At the Bedside

  • Initial priorities
  • ABCs, airway protection, aspiration risk, cervical spine precautions if trauma possible.
  • Check point-of-care glucose immediately in any altered patient.
  • Assess temperature — intoxicated patients are prone to hypothermia.
  • Full trauma exam; maintain low threshold for head CT if fall, anticoagulation, focal deficit, persistent AMS, or unreliable history.
  • Key exam findings
  • Slurred speech, ataxia, nystagmus, disinhibition, CNS depression.
  • Severe toxicity: respiratory depression, coma, hypothermia, hypotension, aspiration.
  • Diagnostic workup
  • Mild uncomplicated intoxication may need only glucose and observation.
  • Consider:
  • BMP/CMP: hypoglycemia, electrolyte abnormalities, renal/liver disease.
  • Serum ethanol level if diagnosis unclear, legal/occupational need, or persistent AMS.
  • Serum osmolality/osmolar gap if concern for toxic alcohol co-ingestion.
  • VBG/ABG, lactate, ketones if acidotic, hypotensive, or ill-appearing.
  • EKG and acetaminophen/salicylate levels for unclear overdose.
  • Pregnancy test when relevant.
  • CT head/C-spine based on trauma risk or exam.
  • Management
  • Supportive care is definitive for isolated ethanol intoxication.
  • Do not delay dextrose for thiamine if hypoglycemic.
  • Treat hypoglycemia, hypothermia, dehydration, vomiting, aspiration, trauma.
  • IV fluids only if clinically volume depleted; they do not meaningfully accelerate ethanol clearance.
  • Agitation:
  • Verbal de-escalation, low-stimulation environment.
  • If medication needed, antipsychotic often preferred over benzodiazepines in isolated ethanol intoxication because benzos can worsen respiratory depression.
  • Severe CNS/respiratory depression: airway positioning, suction, oxygen, intubation if unable to protect airway.
  • Disposition
  • Discharge when clinically sober enough for safe ambulation, PO tolerance, stable vitals, no occult injury/medical issue, and safe ride/place to go.
  • Admit for persistent AMS, trauma, severe metabolic derangement, aspiration pneumonia, hypothermia, withdrawal risk without safe monitoring, or significant co-ingestion.
A Classic Presentation
A 24-year-old man is brought from a bar for altered mental status after a fall. He smells of alcohol and is somnolent but arousable. Glucose is 42 mg/dL, temperature is 35°C, and he has an occipital scalp hematoma. He receives IV dextrose, warming, thiamine, and CT head due to trauma and unreliable exam. Imaging is negative, mental status improves over several hours, and he is discharged with a sober ride once ambulatory and tolerating PO.

Study Directive

  • Practice a 60-second altered mental status checklist: glucose, oxygenation, temperature, trauma, tox, infection, electrolytes.
  • Review indications for CT head in intoxicated trauma patients.
  • Memorize discharge criteria for uncomplicated intoxication: stable vitals, improving mental status, ambulatory, tolerating PO, safe disposition.
  • Compare ethanol intoxication vs toxic alcohol poisoning by drawing the osmolar gap/anion gap timeline from memory.

Recent Literature