Neurology Book



Clinical Sobriety

Aka: Clinical Sobriety, Clinically Sober
  1. Signs: Clinical Sobriety
    1. Eating drinking
    2. Walking without Ataxia, unsteady gait
    3. Baseline mental status
    4. Appropriate decision making
  2. Labs
    1. Blood Alcohol Level
      1. Legal limit in all U.S. states: 0.08% (80 mg/dl)
      2. Rate of Alcohol metabolization
        1. Non-chronic drinkers: 0.02 g/dl/h (20 mg/dl/h)
          1. Blood Alcohol 0.16% (160 mg/dl) will require 4 hours to fall below 0.08% (80 mg/dl)
        2. Chronic heavy drinkers: 0.03 g/dl/h (30 mg/dl/h)
          1. Blood Alcohol 0.16% (160 mg/dl) will require 3 hours to fall below 0.08% (80 mg/dl)
  3. Precautions
    1. Blood Alcohol correlates poorly with signs of Intoxication
      1. At a given Blood Alcohol Level, chronic drinkers appear less intoxicated than occasional drinkers
        1. Olson (2013) Alcohol Alcohol 48(3): 386-9 [PubMed]
      2. Signs of Intoxication may occur at Blood Alcohol Levels well below limits
        1. Phillips (2015) Inj Prev 21(e1): e28-35 +PMID+24397929 [PubMed]
      3. Intoxication may be be compounded by coingested substances
        1. Other recreational drugs may result in greater Impairment than the BAL implies
    2. Blood Alcohol Level does not need to be drawn to document sobriety for discharge
      1. Sobriety for discharge (not driving) may be determined clinically
      2. If Blood Alcohol Level is obtained, patient is considered intoxicated above 0.08%
      3. Consider limiting Blood Alcohol to cases where cause of Intoxication is unclear
      4. Waiting for Blood Alcohol to fall to legal limit in chronic drinkers may result in Alcohol Withdrawal
  4. Management: Disposition
    1. Document the functional abilities and limitations of the patient (see exam above)
      1. A legal Blood Alcohol alone is not sufficient to declare sobriety
      2. As noted above, Clinical Sobriety may be determined solely on clinical examination
    2. Clinical Sobriety by examination
      1. Discharge home
    3. Continued Intoxication
      1. Injury prior to presentation, neurologic changes or need for serial examination when sober
        1. Continued observation
      2. Improving, alert, clinical stability and no concern for missed clinical findings
        1. Continued observation OR
        2. Discharge to sober, responsible adult who remain with the patient until sober OR
        3. Transfer to detox center
    4. Leaving Against Medical Advice (AMA)
      1. Evaluate Clinical Sobriety and decision making capacity
      2. If intact decision making capacity, the patient may not be held
      3. Patients who had other ingestion requiring reversal (e.g. Opioid Overdose) they may be held to observe for recurrence
      4. If discharged Against Medical Advice, consider notifying police of concerns regarding intoxicated patient
  5. References
    1. Delaney, Ashoo, Henry and Swaminathan in Herbert (2015) EM:Rap 15(8): 5-7

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