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ETOH Intoxication

    Management:

    • Ensure airway, adequate respiratory drive, and management of secretions/emesis
    • Thiamine, consider folate/MVI, D5NS (for volume and glycogen/NAD+ depletion - will not enhance elimination )
    • Check FSBG. Hypoglycemia is caused by impaired gluconeogenesis in poorly nourished patients with depleted or low glycogen stores.
    • Search for other causes if mental status not clearing in 3 to 4 hours.
    • Alcoholic ketoacidosis: Volume repletion, thiamine, and supplemental glucose
    • Start CIWA protocol for all suspected chronic alcoholics

    Symptoms:

    1. Tremulousness (6-12 hours after last drink)

    • Pt irritable, hypervigilant, agitated. coarse tremor of hands and tongue
    • Thiamine 100mg IV, MVI, Folate 1 mg IV/PO. Give thiamine before glucose
    • Mg replacement, watch for drop in phosphate
    • Valium 5-2010 mg IV q20minq5-10min until stops or Librium 25-100 mg poPO q6hrs.hourly. monitorMonitor closely for oversedation

    2. Seizures

    • If no past h/o seizure, work up to r/o head trauma, meningitis, brain abscess, etc.
    • If past h/o EtOH seizure, treat as other seizures but loading with anticonvulsants not indicated

    3. Delirium Tremens - autonomic instability with fluctuating mental status. 2-7 days after last drink, usually with visual hallucinations, perspiration, fever, tachycardia, hypertension. This is a medical emergency. mortality is approx. 5%

    • Valium 5-10 mg q4-6hIV orevery 5 to 10 minutes until appropriate sedation is achieved.
    • Librium 25-100 mg poPO at presentation, repeat as needed inhourly. 1Monitor hr, then 25-100 mg q 4-6 hr x 24 hrs. Reduce the initial 24 hr dose by 25% over next 2-3 days in divided doses. monitor respirationsrespirations.
    • thiamine,Thiamine, folate, MVI iv/po
    • replete Replete Mg, K, Ca, PO4
    • ruleRule out infection, pneumonia
    • admitAdmit to monitored setting

    4.Other Starttoxic CIWAalcohols:

    protocol
    • Send forethanol alllevel to calculate corrected osmole gap in the case of suspected chronicconcurrent alcoholicsethylene glycol or methanol ingestion.
    • Toxic alcohol panel (ethylene glycol, methanol, isopropyl alcohol) can be sent but do not delay treatment if clinical suspicion is high.
    • Most common differential diagnosis is alcoholic ketoacidosis, which can cause severe anion gap acidosis and moderate osmolar gap. Send a beta hydroxybutyrate level, which is more reliable than standard ketone test (acetoacetate).

    References:
    Kraut JA, Kurtz I. Toxic alcohol ingestions: Clinical features, diagnosis, and management. Clin J Am Soc Nephrol 2008 Jan;3(1!):208-25.
    Goldfrank's Toxicology Emergencies, 9th ed 2010.
    Poisoning and Drug overdose, 6th ed. 2012.
    UpToDate. (2022). https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes.

     

     

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