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Updated: May 25 2023

Acute Alcohol Intoxication

  • A 22-year-old male is brought in by police after being removed forcefully from a bar. According to the police report, the patient had fallen several times during an altercation with another bar patron. In the ED, he is agitated and cannot follow questions.
  • One of the most commonly abused substances
  • Particularly dangerous when combined with stimulants (caffeine, cocaine)
  • Symptoms (in order of increasing EtOH plasma level) 
    • disinhibition
    • emotional lability
    • slurred speech
    • gait disturbances
    • blackouts
    • coma
  • Blood alcohol level
  • Pharmacologic
    • nutritional - in chronic alcoholics or if you suspect deficiency
      • thiamine
        • must give prior to glucose administration
      • folate
      • multivitamin
    • sedative-hypnotics with taper (for agitation)
      • e.g., clonidine or propranolol
      • haloperidol if severe aggression or psychosis
    • intubation - if airway loss is concern
    • withdrawal
      • long-acting benzodiazepines with taper
    • addiction
      • disulfiram
        • inhibits acetaldehyde dehydrogenase → aversive conditioning
      • naltrexone
        • decreases desire to drink
      • gabapentin
      • topiramate
        • also an anti-seizure and anti-migraine medication
Prognosis, Prevention, and Complications
  • Complications
    • Mallory-Weiss syndrome
      • repeat wretching/vomiting causes bleeding of mucosa
      • best initial step: IV fluids
      • best next step: endoscopy for diagnosis, photocoagulation, rubber band ligation for treatment
      • ultimate refractory therapy: Blakemore catheter (usually the WRONG answer)
    • Boerhaave Syndrome - esophageal perforation (repeat vomiting)
      • best next step: gastrografin swallow followed by surgical repair (after ABC's) 
    • Wernicke-Korsakoff syndrome
      • best next step: thiamine, multivitamin, IV fluids followed by glucose (order matters)
    • may require mechanical ventilation
    • much greater risk of physical harm
      • e.g., homicides, suicide, car accidents, fires, etc.
ED Management
Inpatient Management
Chronic Management
  • Prevent further ethanol intake
  • Prevent individual from harming self or others
  • Sedate patient if agitated or aggressive
  • Order urine toxicity screen
  • Stabilize vitals if necessary
  • Administer (in order)
    • thiamine and Mg2+
    • multivitamin
    •  B12/folate
    • IV fluids + dextrose
  • Begin CIWA and benzodiazepine taper if signs of withdrawal
  • Do not administer medications that lower seizure threshhold (bupropion, haloperidol)
  • Begin psychotherapy (must occur with medications)
    • individual
    • group (AAA)
  • Begin medication immediately
    • disulfiram
    • naltrexone
    • acamprosate
    • gabapentin
    • topiramate
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