Alcohol Poisoning

Basics

Description

  • Alcohol (ethanol) is the most commonly abused recreational agent among ED patients
  • Alcohol is frequently associated with traumatic injuries

Etiology

  • Alcohol intoxication:
    • Directly depresses CNS function
    • Blood ethanol levels drop by 15–30 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 ethanol level >100 mg/dL (eg, “intoxicated”)
    • Primarily due to loss of chronic CNS inhibition:
      • Profound CNS excitation
      • Increased catecholamine release and adrenergic tone

Diagnosis

Signs And Symptoms

Acute Alcohol Intoxication

  • CNS effects occur on a spectrum:
    • Relaxation
    • Euphoria
    • Sedation
    • Memory loss
    • Impaired judgment
    • Ataxia
    • Slurred speech
    • Obtundation/coma
  • May also cause GI upset

Alcohol Withdrawal Syndrome

  • Typically depend on time since last drink, and progressively worsen:
    • <8 hr after last drink:
      • Dysgeusia (“hangover”)
      • GI: Nausea +/– vomiting
      • Neuro: Headache
    • 12 hr after last drink:
      • GI: Increasing nausea/vomiting, anorexia
      • Neuro: Headache, vivid dreams/nightmares
      • Myalgias
    • 12–36 hr after last drink:
      • VS: Hyperdynamic (tachycardia, HTN)
      • GI: Symptoms persist
      • Neuro: Agitation/irritability, tremulousness
    • 24–48 hr after last drink
    • Alcoholic hallucinosis:
      • Visual hallucinations (bug crawling)
      • Auditory hallucinations (buzzing/clicking)
      • Visual > auditory
      • Present in minor and major withdrawal
    • Alcoholic withdrawal seizures:
      • As early as 8–12 hr after last drink, though typically later
      • Brief, spontaneously abating tonic–clonic activity
      • Precedes delirium tremens (DTs)
  • DTs (major withdrawal):
    • 48–72 hr after last drink
    • DTs:
      • Neuro: Delirium, tremulousness, disorientation, hallucinations
      • VS: Hyperdynamic (tachycardia, hypertension, hyperthermia)
      • Diaphoresis

History

  • Often provided by EMS, family, or friends
  • Beware the “frequent flyer” in the ED:
    • May have other alcohol-related causes of AMS:
      • Hepatic disease/encephalopathy
      • Seizures (postictal)
      • Hypoglycemia
      • Head injury or intracranial bleeding

Physical Exam

  • Vital signs:
    • Acute intoxication: Normal or depressed
    • Withdrawal: Usually elevated
  • Mental status:
    • Acute intoxication: Somnolent, obtunded, or comatose
    • Withdrawal: Hyperalert, agitated
  • Signs of hepatic injury:
    • Jaundice
    • Icterus
    • Spider angiomas
    • Asterixis
    • Hepatomegaly
  • Signs of malnutrition:
    • Alopecia
    • Poor dentition
    • Poor muscle mass
    • Abdominal wasting
    • Temporal wasting

Essential Workup

  • Obtain accurate alcohol ingestion and abstinence history
  • Investigate for life-threatening causes of seizures:
    • Hypoglycemia (get rapid bedside glucose)
    • Intracranial hemorrhage
    • CNS infection
    • Electrolyte abnormalities
  • Evaluate for occult trauma
  • Monitor all vital signs frequently:
    • Hyperthermia predicts poorer outcomes

Diagnostic Tests And Interpretation

Lab

  • Ethanol level if abnormal mental status
  • Urine toxicology panel to screen for coingestants
  • Electrolytes, BUN, creatinine, and glucose
  • CBC
  • Magnesium, calcium, and phosphate
  • PTT, PT/INR if coagulopathy suspected
  • LFTs if liver disease suspected
  • Ammonia level if hepatic encephalopathy suspected
  • Urinary ketones or serum acetone if alcoholic ketoacidosis suspected
  • Imaging
  • CT of head if:
    • Alteration in mental status is out of proportion to expected AMS based on serum alcohol level
    • Suspected head trauma
    • Signs of increased intracranial pressure or focal findings on neurologic exams
    • New-onset seizure
    • Unimproved or deteriorating level of consciousness
  • EEG differentiates alcohol withdrawal seizures from idiopathic epilepsy
  • Chest radiograph if suspected aspiration or pneumonia

