A 56-year-old homeless man is brought in by EMS after being found down outside a convenience store. He was alone and lying in a puddle of urine.
Vital Signs
BP 156/90 mm Hg, HR 89/min, RR 20/min, POx 94% on RA, T 98.9 F
He is sleeping and appears disheveled, covered in soil. He smells like alcohol. He has no obvious signs of head trauma. He does not arouse when his name is called, but he has a normal respiratory rate with good chest rise.
If patient is not initially able to answer questions:
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Monitor serial vital signs. Make sure you include a fingerstick glucose
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Do a thorough head/ear/nose/throat exam including pupils for constriction/dilation that may point to another substance on board. Examine head for signs of trauma and ears for hemotympanum
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Examine for crackles or rhonchi on lung exam – consider aspiration pneumonitis
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Look for signs of extremity trauma or infection to suggest fractures or cellulitis
If it’s just EtOH, the patient’s mental status should start to get better with time. Consider sending a ethyl alcohol level early if you have any question in your mind whether this is really ETOH intoxication alone, but don’t get complacent if it’s positive. The patient could be presenting with multiple comorbidities. Maintain a broad differential diagnosis early.
Timeline for EtOH withdrawal presentations:
6-24 hours: mild withdrawal symptoms including anxiety, minor agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, alcohol craving
12-24 hours: alcohol hallucinosis – visual, auditory, tactile
6-48 hours: alcohol withdrawal seizures
72-96 hours: delirium tremens
Questions to ask patients when they are capable:
How much do you drink everyday?
How much did you drink today?
What time was your last drink?
Did you use other drugs or substances?
Have you had alcohol withdrawal in past? What happens? Seizures, ICU stay/intubations?
Falls/trauma/head injury?
Have you had other medical comorbidities such as pancreatitis, spontaneous bacterial peritonitis, prior GI bleed, esophageal varices, malignancy, HIV, Hepatitis B/C?
Do you have thoughts of hurting yourself? Did you drink tonight with the intention of killing yourself
If patients are not getting better with time, consider other pathologies that can mimic ETOH intoxication:
– Intracranial hemorrhage or ischemia -> consider head CT
– Systemic infections -> consider urine testing, chest radiography, CT/LP, cultures, WBC/band count/lactate if you have suspicion of sepsis
– Metabolic abnormalities such as ketoacidosis, hypomagnesemia, hypoglycemia, and hypocalcemia -> consider electrolyte supplementation, dextrose-containing fluids
– Endocrine abnormalities: myxedema crisis or Hashimoto encephalopathy
– Hepatic encephalopathy (may be triggered by GI bleed, sepsis, or recent surgery/trauma)
– Toxic exposures: carbon monoxide, severe lead poisoning, cyanide
– Seizure/post-ictal state
What to use if patient is aggressive or combative:
– Consider restraints
– 5 mg/kg ketamine IM or 5 mg haloperidol with 2 mg midazolam.*
*Editor’s note: It may be reasoned that the general approach of administering of haloperidol and midazolam to the agitated, EtOH-intoxicated patient will increase the risk of respiratory depression due to the simultaneous/additive GABA receptor agonism by benzodiazepine and alcohol.
Dedicated studies need to be done looking at the sedation of acutely agitated or combative patients who are intoxicated with alcohol.
Summary:
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Undress patients completely and perform full head to toe exam; rule out all trauma and infection
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Get full history to risk stratify
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Consider other medical emergencies
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Check glucose. Give thiamine before glucose to [theoretically] prevent Wernicke Encephalopathy (unless the patient has acute symptomatic hypoglycemia, in which case giving dextrose immediately is essential).
Further author commentary: I’ve seen a particularly higher number of “Alcohol Intoxication” pop up on the triage board lately with an initial presentation just like this, and because I’m seeing more of them, I’m also realizing how vastly different each one is from the other if you really take the time to talk to them once they’ve sobered up. A Core EM podcast I listened to recently called “Evaluation of the Alcohol Intoxicated Patient” helped a lot with re-thinking how to approach these patients. There have been shifts where I made sure there was no other substance on board, that they did not endorse suicidal ideation or homicidal ideation, and there was no head trauma or other injury or medical complaint being masked by the alcohol intoxication. But, I often did not take the time to actually talk to these patients after they’d sobered up to get their story. If we really talk to these patients, we may discover that they are seeking detoxification, and we could offer them so much more than just a place to “sober up.” In the past month, I have had one patient open up to me about his life as a musician and another tell me about his chronic leg pain. A couple months ago, I didn’t have these stories, and I didn’t know these patients as well.
Sources:
Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 8th edition.
Chemical agents for the sedation for the sedation of agitated patients in the ED: a systematic review. Korczak et al. American Journal of Emergency Medicine. 2017.
Episode 114.0. “Evaluation of the Alcohol Intoxicated Patient.” Core EM Podcast https://coreem.net/podcast/episode-114-0/. September 25, 2017
Alcohol Intoxication Mimics: ED DDx + Approach to Management. Bennett, J et al. emDocs.net http://www.emdocs.net/alcohol-intoxication-mimics-ed-ddx-approach-management/
Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis. Pace, C et al. UpToDate. https://www.uptodate.com/contents/alcohol-withdrawal-epidemiology-clinical-manifestations-course-assessment-and-diagnosis?source=search_result&search=Alcohol%20Withdrawal%20Syndrome&selectedTitle=2~140
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Surriya
PGY4 clinical monster in training/EMIM resident/improviser
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