Clinical Commander

Back to dossier
tox.alcohol-intoxication.core.v1PRODUCTION
tox.alcohol-intoxication.core.v1

Acute alcohol intoxication

toxicologyacuteadult
Hard-required inputs
0 / 23
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute ethanol intoxication; distinguish from other causes of AMS — ACEP 2023

Inputs
6
Actions
0
Advance rule
Set
Advance when

Ethanol intoxication suspected based on clinical presentation (ataxia, slurred speech, disinhibition, alcohol odor) — ACEP 2023

Patient inputs (28)

GCS quantifies CNS depression depth; GCS <8 = airway-protection threshold; GCS correlates poorly with BAL in chronic drinkers — ACEP 2023

RR <12 indicates severe CNS depression; respiratory failure is the primary death mechanism in lethal intoxication — ACEP 2023

SpO2 <92% triggers supplemental O2; aspiration may cause silent hypoxia — ACEP 2023

Hypothermia common in severe intoxication due to vasodilation + environmental exposure; hyperthermia suggests co-ingestion or withdrawal — ACEP 2023

Hypotension from vasodilation + volume depletion; hypertension may suggest withdrawal or co-ingestion — ACEP 2023

Tachycardia expected from dehydration and adrenergic response; bradycardia suggests severe CNS depression — ACEP 2023

Age influences metabolism rate, complication risk, and disposition — ACEP 2023

Chronic use increases tolerance (alert at BAL 300+), raises Wernicke risk, and predicts withdrawal — NICE 2024; ACEP 2023

Time of last drink predicts peak intoxication and withdrawal onset (6-24 h after cessation) — NICE 2024

Co-ingestion of benzodiazepines, opioids, stimulants, or toxic alcohols critically changes management — ACEP 2023

History of withdrawal seizures or delirium tremens predicts severe withdrawal and need for prophylactic benzodiazepines — NICE 2024

Malnutrition increases Wernicke encephalopathy risk; thiamine deficiency prevalence 30-80% in chronic alcoholics — NICE 2024

Head trauma must be excluded in all intoxicated patients with AMS; GCS deficit may be from subdural not alcohol — ACEP 2023

BAL quantifies intoxication; >300 mg/dL = stupor in non-tolerant; >400 mg/dL = potentially lethal; tolerant drinkers may be alert at 300+ — ACEP 2023

BMP screens for hypoglycemia, metabolic acidosis (anion gap from toxic alcohols), hyponatremia, hypokalemia, hypomagnesemia — ACEP 2023

VBG assesses acid-base status; anion gap metabolic acidosis raises concern for toxic alcohol co-ingestion (methanol, ethylene glycol) — ACEP 2023

Osmolal gap >10 mOsm/kg in the setting of anion gap acidosis suggests toxic alcohol co-ingestion — ACEP 2023

Hypoglycemia is a life-threatening complication of alcohol intoxication; ethanol inhibits gluconeogenesis especially in malnourished/fasting patients — ACEP 2023; UpToDate 2026

Hypomagnesemia is common in chronic alcohol use; must correct before thiamine will be effective; hypoMg worsens seizure risk — NICE 2024

Co-ingestion screen critical; polysubstance intoxication is the norm not the exception — ACEP 2023

Acetaminophen co-ingestion screening is standard of care in all intoxicated patients — ACEP 2023

Salicylate co-ingestion screen in all AMS presentations with metabolic acidosis — ACEP 2023

ECG screens for QTc prolongation, arrhythmia, electrolyte-related changes (hypoK, hypoMg) — ACEP 2023

Weight used for BAL calculation (Widmark formula) and fluid resuscitation targets — ACEP 2023

Hypophosphatemia common in malnourished alcoholics; refeeding syndrome risk — NICE 2024

Lipase screens for alcoholic pancreatitis as cause of abdominal pain in intoxicated patients — ACEP 2023

AST/ALT/GGT/bilirubin screen for alcoholic hepatitis; AST:ALT >2:1 classic for alcohol-related liver disease — NICE 2024

Lactate elevation from tissue hypoperfusion, hepatic impairment, or thiamine deficiency (impaired pyruvate dehydrogenase) — ACEP 2023

