Managing the Patient with Alcohol Intoxication

Background: Acute alcohol intoxication is often identified early in a patient’s visit by behavioral changes accompanied by slurred speech, ataxia, nystagmus, or the smell of alcohol. However, evaluating and managing patients with acute alcohol intoxication in the emergency department can be challenging. Patients may be agitated or altered, hindering their initial evaluation and diagnostic workup. The situation is more dangerous given the high incidence of chronic disease, critical illness, and acute trauma. (Klein 2018)

Despite the high risk of pathology and decompensation, many patients with presumed alcohol intoxication can be evaluated and discharged without any labs or imaging. However, because of the high morbidity and mortality associated with alcohol use, patients presenting with presumed intoxication should receive a thorough and methodical evaluation with a low threshold for further workup. 

After your primary ABCs assessment, consider “D” for dextrose and check for occult hypoglycemia. Once a patient has been deemed stable, and you have addressed ABCD, begin your assessment.

Taking a History:

If your patient cannot participate in an interview due to intoxication or chemical sedation, the initial assessment will rely heavily on the physical exam. However, if (or when) the patient can talk with at least limited participation, run through a checklist of items.

• Suicidal Ideation and Homicidal Ideation (SI/HI): Alcohol use is a risk factor for suicide attempts (Suokas 1995), and individuals presenting with acute intoxication should be evaluated for SI. (Pompili 2010) However, >65% of patients who endorse suicidal ideation when intoxicated no longer endorse suicidal ideation once sober. It is reasonable to wait to consult psychiatry until clinical sobriety is achieved. (Keyes 2022)
• Auditory and Visual Hallucinations (AH/VH): The differential diagnosis for hallucinations is broad and includes medical pathology, psychiatry pathology, and transient causes such as acute drug intoxication. (Prerost 2014) In a patient with chronic alcohol use, hallucinations should prompt consideration of acute intoxication, alcoholic hallucinosis, or delirium tremens (DT). While DT is accompanied by vital sign abnormalities and findings consistent with severe alcohol withdrawal, alcoholic hallucinosis may present in a more stable patient. It may be mistaken for acute intoxication, psychiatric illness, or other occult pathology. Consider a psychiatric consult (and labs needed for psychiatric admission) or check blood work if there is a concern for concomitant underlying medical pathology as a cause of hallucinations.
  
• Trauma: Discoordination and a decreased pain response predispose individuals to trauma with lack of insight into their injuries. Brain atrophy and liver dysfunction with decreased clotting factors put patients at high risk of intracranial hemorrhage. Any report of trauma should prompt evaluation with imaging.
• Pain / Additional Complaints: Alcohol can weaken the immune system with only moderate use, predisposing individuals to pneumonia, soft tissue infections, and sepsis. (Barr 2016, Trevejo-Nunez 2015) Patients are at high risk of bleeding from the GI tract due to clotting factor impairment or devastating hemorrhage from esophageal varices in the setting of portal hypertension. (Osna 2017) Alcohol can contribute to pancreatitis, CKD, epilepsy, and countless other conditions. Have a low threshold to work up additional complaints. 
  
• Alcohol use before arrival: If an altered patient denies alcohol use, this should prompt immediate concern for alternative underlying pathologies such as electrolyte abnormalities, uremia, hyperammonemia, infection, or intracranial pathology. If there is a strong clinical suspicion of alcohol use, but a patient denies drinking, it is reasonable to send an alcohol level. However, a positive alcohol level does not exclude underlying pathology. If the diagnosis of isolated acute alcohol intoxication is not patently obvious, patients should undergo a broad workup.

The Physical Exam:

The most crucial part of the assessment of a patient with acute alcohol intoxication is the physical exam. It should resemble a trauma evaluation, including a thorough primary and secondary exam with full exposure. Ensure that the patient has stable vitals, appears comfortable, and is not diaphoretic (which could be concerning for withdrawal, cardiac event, or underlying medical pathology). 

• Airway, breathing, and circulation: Assess and reassess the ABCs and evaluate for an intact airway, including a clear oropharynx without active emesis or excessive secretions, normal respiratory rate with bilateral breath sounds, and good pulses.
• Assess for head and neck trauma: A 2014 study out of NYU/Bellevue Hospital found that 39% of patients who frequented the emergency department with acute alcohol intoxication had a moderate to severe brain injury over a three-year period. (Hamilton 2014) Patients with alcohol intoxication have an extremely high risk of intracranial pathology, and the threshold for obtaining head imaging should be very low. Any facial or scalp lacerations, abrasions, ecchymosis, or deformities should prompt imaging.  Assess for blood in the nares or signs of basal skull fracture, including battle signs, raccoon eyes, or hemotympanum. Do a pupillary exam and ensure pupils are mid-range, equal, round, and reactive to light. 
• The extremities and torso: Ensure that a patient, at minimum, moves all four extremities to noxious stimuli, has good distal pulses, and has a normal passive range of motion. Check that clavicles are intact and that there are no obvious rib fractures or spinal step-offs. Remove all clothing and do a full skin exam. Look for skin ecchymosis, abrasions, lacerations, erythema, temperature differentials, petechiae, or lower extremity edema. Work up appropriately.
• Wernicke’s Encephalopathy (WE): WE is present in over 12% of patients with alcohol use disorder (AUD) (Donnino 2007) and is misdiagnosed in up to 80% of patients (Sechi 2007), and carries a mortality rate of 10-17%. (Sanvisens 2017) Consideration of WE when conducting a physical exam can be lifesaving. The diagnosis can be made if a patient is malnourished (as many patients with AUD are) and has any persistent unexplained finding of ocular symptoms (i.e., nystagmus or sixth nerve palsy), ataxia or mental status change. (Caine 1997) For high suspicion for WE, initiate high dose thiamine (500mg IV TID) and admit for treatment.

