Acute alcohol intoxication
Encounter flow
12/12 authoredCanonical 12-phase frame with authored status for this dossier.
Frame
Confirm acute ethanol intoxication; distinguish from other causes of AMS — ACEP 2023
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)
- informationallife_threateningrespiratory_failureRR <8 or SpO2 <90% with severe alcohol intoxication — ACEP 2023Trigger could not be auto-evaluated — needs clinician judgement.
- informationallife_threateninghypoglycemiaGlucose <60 mg/dL in intoxicated patient — ethanol inhibits gluconeogenesis — ACEP 2023Trigger could not be auto-evaluated — needs clinician judgement.
- informationallife_threateningwernicke_encephalopathyClassic triad: ophthalmoplegia (CN VI palsy) + ataxia + confusion in malnourished alcoholic — NICE 2024Trigger could not be auto-evaluated — needs clinician judgement.
- informationallife_threateningtoxic_alcohol_co_ingestionOsmolal gap >10 mOsm/kg + anion gap metabolic acidosis in intoxicated patient — suspect methanol or ethylene glycol co-ingestion — ACEP 2023Trigger could not be auto-evaluated — needs clinician judgement.
- informationalsevereaspirationVomiting while obtunded (GCS <8) with hypoxia or CXR infiltrate — ACEP 2023Trigger could not be auto-evaluated — needs clinician judgement.
- informationalseveregcs_bal_mismatchGCS not improving at expected rate (20-25 mg/dL/h BAL clearance) — occult pathology suspected — ACEP 2023Trigger could not be auto-evaluated — needs clinician judgement.
- informationalseveresevere_hypothermiaCore temperature <32C in intoxicated patient — alcohol-induced vasodilation + environmental exposure — ACEP 2023Trigger could not be auto-evaluated — needs clinician judgement.
Workflow calculators
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Recommended regimen
Supportive care: thiamine, folate, MgSO4, banana bag, glucose correction — NICE 2024; ACEP 2023- thiaminefirst linevitamin_B1500 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_glucoseCRITICAL: 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 CG100rxcui 10454
ed playbook — drug actions (5)
- 1. thiamine_IV_high_doserxcui 10454500 mg IV over 30 min • IV • STAT then TID for 3 daystrigger: Any intoxicated patient before glucose — NICE 2024Wernicke prevention: thiamine MUST precede glucose; 500 mg IV > 100 mg IM for bioavailability — NICE 2024
- 2. dextrose_50rxcui 485025 g IV • IV • PRN for glucose <70trigger: Hypoglycemia AFTER thiamine given — ACEP 2023Correct hypoglycemia only AFTER thiamine to prevent Wernicke precipitation — NICE 2024; ACEP 2023
- 3. magnesium_sulfaterxcui 65852 g IV over 1 h • IV • may repeat x1; then 1 g q6htrigger: Hypomagnesemia or chronic alcohol use — NICE 2024Mg cofactor for thiamine utilization; must correct alongside thiamine — NICE 2024
- 4. banana_bagthiamine 100 mg + folate 1 mg + MVI + MgSO4 2 g in 1 L NS • IV • dailytrigger: Chronic alcohol use with nutritional depletion — UpToDate 2026Comprehensive micronutrient repletion after initial high-dose thiamine — UpToDate 2026
- 5. haloperidolrxcui 50935 mg IM • IM • may repeat x1 in 30 mintrigger: Severe agitation unresponsive to verbal de-escalation — ACEP 2023Preferred over benzodiazepines for agitation in intoxicated patients — ACEP 2023
Auto-drafted A&P note
edSubjective
- 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.
- 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
- Cited evidence (PMID 19046719) — PMID:19046719