Key Facts

Alcohol intoxication and its complications represent a major burden on UK emergency services. The key challenge is not managing intoxication itself but identifying and treating co-existing or mimicking conditions that may be masked by alcohol.

Epidemiology

Alcohol-related hospital admissions in England exceed 1 million per year. ED attendances related to alcohol account for approximately 12-15% of all presentations (higher at weekends and overnight). Alcohol-related deaths in the UK: approximately 10,000 per year. Alcohol misuse costs the NHS approximately £3.5 billion annually.

Aetiology

• Acute intoxication: Binge drinking, chronic heavy drinking
• Alcohol use disorder: Affects approximately 6% of adults in England
• High-risk groups: Young adults (binge drinking), homeless populations, those with mental health comorbidity

Pathophysiology

Ethanol is a CNS depressant acting primarily via GABA-A receptor potentiation and NMDA receptor inhibition. It causes dose-dependent sedation, impaired coordination, slurred speech, and at high doses, respiratory depression and coma. Chronic use leads to neuroadaptation (GABA downregulation, NMDA upregulation), explaining tolerance and the potentially life-threatening withdrawal syndrome when alcohol is ceased.

Stages of Intoxication

• Mild (50-150mg/dL): Disinhibition, impaired judgement, slurred speech
• Moderate (150-250mg/dL): Ataxia, dysarthria, emotional lability, nausea/vomiting
• Severe (250-400mg/dL): Stupor, marked ataxia, hypothermia, risk of aspiration
• Potentially fatal (>400mg/dL): Coma, respiratory depression, cardiovascular collapse

Red Flags

• Reduced GCS not proportionate to estimated alcohol intake — consider head injury, co-ingestion, metabolic cause
• Focal neurological signs — CT head to exclude intracranial pathology
• Hypoglycaemia — common in chronic drinkers and malnourished patients
• Hypothermia — particularly outdoor exposure while intoxicated
• Persistent vomiting — risk of Mallory-Weiss tear, aspiration, Boerhaave syndrome
• Confusion disproportionate to alcohol level — Wernicke's encephalopathy

Bedside

• ABCDE assessment: Airway protection is priority
• Blood glucose: Immediately — treat hypoglycaemia
• GCS: Serial monitoring — should improve over time; if not, investigate further
• Temperature: Hypothermia risk
• ECG: Arrhythmias (holiday heart syndrome — AF)

Bloods

• Blood alcohol level: Confirms intoxication; correlate with clinical state
• Blood glucose: Hypoglycaemia (impaired gluconeogenesis)
• U&Es: Electrolyte disturbance (hyponatraemia, hypokalaemia, hypomagnesaemia)
• LFTs: Acute/chronic liver damage
• FBC: Macrocytosis (chronic alcohol use), thrombocytopenia
• Paracetamol level: Always check for co-ingestion
• VBG/ABG: Lactate, pH, ketones
• Amylase/lipase: If abdominal pain (pancreatitis)

Imaging

• CT head: If head injury suspected, focal neurology, GCS not improving, anticoagulated

Special Tests

• AUDIT score: Alcohol Use Disorders Identification Test — screen before discharge
• Serum magnesium: Often low in chronic alcohol use

Non-pharmacological

• Airway protection: Recovery position if unable to maintain airway; intubation if GCS ≤8 with no improvement
• Observation: Safe, monitored environment; serial GCS
• Rehydration: IV fluids (0.9% NaCl or Hartmann's) if dehydrated
• Warming: If hypothermic
• Brief intervention: For hazardous/harmful drinking — evidence-based approach at discharge

Pharmacological

• IV glucose: 100mL 20% glucose if hypoglycaemic — but give IV Pabrinex FIRST if Wernicke's suspected
• IV Pabrinex (high-potency B vitamins including thiamine): Pairs 1+2 TDS for 3-5 days if malnourished, suspected Wernicke's, or chronic alcohol use — BEFORE glucose administration
• Antiemetics: Ondansetron 4mg IV if significant vomiting
• Alcohol withdrawal management (if developing):
  • Chlordiazepoxide reducing regimen (e.g., 30mg QDS day 1, reducing over 5-7 days) — guided by CIWA-Ar score
  • Symptom-triggered dosing is safer than fixed-dose regimens
  • Pabrinex throughout withdrawal period

Surgical/Interventional

• Not usually required; manage complications as they arise

Referral Criteria

• AUDIT score ≥8: Brief intervention; ≥16: Referral to alcohol services
• Dependent drinking: Alcohol liaison nurse, community alcohol team
• Recurrent presentations: Safeguarding, social services, dual diagnosis team if mental health comorbidity
• All deliberate self-harm with alcohol: Psychiatric assessment

• Acute intoxication: Self-limiting if uncomplicated; death from aspiration, respiratory depression, or hypothermia is preventable
• Alcohol-related liver disease: Leading cause of liver disease in the UK; ~6,000 deaths/year
• Alcohol withdrawal: Mortality from delirium tremens ~5% if untreated, <1% with treatment
• Brief interventions: NNT 8 to reduce hazardous drinking by 1 person
• Wernicke's encephalopathy: If untreated → 80% develop Korsakoff's syndrome (irreversible amnesia)

CIWA-Ar Score Components

Score >8: Treat; >15: Moderate withdrawal; >20: Severe withdrawal.

Alcohol Withdrawal Timeline