Alcohol Intoxication

Key Points

• Naive alcohol users are impaired at lower levels.

• Always give thiamine to alcoholic patients.

• Urine toxicology is frequently helpful for concomitant drug use.

Alcohol intoxication is frequently seen as a component of trauma, domestic violence, or suicide attempts (McGinnis and Foege, 1993). The degree of intoxication is determined by the amount of alcohol ingested, the duration of the ingestion, and the patient's tolerance, if any, for the alcohol. Subtle effects occur at levels of 20 mg/dL and include mild euphoria, mild impairment of coordination, and mood alterations. At 80 to 100 mg/dL, delayed reaction times and slurred speech may be noted. This 80-mg/dL level is generally accepted as an unsafe level for motor vehicle operation. Between 100 and 200 mg/dL, ataxia, grossly slurred speech, and incoordination occur. As the level climbs to 300 mg/dL, the ataxia becomes more marked, and drowsiness, lethargy, and vomiting may occur. In naive drinkers, levels above 400 mg/dL are associated with coma, respiratory depression, hypothermia, and death from central nervous system (CNS) depression, loss of airway integrity, or pulmonary aspiration. Chronic alcoholics will have different tolerance responses than those just listed and may be in severe withdrawal at substantial levels.

Alcohol-induced coma can be managed by protecting the airway and performing basic resuscitation, if necessary. The patient should be placed in a warm protective environment, with careful monitoring of vital signs. Gastric emptying is rarely helpful because of the rapid absorption of alcohol, but it may be considered if the ingestion has occurred within 60 minutes. Alcohol is eliminated mostly by hepatic metabolism, which follows zero-order kinetics. The rate does not change with changes in the alcohol blood level. Fructose can enhance elimination but is not typically used. In extreme cases, hemodialysis may be effective in reducing the level quickly. Activated charcoal does not efficiently absorb ethanol but may be given if other toxins have been ingested (Mayo-Smith, 2009).

Thiamine and glucose should always be administered, because chronic alcoholism is associated with hypoglycemia and thiamine deficient states such as Wernicke's encephalopathy (mental confusion, cranial nerve palsies, ataxia). Thia-mine should be given immediately before or with glucose to prevent hypoglycemia because glucose is metabolized with the enzyme thiamine pyrophosphorylase. The physician should look for additional drug use in all patients because the effects of other drugs may be obscured by the obvious alcohol intoxication (Mayo-Smith, 2009). A urine toxicology screen may be positive for concomitant intoxicants.

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