Differential Diagnosis

  • Acute alcohol intoxication:
    • Hypoglycemia
    • Carbon dioxide narcosis
    • Mixed-drug overdose (benzodiazepines most commonly mimic)
    • Ethylene glycol, methanol, or isopropanol poisoning
    • Hepatic encephalopathy
    • Psychosis
    • Severe vertigo
    • Psychomotor seizure
  • Alcohol withdrawal and seizures:
    • Sedative-hypnotic withdrawal
    • Acute intoxication or poisoning:
      • Carbon monoxide
      • Isoniazid (especially if prolonged seizures not responding to standard therapy)
      • Amphetamine
      • Anticholinergic
      • Cocaine
    • Secondary seizure disorders:
      • Infection
      • Meningitis
      • Encephalitis
      • Brain abscess
    • Trauma
    • Intracranial hemorrhage
    • CVA
    • Tumor
    • Anticonvulsant noncompliance
    • Thyroid disorder

Treatment

Prehospital

  • Administer benzodiazepines for seizures
  • Give naloxone, oxygen, and dextrose for comatose individuals
  • Intubate as necessary for airway protection to prevent aspiration
  • C-spine immobilization if suspected trauma

Initial Stabilization/Therapy

  • Airway, breathing, circulation (ABCs)
  • Evaluate C-spine if suspected trauma
  • Initial IV rehydration with 0.9 NS, then D5 0.45 NS
  • Administer naloxone, thiamine, and glucose (or Accu-Chek) if altered mental status
  • Benzodiazepines for seizures (may require large doses)

Pediatric Considerations

  • Young children have decreased hepatic glycogen reserves
  • Cannot mount an appropriate response to increased glucose needs
  • Rapid bedside glucose (Accu-Chek) is ESSENTIAL:
    • Administer dextrose if indicated with D5 (10 mL/kg), D10 (5 mL/kg), or D25 (2 mL/kg) depending on age and size

Ed Treatment/Procedures

  • Alcohol intoxication:
    • Rehydrate with IV fluids
    • Correct electrolyte abnormalities:
      • Magnesium
      • Potassium
      • Folate
      • Thiamine
      • Multivitamins
  • Alcoholic ketoacidosis:
    • Aggressive rehydration with D5 0.9 NS
    • Exclude other causes of wide anion-gap metabolic acidosis
  • Alcohol withdrawal syndrome:
    • CIWA-Ar:
      • Validated scale for assessing withdrawal severity
      • Guides initial pharmacotherapy
      • Gauges response to therapy and needs for repeat dosing (“symptom-triggered” therapy)
    • Benzodiazepines are the agent of choice:
      • Cross-tolerant with alcohol
      • Increases GABAA-mediated transmission
      • Anticonvulsant effect
      • Large, frequent doses required with significant withdrawal
      • May halt progression to DTs
      • Well tolerated as outpatient therapy
    • Barbiturates (phenobarbital):
      • Useful if severe withdrawal or DTs refractory to large doses of benzodiazepines
      • May also be used as outpatient therapy
    • Propofol:
      • Agent of choice for intubated patients
      • Completely suppresses seizure activity
      • Requires intubation/ventilation
      • Caution if hypotensive
    • β-Blocker (labetalol, esmolol, or metoprolol):
      • Normalizes vital sign abnormalities
      • Does not treat CNS complications of alcohol use or withdrawal
    • α-Agonists (clonidine/dexmedetomidine):
      • Centrally acting α2-adrenergic agonists
      • Normalizes vital sign abnormalities
      • Do not treat CNS complications of alcohol use or withdrawal
    • Phenytoin:
      • Not indicated in seizures primarily due to alcohol withdrawal
      • Indicated if seizures secondary to idiopathic epilepsy, posttraumatic, or status epilepticus