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningrespiratory_failure
    RR <8 or SpO2 <90% with severe alcohol intoxication — ACEP 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghypoglycemia
    Glucose <60 mg/dL in intoxicated patient — ethanol inhibits gluconeogenesis — ACEP 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningwernicke_encephalopathy
    Classic triad: ophthalmoplegia (CN VI palsy) + ataxia + confusion in malnourished alcoholic — NICE 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtoxic_alcohol_co_ingestion
    Osmolal gap >10 mOsm/kg + anion gap metabolic acidosis in intoxicated patient — suspect methanol or ethylene glycol co-ingestion — ACEP 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaspiration
    Vomiting while obtunded (GCS <8) with hypoxia or CXR infiltrate — ACEP 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregcs_bal_mismatch
    GCS not improving at expected rate (20-25 mg/dL/h BAL clearance) — occult pathology suspected — ACEP 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hypothermia
    Core temperature <32C in intoxicated patient — alcohol-induced vasodilation + environmental exposure — ACEP 2023
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Supportive care: thiamine, folate, MgSO4, banana bag, glucose correction — NICE 2024; ACEP 2023
axis: supportive_carestep 1 - Thiamine BEFORE glucose — Wernicke prevention — NICE 2024
Selected step "Thiamine BEFORE glucose — Wernicke prevention — NICE 2024" — All intoxicated patients, especially chronic alcohol use or malnutrition; thiamine MUST be given BEFORE any glucose-containing fluids to prevent precipitating Wernicke encephalopathy — NICE 2024
  • thiamine
    first line
    vitamin_B1
    500 mg IV over 30 min • IV • TID for 3 days then 250 mg IV daily for 3-5 days (Wernicke prophylaxis) — NICE 2024 (max: 500 mg IV TID — NICE 2024)
    triggers: chronic_alcohol_use, malnutrition, any_intoxicated_patient_before_glucose
    CRITICAL: Thiamine MUST be given BEFORE glucose. Glucose metabolism consumes thiamine; administering glucose without thiamine can precipitate or worsen Wernicke encephalopathy. High-dose IV thiamine (500 mg) recommended over IM 100 mg as absorption is unreliable in malnourished patients — NICE 2024 CG100
    rxcui 10454

ed playbook — drug actions (5)

  1. 1. thiamine_IV_high_dose
    rxcui 10454
    500 mg IV over 30 min • IV • STAT then TID for 3 days
    trigger: Any intoxicated patient before glucose — NICE 2024
    Wernicke prevention: thiamine MUST precede glucose; 500 mg IV > 100 mg IM for bioavailability — NICE 2024
  2. 2. dextrose_50
    rxcui 4850
    25 g IV • IV • PRN for glucose <70
    trigger: Hypoglycemia AFTER thiamine given — ACEP 2023
    Correct hypoglycemia only AFTER thiamine to prevent Wernicke precipitation — NICE 2024; ACEP 2023
  3. 3. magnesium_sulfate
    rxcui 6585
    2 g IV over 1 h • IV • may repeat x1; then 1 g q6h
    trigger: Hypomagnesemia or chronic alcohol use — NICE 2024
    Mg cofactor for thiamine utilization; must correct alongside thiamine — NICE 2024
  4. 4. banana_bag
    thiamine 100 mg + folate 1 mg + MVI + MgSO4 2 g in 1 L NS • IV • daily
    trigger: Chronic alcohol use with nutritional depletion — UpToDate 2026
    Comprehensive micronutrient repletion after initial high-dose thiamine — UpToDate 2026
  5. 5. haloperidol
    rxcui 5093
    5 mg IM • IM • may repeat x1 in 30 min
    trigger: Severe agitation unresponsive to verbal de-escalation — ACEP 2023
    Preferred over benzodiazepines for agitation in intoxicated patients — ACEP 2023

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Altered mental status with alcohol on breath or witnessed heavy drinking — ACEP 2023; Witnessed binge drinking episode with progressive obtundation — ACEP 2023; Found intoxicated in public setting brought by EMS, unable to care for self — ACEP 2023.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute alcohol intoxication** (tox.alcohol-intoxication.core.v1).
Phenotype framing: Rule out toxic alcohol ingestion (methanol, ethylene glycol, isopropanol), diabetic ketoacidosis, hepatic encephalopathy, subdural hematoma, postictal state, hypoglycemia, benzodiazepine/opioid intoxication, sepsis, Wernicke encephalopathy — ACEP 2023; UpToDate 2026
Scope: Confirm acute ethanol intoxication; distinguish from other causes of AMS — ACEP 2023

No severity triggers fired against current inputs.

