Alcohol Intoxication

Aka: Alcohol Intoxication, Drunkenness, Inebriation, Alcohol Poisoning, Alcohol Overdose, Ethanol Intoxication, Ethanol Poisoning

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II. Definitions

  1. Alcohol Intoxication
    1. Excessive ingestion (or Overdose) of Alcohols resulting in an acute brain syndrome
    2. Alcohol Intoxication, although typically due to Ethanol ingestion, may include toxic or parent Alcohols
    3. Toxic Alcohols in Methanol, Ethylene Glycol and Isopropyl Alcohol

III. Epidemiology

  1. Ethanol ingestion in children age < 6 years accounts for thousands of U.S. Poison Control contacts per year
    1. Most exposures (90%) are related to home products containing Ethanol (see below)

IV. Physiology

  1. See Ethanol

V. Sources

  1. Alcoholic Beverages (Ethanol): Standard Drink Equivalents (12 grams of Alcohol)
    1. Can of 4.5% Beer (12 ounces)
    2. Glass of 12.9% wine (5 ounces)
    3. Glass of 40% or 80-proof liquor (1.5 ounces)
  2. Other Ethanol sources (esp. Accidental Ingestion in children)
    1. Aftershave, Colognes and Perfumes
    2. Cosmetics
    3. Cough Syrup
    4. Glass Cleaner
    5. Hand Sanitizer
    6. Kombucha
    7. Mouthwash
    8. Vanilla Extract
  3. Toxic Alcohols
    1. See Methanol Poisoning
    2. See Ethylene Glycol Poisoning
    3. See Isopropyl Alcohol Poisoning

VI. Differential Diagnosis

  1. See Altered Level of Consciousness Causes
  2. Closed Head Injury (e.g. acute Subdural Hematoma)
  3. Meningitis or Encephalitis
  4. Wernicke's Encephalopathy
  5. Hepatic Encephalopathy
  6. Gastrointestinal Bleeding (Esophageal Varices, Peptic Ulcer Disease)
  7. Substance
    1. See Unknown Ingestion
    2. See Drugs of Abuse
    3. See Date Rape Drug

VII. Signs: Ethanol Intoxication

  1. See Methanol Poisoning
  2. See Ethylene Glycol Poisoning
  3. See Isopropyl Alcohol Poisoning
  4. Slurred Speech
  5. Impaired Judgement and risky behavior
  6. Disorientation
  7. Ataxia
  8. Nystagmus
  9. Bradycardia
  10. Hypothermia
  11. Diuresis (may result in Hypovolemia and Hypotension)
  12. Respiratory Depression
  13. Lethargy to Coma
  14. Hypoglycemia
    1. Seen in younger children, and when Alcohol is combined with Sulfonylureas

VIII. Evaluation: General

  1. See Unknown Ingestion
  2. See Alcoholism
  3. See Alcohol Withdrawal
  4. Careful examination for signs of Trauma, infection
  5. Alcohol level is not needed in routine cases of Alcohol Intoxication
    1. Use Clinical Sobriety and decision making capacity to determine observation and disposition
    2. Obtain Blood Alcohol Level when cause of altered status is unclear
      1. See Altered Level of Consciousness and Unknown Ingestion
      2. Evaluate other causes (e.g. Methanol, Ethylene Glycol) when Blood Alcohol is too low to explain status
      3. Consider Head CT (esp. if external signs of Trauma)
  6. Evaluate for risk of Alcohol Withdrawal
    1. Daily Alcohol use?
    2. Last Alcohol intake?
    3. Prior Alcohol Withdrawal, Delirium Tremens, Seizures, hospitalizations?
  7. Markers of Critical Illness in an intoxicated patient
    1. Hypoglycemia
    2. Abnormal Vital Signs
    3. Need for Chemical Restraint
    4. Klein (2017) Ann Emerg Med +PMID:28833504 [PubMed]

IX. Evaluation: Children with Alcohol Poisoning

  1. See Unknown Ingestion
  2. Signs
    1. Nausea or Vomiting
    2. Altered Level of Consciousness (e.g. stupor, coma)
    3. Ataxia
    4. Hypoglycemia (young children)
    5. Hypothermia (young children)
  3. Toxic dose of Ethanol
    1. Young children: 0.4 ml/kg
    2. Peak serum level >50 mg/dl
  4. Obtain broad-based toxicology evaluations
    1. Bedside Glucose (Hypoglycemia is common)
    2. Venous Blood Gas
    3. Basic metabolic panel
      1. Evaluate for Metabolic Acidosis with Anion Gap (Toxic Alcohols)
    4. Blood Alcohol Level
    5. Acetaminophen level
    6. Salicylate level
    7. Urine Drug Screen
    8. Serum Osmolality
      1. Calculate Osmolal Gap (Toxic Alcohols)
    9. Urinalysis
      1. Calcium oxalate crystals may be seen in Ethylene Glycol Poisoning

X. Course

  1. Blood Alcohol decreases 0.02 g/dl/h in non-Alcoholics
  2. Blood Alcohol decreases 0.03 g/dl/h in Alcoholics and in children

XI. Management: Acute or chronic Alcohol Intoxication in chronic Alcoholism

  1. See Alcohol Withdrawal for labs, supplementation (e.g. Thiamine, Folate, MVI)
  2. See Alcoholic Ketoacidosis
  3. Prevent Alcohol Withdrawal
    1. Admit to Alcohol Detoxification
      1. Indicated if patient is interested in sobriety and Alcohol Abuse treatment
    2. Alcohol Withdrawal management if signs present
      1. Re-evaluate closely (every 1-2 hours)
      2. Early Benzodiazepines
    3. Early discharge when patient is Clinically Sober (not based on Alcohol level)
      1. See Clinical Sobriety
  4. Manage acute exacerbations of
    1. Wernicke's Encephalopathy
    2. Alcoholic Hepatitis or Cirrhosis
    3. Acute Pancreatitis
    4. Upper Gastrointestinal Bleeding (Esophageal Varices, Peptic Ulcer Disease)
    5. Malnutrition

XII. Management: Acute Alcohol Intoxication in non-Alcoholic adults

  1. See Altered Level of Consciousness
  2. Obtain Alcohol level to help confirm Alcohol as cause of altered status
  3. Supportive care
    1. Manage airway as needed (aspiration risk)
    2. Fluid Resuscitation as needed

XIII. Management: Children (Acute Poisoning)

  1. See Alcohol Poisoning
  2. Hypoglycemia (due to impaired Gluconeogenesis)
    1. Monitor Serum Glucose every 1-2 hours after ingestion until Blood Alcohol Level 0 for at least 1-2 hours
  3. Altered Level of Consciousness with CNS depression
    1. Exaggerated response to a given Blood Alcohol Level when compared with adults
  4. Respiratory depression
  5. References
    1. Claudius and Levine in Herbert (2012) EM:RAP 12(5): 6

XIV. Complications

  1. Fatal motor vehicle crashes
  2. Behavior problems affecting school, work and home
  3. Gateway to other Substance Abuse
  4. Risky sexual behavior

XV. References

  1. Mason and Armenian in Herbert (2018) EM:Rap 18(3): 18
  2. Rodriguez (2022) Crit Dec Emerg Med 36(4): 26-31

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