Medication

  • Dextrose: D50W 1 amp: 50 mL or 25 g (peds: 1–2 mL/kg of D25W; infants: 2.5–5.0 mL/kg of D10%) IV
  • Dexmedetomidine (Precedex): 0.2–1.4 mcg/kg/hr IV continuous infusion
  • Diazepam (Valium): 5–10 mg IV q5–10min until patient calm
  • Lorazepam (Ativan): 0.5–4 mg IV/IM q5–10min until patient calm
  • Naloxone (Narcan): 0.4–2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  • Phenobarbital: 2 options
    • 10 mg/kg IV (monitor for respiratory depression)
    • 260 mg IV (loading dose) with 130 mg IV q30min as needed for symptoms (max dose 15–20 mg/kg)
  • Phenytoin: 15–18 mg/kg IV not to exceed 25 mg/min:
    • May give fosphenytoin at 15–20 mg PE/kg IV at a maximum rate of 150 mg PE/min
  • Propofol: 0.5–1 mg/kg IV (loading dose) then 5–50 mcg/kg/min (maintenance dose)
  • Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM

Follow-Up

Disposition

Admission Criteria

  • Inability to control seizures or withdrawal symptoms with oral medications
  • Hepatic failure, infection, dehydration, malnutrition, cardiovascular collapse, cardiac dysrhythmia, or trauma
  • Hallucinations, persistently abnormal vital signs, severe tremors, or extreme agitation
  • Wernicke encephalopathy
  • Confusion or delirium

Discharge Criteria

  • Clinically sober
  • Seizure free for 6 hr (with negative workup if 1st seizure)

Issues For Referral

Discuss with social worker and/or police and/or department of family services for pediatric patients

Follow-Up Recommendations

Substance abuse referral for patients with recurrent alcohol intoxication/use

Pearls And Pitfalls

  • Failure to appreciate AMS due to nonalcoholic causes in chronic alcoholics:
    • Serum levels should drop by 15–40 mg/dL/hr
    • If mental status not improving (or worsening) need to investigate further
  • Failure to adequately treat with benzodiazepines:
    • May require massive doses (eg, 200–300 mg of diazepam) to control
    • If unable to control, consider other GABAergic agents (phenobarbital, propofol)
  • Failure to appreciate hypoglycemia as a common entity in these patients:
    • Can masquerade as “intoxication”
    • Can result in poor outcomes
    • Frequently occurs in chronic alcoholics and children

Additional Readings

  1. Knight-Dunn L, Gorchynski J. Alcohol-related metabolic emergencies. Emerg Med Clin North Am. 2023;41(4):808–819  [PMID:37758425]
  2. LaHood AJ, Kok SJ. Ethanol toxicity. [Updated 2023 Jun 21]. In: StatPearls [Internet]. StatPearls Publishing; 2024.
  3. Lee CM, Dillon DG, Tahir PM, Murphy CE 4th. Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis. Acad Emerg Med. 2024;31(5):515–524. Epub 2024.  [PMID:37923363]
  4. Murphy JA, Curran BM, Gibbons WA 3rd, Harnica HM. Adjunctive phenobarbital for alcohol withdrawal syndrome: A focused literature review. Ann Pharmacother. 2021;55(12):1515–1524. Epub 2021.  [PMID:33678057]
  5. Murray BP, Kiernan EA. Physiologic effects of substance use. Emerg Med Clin North Am. 2024;42(1):69–91.  [PMID:37977754]
  6. Suen LW, Makam AN, Snyder HR, et al. National prevalence of alcohol and other substance use disorders among emergency department visits and hospitalizations: NHAMCS 2014–2018. J Gen Intern Med. 2022;37:2420–2428.  [PMID:34518978]
  7. Wolf C, Curry A, Nacht J, Simpson SA. Management of alcohol withdrawal in the emergency department: Current perspectives. Open Access Emerg Med. 2020;12:53–65.  [PMID:32256131]
  8. Yip L. Ethanol. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS, eds. Goldfrank’s Toxicologic Emergencies. 11th ed. McGraw-Hill Education; 2019.

See Also (Topic, Algorithm, Electronic Media Element)

Authors

Timothy J. Meehan