Alcohol (Ethanol) Intoxication
- Acute ingestion (accidental or intended) of alcohol, resulting in loss of inhibition, often associated with unruly/violent behavior, impaired judgment and/or coordination, diminished alertness/responsiveness, and sedation or coma
- Accidental ingestion is more common in toddlers and younger children.
- Frequency of intentional alcohol use increases with age.
- Alcohol–drug interactions are common because acute intoxication reduces hepatic clearance for other drugs, thereby increasing their serum concentrations.
Alcohol is the most used drug by young people: 30% of 8th graders, 69% of 12th graders, and 81% of college students have consumed alcohol.
- 71% of high school students have consumed alcohol in their lifetime; 21% had their first drink before age 13 years; 39% had one drink in past 30 days; 54% of 12th graders and 13% of 8th graders have been drunk at least once.
- Underage (12–20 years old) drinkers are 3 times more likely than adults to use illicit drugs with alcohol.
- Over 90% of alcohol is consumed through binge drinking; prevalence of binge alcohol use (>5 drinks once in past 2 weeks) in 2012 was 5% of 8th graders, 16% of 10th graders, 24% of 12th graders, 37% of college students, and 36% of young adults.
- 24% of high school students have ridden in a car driven by someone who had been drinking alcohol; 8% had driven a car when they had been drinking.
- 56% of college students mixed energy drinks with alcohol in the past month.
- Household products (medicinal, cosmetic, cleaning, hygiene) can contain up to 100% ethanol; rates of accidental exposure to and intentional intoxication from hand sanitizers are increasing.
Patients with psychiatric conditions are at an increased risk for abuse of alcohol and other drugs.
- Promote family discussions about alcohol use and abuse.
- Provide safety recommendations to prevent accidental ingestions.
- Effects of alcohol ingestion are related to dose, the time in which alcohol was consumed and then absorbed, and the patient’s history of alcohol exposure; peak serum concentrations occur 30–60 minutes after ingestion.
- Alcohol absorption, decreased by the presence of food in the stomach and increased if liquid is carbonated, occurs rapidly and largely in the small intestine.
- Minimal quantities of alcohol are excreted in urine, sweat, and breath.
- >90% of alcohol oxidized in liver follows zero-order kinetics, primarily by alcohol dehydrogenase (ADH) and then acetaldehyde dehydrogenase (ALDH); rate of metabolism is fixed (not related to dose or time) and is proportional to body weight. Ethnic/racial and gender variabilities exist on quantity and efficacy of ADH.
- Ethanol is metabolized by ADH to acetaldehyde, then to acetate, and finally to ketones, fatty acids, or acetone; ketosis and, infrequently, metabolic acidosis can occur.
- Respiratory acidosis can occur secondary to carbon dioxide retention from respiratory depression due to ethanol intoxication.
- Hypoglycemia occurs during acute ethanol intoxication due to impaired gluconeogenesis resulting from changes in the NADH/NAD+ ratio associated with ethanol metabolism.
- Alcohol affects the CNS primarily through the γ-aminobutyric acid (GABA) and glutamate neurotransmitter systems.
Alcohol is produced from fermentation/distillation of sugar from grapes (wine), grains/corn (beer/whiskey), potatoes (vodka), or sugar cane (rum) then mixed into solution to make specific beverages; products are marketed according to alcohol content or proof (twice the percent). Alcohol content ranges from 3–6% (6–12 proof) in beer to 40–75% (80–150 proof) in vodka/rum/whiskey. Alcohol is often consumed concurrently with other substances (licit and illicit), presenting a mixed clinical picture of intoxication.
Commonly Associated Conditions
- Alcohol is involved in 30% of all drug overdoses.
- A significant percentage of adolescent trauma patients, especially victims of gunshot wounds, have positive toxicology screens for alcohol and other drugs. Ethanol use increases trauma risk by 3- to 7-fold.
- Medical: Baseline health will affect patient’s response to alcohol; diabetics, for example, may have worse hypoglycemia.
- Type and dose of other drugs ingested:
- Clinical effects of and treatment for other ingestions can vary depending on substance.
- Polysubstance ingestion is very common.
- Psychiatric history: Evaluate for possible suicidal ideation.
- Gathering details regarding the alcohol consumed (type, amount, and over what time period) may help predict clinical course. For example, blood alcohol concentration (BAC) may continue rising if ingestion occurred recently.
- Intoxication presents clinically with signs ranging from lack of coordination, slurred speech, and confusion (BAC of 20–200 mg/dL) to ataxia and nausea/vomiting (BAC 200–300 mg/dL) to amnesia, seizures, or coma (BAC >300 mg/dL).
- Bruises, lacerations, and fractures may suggest trauma and raise concern about CNS injury.
- Neurologic exam, including mental status, will assess degree of intoxication and consciousness, including patient’s ability to protect his or her airway, and risk for aspiration.
- Tachycardia and hypotension may indicate dehydration.
- Fever may suggest infection.
- Average time for normalization of mental status in intoxicated adults is 3–3.5 hours; patients without clinical improvement in 3 hours should be evaluated for other causes of altered mental status.
Diagnostic Tests and Interpretation
- Generally correlates with clinical picture
- In children, signs of intoxication may be present at levels of 50 mg/dL.
- Serum levels of 600–800 mg/dL can be fatal.
