Alcohol Poisoning

Basics

Description

Alcohol 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 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
  - 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

Early or minor withdrawal:
- <8 hr after last drink:
  - Symptoms of a hangover
  - Headache
  - Nausea/vomiting
- 12 hr after last drink:
  - 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 after last drink: Alcoholic hallucinosis:
  - Visual hallucinations most common (bug crawling)
  - Auditory hallucinations (buzz, clicks)
  - Present in minor and major withdrawal
- Alcoholic withdrawal seizures:
  - 8–12 hr after last drink
  - Brief, spontaneously abating tonic–clonic activity
  - Precedes delirium tremens (DTs)
Late alcohol withdrawal or major withdrawal:
- 48 hr after last drink
- DTs:
  - Clouded consciousness and delirium
  - Confusion/disorientation
  - Agitation/combativeness
  - Tachycardia/HTN
  - Hyperpyrexia
  - Diaphoresis

History

Often provided by EMS, family, or friends
Beware the “frequent flyer” in the ED:
- Can sometimes have other 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 angiomata
- 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

Alcohol 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
- 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

Pre Hospital

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 if seizing (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 GABA_A-mediated transmission
  - Anticonvulsant effect
  - Large, frequent doses required with significant withdrawal
  - May halt progression to DTs
- Barbiturates (phenobarbital):
  - Useful if severe withdrawal or DTs refractory to large doses of benzodiazepines
- 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: D₂₅W 2–4 mL/kg) 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: 10–20 mg/kg IV (loading dose) monitor for respiratory depression
Phenytoin: 15–18 mg/kg IV not to exceed 25 mg/min:
- May give fosphenytoin at 15–20 mgPE/kg IV at a maximum rate of 150 mgPE/min
Propofol: 25–75 μ/kg/min IV (loading dose) then 5–50 mcg/kg/min (maintenance dose)
Thiamine (vitamin B₁): 100 mg (peds: 50 mg) IV or IM

Ongoing Care

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, 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 first 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 (e.g., 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 Reading

Allison MG, McCurdy MT. Alcoholic metabolic emergencies. Emerg Med Clin N Am. 2014;32(2):293–301.
Gold JA, Nelson LS. Ethanol withdrawal. In: Hoffman RS, Nelson LS, Goldfrank LR, et al., eds. Goldfrank's Toxicologic Emergencies. 10th ed. New York: McGraw-Hill; 2011.
Jesse S, Brathen G, Ferrara M, et al. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurol Scand. 2017;135(1):4–16.
Klein LR, Driver BE, Miner JR, et al. Emergency department length of stay for ethanol intoxication encounters. Am J Emerg Med. 2018;36(7):1209–1214.
Pitzele HZ, Tolia VM. Twenty per hour: Altered mental state due to ethanol abuse and withdrawal. Emerg Med Clin N Am. 2010;28:683–705.
Yip L. Ethanol. In: Hoffman RS, Nelson LS, Goldfrank LR, et al., eds. Goldfrank's Toxicologic Emergencies. 10th ed. New York: McGraw-Hill; 2011.