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
      • 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 GABAA-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-agonist (clonidine):
      • 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
  • 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 not to exceed 25 mg/min:
    • May give Fosphenytoin at 15–20 mgPE/kg at a maximum rate of 150 mgPE/min
  • Propofol: 25-75 μ/kg/min IV (loading dose) then 5–50 μg/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 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 (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

  • D’Onofrio G, Degutis LC. Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review. Acad Emerg Med. 2002;9:627–638.  [PMID:12045080]
  • Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of Alcohol Withdrawal Delirium: An Evidence-based Practice Guideline. Arch Int Med. 2004;164:1405–1412.
  • McKeon A, Frye MA, Delanty N. The Alcohol Withdrawal Syndrome. J Neurol Neurosurg Psychiatry. 2008;79(8):854–862.  [PMID:17986499]
  • Nelson LS, Gold JA. Chapter 78. Ethanol Withdrawal. In: Hoffman RS, Nelson LS, Goldfrank LR, et al., eds. Goldfrank's Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill; 2011.
  • 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.

See Also

  • Ethylene Glycol, Poisoning
  • Methanol, Poisoning

Codes

ICD-9

  • 303.00 Acute alcoholic intoxication in alcoholism, unspecified
  • 305.00 Alcohol abuse, unspecified
  • 980.0 Toxic effect of ethyl alcohol

ICD-10

  • Toxic effect of ethanol, accidental (unintentional), init
  • Toxic effect of ethanol, accidental (unintentional), subs
  • Toxic effect of ethanol, accidental (unintentional), sequela
  • Alcohol abuse with intoxication, unspecified
  • Toxic effect of ethanol

SNOMED

  • 82782008 Toxic effect of ethyl alcohol (disorder)
  • 216633005 accidental poisoning by alcoholic beverages (disorder)
  • 25702006 Alcohol intoxication (disorder)

Authors

Timothy J. Meehan


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