Plan

Regimen axis: **Supportive care: thiamine, folate, MgSO4, banana bag, glucose correction — NICE 2024; ACEP 2023** — step "Thiamine BEFORE glucose — Wernicke prevention — NICE 2024".
1. thiamine 500 mg IV over 30 min IV TID for 3 days then 250 mg IV daily for 3-5 days (Wernicke prophylaxis) — NICE 2024 (vitamin_B1, first line) — CRITICAL: Thiamine MUST be given BEFORE glucose. Glucose metabolism consumes thiamine; administering glucose without thiamine can precipitate or worsen Wernicke encephalopathy. High-dose IV thiamine (500 mg) recommended over IM 100 mg as absorption is unreliable in malnourished patients — NICE 2024 CG100

Setting playbook (ed) — Stabilize acute intoxication, prevent aspiration, give thiamine BEFORE glucose, screen for co-ingestion and trauma, observe for sobriety or transition to withdrawal management — ACEP 2023; NICE 2024
2. thiamine_IV_high_dose 500 mg IV over 30 min IV STAT then TID for 3 days — Any intoxicated patient before glucose — NICE 2024 (Wernicke prevention: thiamine MUST precede glucose; 500 mg IV > 100 mg IM for bioavailability — NICE 2024)
3. dextrose_50 25 g IV IV PRN for glucose <70 — Hypoglycemia AFTER thiamine given — ACEP 2023 (Correct hypoglycemia only AFTER thiamine to prevent Wernicke precipitation — NICE 2024; ACEP 2023)
4. magnesium_sulfate 2 g IV over 1 h IV may repeat x1; then 1 g q6h — Hypomagnesemia or chronic alcohol use — NICE 2024 (Mg cofactor for thiamine utilization; must correct alongside thiamine — NICE 2024)
5. banana_bag thiamine 100 mg + folate 1 mg + MVI + MgSO4 2 g in 1 L NS IV daily — Chronic alcohol use with nutritional depletion — UpToDate 2026 (Comprehensive micronutrient repletion after initial high-dose thiamine — UpToDate 2026)
6. haloperidol 5 mg IM IM may repeat x1 in 30 min — Severe agitation unresponsive to verbal de-escalation — ACEP 2023 (Preferred over benzodiazepines for agitation in intoxicated patients — ACEP 2023)

Non-pharmacologic actions:
- Lateral decubitus (recovery) position for obtunded patients to prevent aspiration — ACEP 2023
- Suction at bedside for vomiting — ACEP 2023
- Supplemental O2 if SpO2 <92% — ACEP 2023
- IV access x1-2 — ACEP 2023
- Continuous cardiac + SpO2 monitoring — ACEP 2023
- Search clothing/belongings for substances, pill bottles, or suicide note — ACEP 2023
- Psychiatric safety assessment once sober (suicidal ideation screen) — ACEP 2023
- Social work referral — NICE 2024
- Brief motivational intervention if AUD suspected — NICE 2024

AVOID / contraindication checks:
- NEVER_give_glucose_before_thiamine_Wernicke_precipitation_risk — NICE 2024
- Correct_hypomagnesemia_before_or_with_thiamine_Mg_cofactor_for_thiamine_utilization — NICE 2024
- Avoid_lactated_ringers_if_severe_hepatic_dysfunction_impaired_lactate_clearance — ACEP 2023

Monitoring

Regimen monitoring:
- point of care glucose q1h until stable — ACEP 2023
- Mg level q6h until repleted — NICE 2024
- serial BMP q6-12h for electrolyte correction — ACEP 2023
- urine output monitoring — ACEP 2023

Setting (ed) monitoring:
- GCS q30-60min; expect improvement at 20-25 mg/dL/h BAL clearance — ACEP 2023
- Point-of-care glucose q1h until >100 mg/dL × 2 — ACEP 2023
- Continuous SpO2 + cardiac monitoring — ACEP 2023
- Repeat BAL at 2-4 h if GCS not improving as expected — ACEP 2023
- CIWA-Ar scoring q1h once BAL declining toward zero for withdrawal monitoring — NICE 2024
- Temperature monitoring for hypothermia — ACEP 2023

Follow-up plan: Alcohol use disorder screening (AUDIT-C); brief motivational intervention; referral to addiction medicine/counseling; link to alcohol withdrawal engine if anticipated; social work for housing/safety; thiamine supplementation continued oral (100 mg PO daily) if chronic use — NICE 2024; ACEP 2023; UpToDate 2026
- Close-out criterion: AUD screening complete, brief intervention documented, outpatient referrals placed, withdrawal prevention plan set — NICE 2024; ACEP 2023

Monitoring phase: Serial GCS q30-60min; expected BAL clearance 20-25 mg/dL/h (chronic drinkers may clear faster at 25-35 mg/dL/h); if GCS not improving as BAL declines → reassess for occult pathology (subdural, toxic alcohol, infection); monitor for withdrawal onset 6-24 h after last drink (CIWA-Ar scoring); aspiration watch in obtunded patients — ACEP 2023; NICE 2024

Disposition

Current setting: ed — Stabilize acute intoxication, prevent aspiration, give thiamine BEFORE glucose, screen for co-ingestion and trauma, observe for sobriety or transition to withdrawal management — ACEP 2023; NICE 2024