- Blood and/or urine toxicology screen
- Most urine toxicology screens do not test for alcohol.
- Concurrent ingestions are common.
- Acetaminophen level
- Usually not part of the general serum toxicology screen
- Consider if polysubstance ingestion suspected and/or if patient has suicidal ideation
- Serum electrolytes
- Alcohol is a diuretic. The associated nausea and vomiting seen with intoxication may result in severe dehydration.
- Ketosis and, infrequently, metabolic acidosis can occur.
- Serum glucose level: Ethanol inhibits gluconeogenesis and can be associated with hypoglycemia.
- Blood gas can show both respiratory and metabolic acidosis.
- Other ingestions (overdose of sedatives or illicit drugs, such as benzodiazepines, marijuana, narcotics, lysergic acid diethylamide [LSD], and phencyclidine [PCP])
- Toxic exposures (ethylene glycol, methanol, carbon monoxide)
- Head trauma
- Tumor: brain tumor
- Electrolyte imbalances (hyponatremia, hypernatremia)
- Increased intracranial pressure from hydrocephalus, mass, other
IV dextrose as needed for hypoglycemia
- Assess airway, breathing, and circulation (ABC).
- Protect airway: The patient may require intubation and mechanical ventilation.
- Mainstay is supportive therapy as no specific ethanol antidote exists.
- Appropriate trauma management as needed
- Because alcohol is absorbed rapidly, gastric lavage is indicated only if the patient is seen immediately after ingestion (within minutes).
Issues for Referral
- Refer to substance abuse specialist (addiction medicine, psychiatrist, or certified addictions counselor) for detailed evaluation and treatment.
- Refer for psychiatric evaluation if depression, anxiety, suicidal ideation, or any other mental health condition is suspected.
- Assess for other risk-taking behaviors—including other substance use, sexual activity, use of motor vehicles while intoxicated, weapon carrying, and delinquency—and their sequelae, including pregnancy, sexually transmitted infections, and violence.
Keep patient awake; watch for vomiting as patients are at risk for choking owing to depressed gag reflex.
- Unstable vital signs (hypotension)
- Persistent CNS depression/impaired mental status
- Potential severity of comorbid psychiatric conditions (depression/suicidality)
- Inability to contact a parent/guardian
IV fluids for dehydration and hypotension
Observe and monitor vital signs and neurologic status.
- Stable vital signs
- Patient awake, alert, responsive, and oriented
- Decreasing BAC
- Parent/guardian fully informed about patient’s alcohol use
NPO secondary to depressed gag reflex
BAC serum levels of 600–800 mg/dL can be fatal.
- Diuresis and dehydration
- Vasodilation and hypotension
- Vomiting, aspiration, potential respiratory arrest
- Metabolic acidosis
- Impaired mental status
- Engagement in risk-taking behaviors (e.g., other drug use, unprotected intercourse) while intoxicated
- CNS depression
- GI bleeding
- Acute pancreatitis
- Motor vehicle collisions associated with driving while intoxicated
- Alcohol withdrawal following a period of intoxication in chronic users (symptoms include tachycardia, elevated blood pressure, irritability, nausea, vomiting, and tremor)
- Centers for Disease Control and Prevention. 2011 Youth Risk Behavior Survey. www.cdc.gov/yrbs. Accessed September 1, 2013. [PMID:23330172]
- Howland J, Rohsenow DJ. Risks of energy drinks mixed with alcohol. JAMA. 2013:309(31):245–246. [PMID:23330172]
- Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the Future National Results on Drug Use: 2012 Overview, Key Findings on Adolescent Drug Use. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2013.
- Rayar P, Ratnapalan S. Pediatric ingestions of household products containing ethanol: a review. Clin Pediatr. 2013;52(3):203–209. [PMID:23299839]
- The Center on Alcohol Marketing and Youth. Prevalence of underage drinking. http://www.camy.org/factsheets/sheets/Prevalence_of_Underage_Drinking.html. Accessed September 1, 2013.
- 305.00 Alcohol abuse, unspecified
- 980.0 Toxic effect of ethyl alcohol
- F10.929 Alcohol use, unspecified with intoxication, unspecified
- T51.0X4A Toxic effect of ethanol, undetermined, initial encounter
- F10.920 Alcohol use, unspecified with intoxication, uncomplicated
- T51.0X1A Toxic effect of ethanol, accidental (unintentional), init
- T51.0X2A Toxic effect of ethanol, intentional self-harm, init encntr
- 25702006 Alcohol intoxication (disorder)
- 82782008 Toxic effect of ethyl alcohol (disorder)
- 15167005 Alcohol abuse (disorder)
- Q: How quickly is alcohol metabolized?
- A: The liver metabolizes ∼10 g of ethanol per hour, which corresponds to a decline in BAC of 18–20 mg/dL/h.
- Q: What is binge drinking in youth?
- A: For children 9–13 years old and girls 14–17 years old, 3 or more drinks; for boys 14–15 years old, 4 or more
- Q: Are younger children at any increased risk from alcohol poisoning?
- A: Ethanol inhibits gluconeogenesis; younger children have an increased risk of hypoglycemia because they have relatively smaller hepatic glycogen stores; however, children tend to have more rapid clearance rates (up to 30 mg/dL/h).
Ann B. Bruner
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