Alcohol (Ethanol) Intoxication

Objectives

To guide the management of patients with alcohol (ethanol) overdose in the deployed environment. 

Scope

This guideline describes the management of patients with suspected ethanol toxicity in a forward medical context or deployed Emergency Department. It should not be used in the Firm Base where reference to TOXBASE® would be appropriate. 

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in forward medical locations or in an Emergency Department on deployed operations.

Initial Assessment & Management

Sources of ethanol include alcoholic beverages but also household products (solvents), perfumes, detergents, hand sanitisers.

Alcohol (ethanol) is rapidly absorbed after ingestion. Absorption through the skin is negligible but it is irritating to the eyes and skin. 

Individual tolerance for ethanol varies widely and tolerance develops with chronic exposure.  

Blood alcohol concentration peaks approximately one hour after consumption and is metabolised at a fixed rate, with high individual variability.

Most of the smell associated with ‘alcohol’ results from its metabolism to aldehydes and ketone production. The absence of the smell of alcohol should not be used to rule out a significant ethanol toxicity. 

Symptoms and signs

Key features are progressive disinhibition, confusion, aggression, incoordination, reduced consciousness, respiratory depression, seizures.

Co-ingestion of alcohol with other central nervous system depressants potentiates the effect of alcohol and can increase toxicity. 

Management

Maintain airway with adjuncts if required. Place in left lateral position with continual monitoring, if possible, to minimise aspiration risk. Given supplemental oxygen to maintain saturations >92%. 

Check blood glucose. Correct hypoglycaemia (adults <4 mmol/L) with 20g oral glucose if tolerated or with 250 mL 10% or 125 mL 20% glucose IV. Check blood glucose after 10 minutes and repeat doses as required. A 10 % glucose IV infusion may be needed to maintain blood sugars with blood glucose starting at 100 mL/hr and titrated to maintain blood sugar >4 mmol/L. Check blood glucose every 10 minutes until stable, then every 30 minutes. For paediatric hypoglycaemia see below. 

Hypotension and fluid status. Fluid resuscitate with intravenous fluids.  Maintain hydration and good urine output (0.5ml/kg/hour) with oral or intravenous fluids. 

Management of violence and aggression. Attempt verbal de-escalation measures. If possible, physical restraint should be avoided as likely to exacerbate anxiety and aggression.

If rapid tranquilisation is required use ketamine or haloperidol. Avoid the use of benzodiazepines as these are additive to the ethanol effect and will increase the risk of airway and breathing compromise. 

Advanced Assessment & Management

Activated charcoal. Alcohol is quickly absorbed by the body so charcoal cannot effectively bind to it - activated charcoal should therefore not be given. 

Metabolic acidosis. If metabolic acidosis does not improve following correction of hypoxia and fluid resuscitation consider alcoholic ketoacidosis or toxic alcohol ingestion. 

Alcoholic ketoacidosis. Alcoholic ketoacidosis may follow an alcoholic binge in chronic ethanol users who are nutritionally deplete. Urinary or blood ketones are raised with pH <7.3 and HCO3 <15 mEq/L, without significant hyperglycaemia (blood glucose may be low, normal or slightly high). Treating with the following over 1 hour will aid differentiation:

500-1000 mL balanced crystalloid (such as Hartmann’s solution) and

IV 10% glucose 250 - 500 mL and 

IV thiamine 400mg (or Pabrinex if available - see accordion content) 

If metabolic acidosis does not improve consider toxic alcohols. If toxic alcohols are present the acidosis will continue to worsen. 

ECG. A 12-lead ECGs should be taken (if available) and serial ECGs may be required.

Hypomagnesaemia. Correct low magnesium concentrations with 8-10 mmol IV magnesium sulphate, particularly in a patients with a history of alcohol abuse. 

Hypokalaemia. Monitor and replace as required. 

Thiamine. Patients a suspected history of chronic ethanol excess should be given thiamine 400 mg TDS IV for the first three days of admission, then 200 mg OD for the following three days. Pabrinex is an alternative if available - see accordion content. See the Alcohol Withdrawal CGO for further advice.

Prolonged Casualty Care

Most intoxicated patients do not require significant intervention and will recover gradually provided their airway and respiratory function are protected. 

Maintain good hydration and urine output. 

If chronic alcohol use is suspected CIWA scoring should be commenced as the patient recovers to monitor for alcohol withdrawal (see alcohol withdrawal CGO). 

Paediatric Considerations

Hypoglycaemia is common in children following ethanol exposure. Check blood glucose and correct conventionally with 10-20 g oral glucose or 2 mL/kg 10% glucose IV. 

Children aged 10 years and older who have no new symptoms since the time of ingestion do not need further management. If symptomatic manage as above. 

Children aged 9 years or younger who have ingested less than 0.4 mL/kg absolute ethanol and have no new symptoms since ingestion do not require further assessment. If a toxic dose is suspected observe for at least 4 hours after ingestion.

Potentially toxic doses by ethanol concentration of product ingested: