On this page
Referral and warning signs
When to refer
Refer to Hospital (H) any patient with: Significant alteration in mental status (stupor, coma, GCS <12-13), Respiratory depression, Hypotension, Hypothermia, Hypoglycemia, Seizures, Suspected significant trauma (head injury), Suspected co-ingestion, OR Need for prolonged observation or management of withdrawal.
Red flags
- Coma (GCS ≤ 8)
- Respiratory depression (RR < 10/min or shallow)
- Hypotension unresponsive to fluids
- Hypothermia (<35°C)
- Hypoglycemia
- Signs of significant trauma (especially head injury)
- Seizures
Signs and symptoms
- Smell of alcohol on breath.
- Early/Mild: Euphoria, disinhibition, talkativeness, impaired judgment, slowed reaction time, mild incoordination.
- Moderate: Slurred speech (dysarthria), ataxia (unsteady gait), drowsiness, labile mood, nausea, vomiting, flushed skin, dilated pupils (can be variable).
- Severe: Stupor, coma (loss of protective airway reflexes), respiratory depression (slow, shallow breathing), hypotension (vasodilation, volume depletion), hypothermia, hypoglycemia (especially in children or malnourished individuals), seizures (rarely directly from ethanol, more often withdrawal or complications like head injury/hypoglycemia).
- Other potential findings: Tachycardia, excessive sweating.
Risk factors
- Binge drinking (consuming large amounts rapidly).
- Accidental ingestion by children.
- Underlying psychiatric conditions, suicide attempt.
- Chronic alcohol use (tolerance affects level of impairment at a given blood alcohol level, but risk of complications remains).
- Use with other CNS depressants (benzodiazepines, opioids, barbiturates) - synergistic effect.
Diagnosis
Clinical assessment
Based on history of recent alcohol consumption and clinical signs of intoxication/CNS depression. Important to rule out other causes of altered mental status, especially trauma (head injury) and metabolic disturbances.
Investigations
- Point-of-care Blood Glucose: ESSENTIAL to rule out hypoglycemia, a common and treatable complication.
- Breath Alcohol Concentration (BrAC) or Blood Alcohol Concentration (BAC): Can confirm presence and level of ethanol, but clinical assessment is paramount (tolerance varies widely). BAC >300mg/dL often associated with coma; >400mg/dL potentially lethal.
- Consider: Electrolytes (may show disturbances), Arterial Blood Gas (ABG) if severe respiratory depression or suspected acidosis, Trauma evaluation (CT Head) if any suspicion of head injury (intoxicated patients are prone to falls/injury), Toxicology screen if co-ingestion suspected.
- Rule out other causes: Check for signs of head injury, stroke, meningitis, diabetic ketoacidosis, hepatic encephalopathy, other poisonings.
Diagnostic criteria
Clinical presentation consistent with alcohol intoxication +/- Measured elevated BrAC/BAC, after excluding other life-threatening causes of altered mental status.
Management
Non-pharmacological management
- Stabilization: ABCDE approach.
- Airway Management: High priority. Position patient to prevent aspiration (recovery position if unconscious but breathing adequately). Assess gag reflex. Intubation often necessary for coma (GCS <8), loss of protective airway reflexes, or severe respiratory depression.
- Breathing Support: Provide supplemental oxygen. Assist ventilation with BVM if needed. Mechanical ventilation if intubated.
- Circulation Support: Establish IV access. IV fluids (Normal Saline or Ringer's Lactate) for dehydration and hypotension. Vasopressors rarely needed unless severe shock/co-morbidity.
- Temperature Management: Passive rewarming (blankets) for mild hypothermia. Active rewarming for moderate/severe hypothermia.
- Observation: Monitor patient closely until clinically sober (alert, oriented, stable vital signs, able to protect airway).
Pharmacological treatment
- Glucose: Administer IV Dextrose (Adult: 50% 25-50ml; Child: 10% 2-5ml/kg) IMMEDIATELY if blood glucose is low or cannot be rapidly checked in patient with altered mental status. Maintain glucose with D5% or D10% infusion as needed.
- Thiamine (Vitamin B1): Give Thiamine 100 mg IV or IM BEFORE or concurrently with glucose administration, especially in malnourished or chronic alcohol users. Prevents precipitation of Wernicke's encephalopathy.
- Electrolyte Correction: Replace potassium, magnesium, phosphate as needed based on lab results (especially in chronic users).
- No Specific Antidote: Management is supportive.
- Sedation: Generally AVOIDED unless severe agitation/withdrawal develops (use benzodiazepines cautiously).
- GI Decontamination (Lavage/Charcoal): NOT indicated for ethanol poisoning due to rapid absorption and risk outweighing benefit.
Monitoring
Frequent monitoring of: Vital signs (HR, BP, RR, SpO2, Temp), Neurological status (GCS, pupillary response, level of alertness), Respiratory status. Monitor blood glucose frequently. Monitor for signs of alcohol withdrawal as intoxication wears off in chronic users.
Complications
- Aspiration pneumonia
- Respiratory depression / arrest
- Hypoglycemia
- Hypothermia
- Electrolyte disturbances
- Cardiac arrhythmias
- Trauma (falls, injuries sustained while intoxicated)
- Wernicke's encephalopathy (if thiamine deficient)
- Alcoholic ketoacidosis
- Withdrawal syndrome upon recovery (in chronic users)
- Death
Prevention
- Moderation in alcohol consumption.
- Awareness of binge drinking risks.
- Avoiding alcohol use with other CNS depressants.
- Safe storage of alcohol away from children.
- Treatment programs for alcohol use disorder.
- Public health campaigns on responsible drinking.
Patient education
- Discuss the dangers of excessive alcohol consumption and binge drinking.
- Provide information on responsible drinking limits.
- Offer resources and referral for alcohol use disorder assessment and treatment if appropriate.
- Advise against driving or operating machinery while intoxicated.
- Warn about mixing alcohol with other drugs.
Uganda-specific notes
Acute alcohol poisoning is common. Always consider and check for hypoglycemia, especially in malnourished individuals or those consuming illicit brews. Thiamine administration before glucose is crucial if malnutrition or chronic use is suspected. Be vigilant for associated trauma. Differentiating from methanol poisoning (common in illicit brews) can be challenging initially - maintain high suspicion if acidosis is severe or visual symptoms present.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.3.12.1