Ethanol toxicity

Background
  • Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcohol intake)

Clinical Features
Alcohol flushing reaction: before (left) and after (right) drinking alcohol.

Classic Features
  • Diminished fine motor control
  • Impaired judgement and coordination
  • Slurred speech
  • Nystagmus
  • Ataxia
  • Nausea and vomiting
  • Alcohol odor on breath
  • Respiratory depression
  • Lethargy
  • Coma

Other Features (if malnourished)

Mellanby effect
  • Impairment is greater at a given blood alcohol concentration when the level is rising than when it is falling. [1]

Differential Diagnosis

Sedative/hypnotic toxicity

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

Evaluation

Clinical diagnosis. No specific workup required when there is clear evidence of alcohol intake, but the following may be considered based on clinical picture/gestalt:

  • Fingerstick glucose (recommended as minimum workup in all patients with AMS)
  • Consider blood alcohol level (BAL) when a good history cannot be obtained or patient fails to improve as expected
    • Correlates poorly with degree of intoxication[2]
  • Maintain low threshold for imaging in intoxicated patient with signs of trauma

Management
  • Supportive care is mainstay of ED treatment and is based on clinical presentation
  • IV fluids are commonly used but do not hasten ETOH elimination or reduce length of stay[3][4]

Vitamin Prophylaxis for Chronic alcoholics
  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[5][6]

Disposition
  • Caution should be taken when BAL is measured on arrival as clinical exam cannot be used alone for discharge
  • Can be discharged once patient at baseline mental status, able to tolerate PO and ambulate without assistance

See Also

References
  1. Wang MQ, Nicholson ME, Mahoney BS, et al. Proprioceptive responses under rising and falling BACs: a test of the Mellanby effect. Percept Mot Skills. 1993 Aug;77(1):83-8.
  2. Olson KN, Smith SW, Kloss JS, et al. Relationship between blood alcohol concentration and observable symptoms of intoxication in patients presenting to an emergency department. Alcohol Alcohol. 2013 Jul-Aug;48(4):386-9. doi: 10.1093/alcalc/agt042.
  3. Perez SR, Keijzers G, Steele M. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151.
  4. Li J, Mills T, Erato R. Intravenous saline has no effect on blood ethanol clearance. J Emerg Med. 1999 Jan-Feb;17(1):1-5.
  5. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  6. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.
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