Acute ethyl (alcoholic) intoxication (drunkenness)

Acute alcohol intoxication is defined as the sudden onset of a stereotypical symptomatology related to alcohol toxicity. It typically follows the ingestion of large quantities of alcoholic beverages or, in rare cases, the inhalation or ingestion of other substances.

It may occur with or without a context of chronic alcohol use and represents a significant public health issue due to its commonality, the medical, psychological, and social costs, its medical complications, and, most notably, the trauma that can occur during intoxication (fights, traffic accidents, abuse).

Drunkenness is poorly defined. Some equate it with acute alcohol intoxication, while others limit its definition to mild symptoms of cognitive-motor excitation or extend it to all clinical degrees.

Clinical Presentation

Symptoms appear at varying levels of blood alcohol concentration depending on the individual, which itself is variably linked to alcohol consumption based on factors such as genetics, weight, hydration status, body fat, sex, and ethnicity. Roughly, for a 70 kg adult male, clinical manifestations may appear at a blood alcohol concentration of > 0.3 to 0.5 g/L, which corresponds to the ingestion of 2 glasses of wine (2 x 125 ml) or beer (2 x 250 ml) or a glass of 40% alcohol (50 ml). A blood alcohol concentration > 4 g/L is considered to pose a high risk of death.

Initially, there is an alcoholic odor, disinhibition, and cognitive-motor agitation. At more advanced stages of intoxication, there may be balance and coordination disturbances, visual impairments, memory disturbances, speech disturbances, and aggression, followed by drowsiness, nausea and vomiting, and polyuria. At a more severe stage, which poses a vital risk, marked vigilance disturbances (stupor, agitated coma, then calm hypotonic coma) may occur, along with respiratory depression, delusions with aggression and/or hallucinations, and cardiac arrhythmias.

The medical history should aim to clarify the circumstances of ingestion, the presence of abdominal pain, gastrointestinal bleeding, trauma, loss of consciousness, convulsions, the use of other toxic substances and medications, and the patient’s medical history (particularly diabetes, epilepsy, cardiovascular conditions).

"Hypersensitivity" or "Intolerance" to Alcohol

Some individuals, due to a genetic defect in hepatic alcohol metabolism, may present with disproportionately high blood alcohol levels in relation to very small amounts of alcohol. These acute alcohol intoxications are sometimes improperly termed "pathological intoxication" (all intoxication is pathological). The only recommended course of action is alcohol abstinence.

Additionally, there have been reports of individuals experiencing acute alcohol intoxication without any alcohol consumption but after meals rich in carbohydrates. This occurs in individuals with an abnormally high rate of intestinal fermentation (gut flora overly rich in yeast) and/or a defect in hepatic alcohol metabolism. These patients may be advised to follow a low-carbohydrate diet, abstain from alcohol, and receive antifungal treatment.

These cases should be differentiated from signs of intoxication or intolerance to substances other than ethanol that may be present in certain alcoholic beverages (e.g., sulfites or pesticides in wine), whose symptoms often overlap with those of alcohol intoxication.

Complications

In addition to the aforementioned manifestations, many potentially serious complications can occur acutely:

• Falls and trauma (particularly head trauma)
• Hypoglycemia (due to inhibition of gluconeogenesis by alcohol), especially in diabetic patients and malnourished alcoholics
• Hypothermia
• Seizures and status epilepticus
• Aspiration pneumonia
• Acute pancreatitis (rare)
• Upper gastrointestinal bleeding (gastritis, peptic ulcer, Mallory-Weiss tear)
• Rhabdomyolysis
• Arrhythmias
• Cardiorespiratory depression
• Alcoholic ketoacidosis

It should be noted that the occurrence of cardiorespiratory arrest during alcohol intoxication is exceptional and should always prompt a search for a complication (hypothermia? septic shock? arrhythmia?), an intercurrent condition, or the use of other toxic substances and psychotropics.

Other complications may occur if there is a context of chronic alcohol use:

• Wernicke's encephalopathy and Korsakoff's syndrome
  • Precipitated by the administration of glucose-containing infusions without vitamin supplementation (consumption of vitamin B1 reserves by carbohydrate metabolism in deficient patients)
• Marchiafava-Bignami encephalopathy (suspected direct toxicity of alcohol)
• Alcohol withdrawal syndrome during management

Additional Examinations

To be performed systematically upon admission:

• Fingerstick blood glucose and then venous glucose
• Ethanol level

No other additional examination should be systematic. Depending on clinical needs, the following may be considered:

• Electrocardiogram
• Laboratory tests
• Urinary and/or blood toxicology
• Arterial blood gases
• Chest X-ray
• Brain CT scan (if there is a history of head trauma or visible craniofacial injuries, focal neurological deficits, altered consciousness, diagnostic uncertainty, etc.)
• Bone X-rays
• Electroencephalogram
• Esophagogastroduodenoscopy
• ...

Legal Implications

Responsibilities of an Emergency Department

Whether the patient presents voluntarily or not, any individual in a state of acute ethanol intoxication must be admitted. The immediate approach, prescription of additional tests, and disposition (simple observation, hospitalization, intensive care) will depend on the clinical situation, the patient’s age, blood glucose levels, and ethanol levels. If the patient wishes to leave against medical advice or refuses tests, they must sign a waiver, or if they refuse, this must be documented in the medical record in the presence of witnesses.