Reassessment:

After the initial history and physical exam, reassess the patient roughly every hour. Be fast but thorough. Recheck ABCs. Look for a new battle sign, developing flank ecchymosis, or other evolving pathology. Importantly, ensure the patient follows an expected clinical course for acute intoxication. Document at each reassessment and always have a low threshold to add on a CTH or labs if the patient is not progressing appropriately.

Generally, patients are ready for discharge when their workup is complete, and they are “clinically sober.”  Clinical sobriety involves being: 

• AOx4 (person, place, time, circumstance)
• able to hold a conversation with minimal prompting, and
• able to walk with an independent steady gait.

Patients must also have a benign physical re-exam, have no additional complaints, and be able to tolerate PO. Note that a patient who drinks daily might be “clinically sober” even when their alcohol level is still elevated. However, in certain practice settings, patients are likely to drive upon discharge. In these cases, it is important to ensure that a patient has a safe discharge plan that does not involve driving while legally intoxicated. Also, be cognizant that getting an alcohol level might be tied to a specific length of stay.  As always, document clinical sobriety before discharge.

References:

1. Klein L, Cole J, Driver B, Battista C, Jelinek R, Martel M. Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 2018 Mar;71(3):279-288. PMID: 28844504
   
2. Suokas J, Lonnqvist J. Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms. Acta Psychiatr Scand. 1995 Jan;91(1):36-40. PMID: 7754784
3. Pompili M, Serafini G, Innamorati M, Dominici G, Ferracuti S, Kotzalidis GD, Serra G, Girardi P, Janiri L, Tatarelli R, Sher L, Lester D. Suicidal behavior and alcohol abuse. Int J Environ Res Public Health. 2010 Apr;7(4):1392-431. Epub 2010 Mar 29. PMID: 20617037
4. Keyes D, Talarico P, Hardin B, Molter A, Lee H, Valiuddin H, Moore B. Suicidal ideation and sobriety: Should acute alcohol intoxication be taken into account for psychiatric evaluation? Alcohol Clin Exp Res. 2022 Jul;46(7):1306-1312. Epub 2022 Jun 9, PMID: 35581530
5. Prerost FJ, Sefcik D, Smith B. Differential Diagnosis of Patients Presenting with Hallucinations. Osteopathic Family Physician. 2014 Mar;6(2). 
6. Barr T, Helms C, Grant K, Messaoudi I. Opposing effects of alcohol on the immune system. Prog Neuropsychopharmacol Biol Psychiatry. 2016 Feb 4;65:242-51. Epub 2015 Sep 14. PMID: 26375241
7. Trevejo-Nunez G, Kolls JK, de Wit M. Alcohol Use As a Risk Factor in Infections and Healing: A Clinician’s Perspective. Alcohol Res. 2015;37(2):177-84. PMID: 26695743
8. Osna NA, Donohue TM Jr, Kharbanda KK. Alcoholic Liver Disease: Pathogenesis and Current Management. Alcohol Res. 2017;38(2):147-161. PMID: 28988570
9. Hamilton BH, Sheth A, McCormack RT, McCormack RP. Imaging of frequent emergency department users with alcohol use disorders. J Emerg Med. 2014 Apr;46(4):582-7. Epub 2014 Jan 10. PMID: 24412058
10. Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007 Dec;50(6):715-21. Epub 2007 Aug 3. PMID: 17681641
11. Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007 May;6(5):442-55. PMID: 17434099.
12. Sanvisens A, Zuluaga P, Fuster D, Rivas I, Tor J, Marcos M, Chamorro AJ, Muga R. Long-Term Mortality of Patients with an Alcohol-Related Wernicke-Korsakoff Syndrome. Alcohol Alcohol. 2017 Jul 1;52(4):466-471. PMID: 28340112.
13. Caine D, Halliday GM, Kril JJ, Harper CG. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry. 1997 Jan;62(1):51-60. PMID: 9010400

Guest Post By:

Lara Silverman, MD
PGY-3, Emergency Medicine Resident
Mount Sinai Hospital, New York, New York

Trevor Pour, MD
Assistant Professor of Emergency Medicine
Assistant Program Director of Emergency Medicine
Mount Sinai Hospital, New York, New York

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami), and Marco Propersi, DO (Twitter: @marco_propersi)