Disposition criteria:
- Discharge: GCS 15 AND ambulating safely AND tolerating PO AND no co-ingestion requiring treatment AND no suicidal ideation AND no anticipated severe withdrawal AND has safe disposition — ACEP 2023
- Observation: BAL declining but not yet sober OR mild withdrawal signs OR awaiting social work/psych — ACEP 2023
- Admit: aspiration pneumonia, persistent AMS out of proportion to BAL, co-ingestion, hypothermia requiring rewarming, anticipated severe withdrawal (DT history), rhabdomyolysis — ACEP 2023; NICE 2024
- ICU: respiratory failure, intubated, refractory hypoglycemia, toxic alcohol poisoning, severe hypothermia — ACEP 2023

Escalation triggers (move to higher acuity):
- Respiratory failure (RR <8 or SpO2 <90) → intubation — ACEP 2023
- GCS not improving with declining BAL → CT head STAT to exclude subdural/epidural hematoma — ACEP 2023
- Anion gap + osmolal gap → toxic alcohol poisoning workup (methanol, ethylene glycol) → fomepizole — ACEP 2023
- Refractory hypoglycemia despite D50 → hepatic failure workup — ACEP 2023
- Seizure → differentiate withdrawal seizure vs head trauma vs toxic alcohol vs hypoglycemia — ACEP 2023; NICE 2024
- Aspiration pneumonia (hypoxia + infiltrate) → antibiotics + ICU — ACEP 2023

Patient Action Plan

**Alcohol intoxication recovery and harm reduction plan — NICE 2024; ACEP 2023**
Personalised values: drinking_pattern, AUD_status, nutritional_status, withdrawal_history.

**Recovery — stable after intoxication — ACEP 2023** (green):
Triggers:
- Alert, oriented, GCS 15 — ACEP 2023
- Tolerating oral fluids and food — ACEP 2023
- No withdrawal symptoms — NICE 2024
Actions:
- Take thiamine 100 mg PO daily as prescribed — NICE 2024
- Eat regular meals to prevent hypoglycemia — ACEP 2023
- Attend outpatient addiction medicine / alcohol counseling appointment — NICE 2024
- Consider medications for AUD (naltrexone, acamprosate, disulfiram) with provider — NICE 2024
- AUDIT-C self-screening tool available online — NICE 2024

**Caution — return precautions — NICE 2024; ACEP 2023** (yellow):
Triggers:
- Tremor, sweating, anxiety, or insomnia 6-24 h after last drink (withdrawal signs) — NICE 2024
- Persistent vomiting or inability to eat — ACEP 2023
- Confusion or drowsiness returning after sobriety — ACEP 2023
Actions:
- Return to ED immediately — withdrawal can be life-threatening — NICE 2024
- Do not attempt to detox at home without medical supervision if history of seizures or DT — NICE 2024
- Take prescribed thiamine — do not skip — NICE 2024

**Crisis — life-threatening emergency — ACEP 2023** (red):
Triggers:
- Seizure — NICE 2024
- Seeing/hearing things that are not there (hallucinations) — NICE 2024
- Very fast heartbeat, high fever, severe confusion (delirium tremens) — NICE 2024
- Not breathing or unresponsive — ACEP 2023
Actions:
- Call 911 immediately — NICE 2024
- Place in recovery position if vomiting — ACEP 2023
- Do not leave the person alone — ACEP 2023
- Inform EMS of alcohol history and last drink time — NICE 2024

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] RR <8 or SpO2 <90% with severe alcohol intoxication — ACEP 2023
- [LIFE_THREATENING] Glucose <60 mg/dL in intoxicated patient — ethanol inhibits gluconeogenesis — ACEP 2023
- [LIFE_THREATENING] Classic triad: ophthalmoplegia (CN VI palsy) + ataxia + confusion in malnourished alcoholic — NICE 2024

Citations

- NICE CG100 — Alcohol-use disorders: diagnosis and management of physical complications (Wernicke prophylaxis; thiamine before glucose) + Mirijello et al, Eur J Intern Med 2022 + Vonghia et al, Eur J Intern Med 2008 (acute alcohol intoxication reviews) + UpToDate 2026 ethanol intoxication in adults [PMID:35985955](https://pubmed.ncbi.nlm.nih.gov/35985955/)
- Cited evidence (PMID 19046719) [PMID:19046719](https://pubmed.ncbi.nlm.nih.gov/19046719/)

Last reconciled with current guidelines: 2026-05-30.
References
  • NICE CG100 — Alcohol-use disorders: diagnosis and management of physical complications (Wernicke prophylaxis; thiamine before glucose) + Mirijello et al, Eur J Intern Med 2022 + Vonghia et al, Eur J Intern Med 2008 (acute alcohol intoxication reviews) + UpToDate 2026 ethanol intoxication in adultsPMID:35985955
  • Cited evidence (PMID 19046719)PMID:19046719