurologic findings, signs of increased ICP, new-onset seizure, or deterioration. EEG differentiates alcohol withdrawal seizures from epilepsy. Chest radiograph if aspiration or pneumonia suspected.
DIFFERENTIAL DIAGNOSIS
Acute intoxication: Hypoglycemia, CO₂ narcosis, mixed-drug overdose, ethylene glycol, methanol, isopropanol poisoning, hepatic encephalopathy, psychosis, severe vertigo, psychomotor seizure.
Withdrawal/seizures: Sedative–hypnotic withdrawal, carbon monoxide poisoning, isoniazid toxicity, amphetamines, anticholinergics, cocaine.
Secondary seizure disorders: Infection, meningitis, encephalitis, brain abscess, trauma, intracranial hemorrhage, CVA, tumor, anticonvulsant noncompliance, thyroid disease.
TREATMENT PRE HOSPITAL
Administer benzodiazepines for seizures. Give naloxone, oxygen, and dextrose for comatose patients. Intubate as needed for airway protection. Immobilize cervical spine if trauma suspected.
INITIAL STABILIZATION/THERAPY
Airway, breathing, circulation (ABCs). Evaluate cervical spine. Initiate IV rehydration with 0.9% NS, then D5 0.45 NS. Administer naloxone, thiamine, and glucose (or Accu-Chek) if altered mental status. Treat seizures with benzodiazepines, often requiring large doses.
Pediatric considerations: Young children have decreased hepatic glycogen reserves and may not mount an adequate glucose response. Rapid bedside glucose is essential; administer dextrose with D5 (10 mL/kg), D10 (5 mL/kg), or D25 (2 mL/kg) depending on age and size.
ED TREATMENT/PROCEDURES
Alcohol intoxication: IV rehydration and correction of electrolyte abnormalities including magnesium, potassium, folate, thiamine, and multivitamins.
Alcoholic ketoacidosis: Aggressive rehydration with D5 0.9 NS; exclude other causes of anion-gap metabolic acidosis.
Alcohol withdrawal syndrome: Use CIWA-Ar scale to assess severity and guide symptom-triggered therapy. Benzodiazepines are first-line; large, frequent doses may be required. Phenobarbital may be used for severe or refractory withdrawal. Propofol is indicated for intubated patients with refractory seizures. β-blockers and α-agonists may normalize vital signs but do not treat CNS complications. Phenytoin is not indicated unless seizures are unrelated to withdrawal.
MEDICATION
Dextrose: D50W 1 amp (50 mL or 25 g); peds D25W 2–4 mL/kg IV.
Diazepam: 5–10 mg IV q5–10 min until calm.
Lorazepam: 0.5–4 mg IV/IM q5–10 min until calm.
Naloxone: 0.4–2 mg IV/IM (peds 0.1 mg/kg).
Phenobarbital: 10–20 mg/kg IV loading dose.
Phenytoin: 15–18 mg/kg (max 25 mg/min); fosphenytoin 15–20 mgPE/kg.
Propofol: 25–75 µg/kg/min loading, then 5–50 µg/kg/min maintenance.
Thiamine: 100 mg IV/IM (peds 50 mg).
FOLLOW-UP DISPOSITION
Admission criteria: Uncontrolled seizures or withdrawal, hepatic failure, infection, dehydration, malnutrition, cardiovascular collapse, dysrhythmia, trauma, hallucinations, abnormal vital signs, severe agitation, Wernicke encephalopathy, confusion, or delirium.
Discharge criteria: Clinically sober and seizure-free for 6 hr with negative workup if first seizure.
FOLLOW-UP RECOMMENDATIONS
Substance abuse referral for patients with recurrent alcohol intoxication or use.
PEARLS AND PITFALLS
Do not attribute AMS solely to alcohol in chronic users. Serum alcohol should fall by 15–40 mg/dL/hr; lack of improvement warrants further evaluation. Inadequate benzodiazepine dosing is common—massive doses may be required. Hypoglycemia frequently mimics intoxication and is common in chronic alcoholics and children.
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