In cases of uncontrollable agitation or aggression or delirium, the approach is the same as in other circumstances.

When a physician is summoned by the police to perform an ethanol level test, it can only be done with the informed consent of the patient, free from any pressure. When the summons involves a clinical examination, refer to the chapter on "Certificate of Non-Admission" or "Seen and Treated". In case of disagreement or pressure from police officers, contact the responsible magistrate if necessary.

Interpretation of Ethanol Levels

The measurement of ethanol levels has prognostic and legal implications, particularly in cases of brawls or accidents (legal maximum for driving in Belgium = 0.5 g/L).

Relationship Between Ethanol Levels and Alcohol Consumption

Ethanol is fully absorbed into the blood approximately 1 hour after ingestion. Its metabolism varies between individuals from 0.08 to 0.22 g/L/hour (average: 0.15 g/L/h) and is slowed in cases of liver pathology. The distribution coefficient of ethanol relates to its non-dissolution (hydrophilic, lipophobic) in fats → 0.68 in men, 0.55 in women.

Subject to individual variations, the ethanol level one hour after consumption = ethanol mass / (body mass x ethanol distribution coefficient).

The ethanol distribution coefficient is 0.68 for men and 0.55 for women. The ethanol mass = ethanol volume x ethanol density (0.789 g/mL). Alcohol volume = "alcohol degree" (mL alcohol/100 mL) x drink volume (in mL) / 100.

Example:

When a 70 kg man reports drinking 1 liter of "regular" beer (pils, 5.2% alcohol) → ethanol volume = 5.2 mL/100 mL x 1000 mL = 52 mL ethanol → ethanol mass = 52 x 0.789 (specific gravity of alcohol) = 41.028 g → expected ethanol level one hour after ingestion = 41.028 / (70 x 0.68) = 0.86 g/L. Conversely, a 100 kg man with a blood alcohol level of 2 g/L one hour after consumption → ethanol mass = 2 x 100 x 0.68 = 136 g → estimated volume of pils beer consumed 136 / 41.028 = 3.3 L of pils beer…

Average ethanol levels one hour after consuming:

• 1 glass of pils beer (250 mL) → 0.22 g/L
• 1 glass of wine (125 mL) → 0.25 g/L
• 1 glass of 40° alcohol (50 mL) → 0.33 g/L

How to Determine Ethanol Levels at a Time Prior to Sampling?

The "last drink" issue: if consumption occurred less than an hour ago, the ethanol level has not yet reached its peak, so a part of it must be subtracted: it is in the rising phase.

Example: A patient has a blood alcohol level of 2 g/L one hour after the event. They had a last beer 30 minutes before the event. The event therefore occurred during the rising phase of the ethanol level, which had not yet reached the maximum concentration → at the time of the event, the ethanol level can be estimated at 2.00 - 0.22/2 = 1.89 g/L (only half of the last beer could have been absorbed at most).

If consumption occurred more than an hour ago, it is in the descending phase: the metabolized part should be added.

Example: More than an hour after drinking heavily (→ maximum ethanol level already reached), the patient commits the act → a sample is taken one hour after the event showing an ethanol level of 2 g/L → the concentration at the time of the event was 2.00 + 0.15 = 2.15 g/L (note: 0.15 g metabolized in 1 hour on average).

Therapeutic Management - Treatments

Immediate management of vital emergencies (hypothermia, shock, severe sepsis, arrhythmias, status epilepticus, respiratory distress, etc.).

Correction of hypoglycemia.

Systematic management:

• Nursing care
• Hydration and vitamin therapy (prevention of Wernicke’s syndrome):
  • If intravenous infusion is needed: 5% glucose solution or mixed IV (never without vitamins) + electrolytes if necessary + Vitamin B1 (= thiamine, 500 to 1500 mg/24 hours), B6 (pyridoxine, 250 mg/24 hours) + B12 and PP (e.g., Cernevit 1 ampoule/24 hours)
  • Otherwise, stimulate oral hydration and vitamin therapy (e.g., Befact)
• Management of any agitation or aggression (balance the risk of respiratory depression with the need for sedation and the risk of withdrawal if benzodiazepines are used)
• Protection against cold
• Anti-ulcer prophylaxis
• Specific management of any complications and intercurrent pathologies or other toxicities
• If respiratory failure or severe altered consciousness → discuss intubation and mechanical ventilation
• If deep coma + ethanol level > 5 g/L → discuss hemodialysis with the intensivist
• Persistence of symptoms beyond 24 hours should prompt reevaluation of the diagnosis or consideration of complications
• Psychiatric consultation in cases of known psychiatric disorders
• Gastric lavage is generally unnecessary (rapid absorption of ethanol). It should be considered in cases of ingestion of other toxins or very recent severe intoxication.

Patient Disposition:

• Resuscitation / Intensive Care:
  • Severe ethanol intoxications (signs of vital distress, coma, delirium, status epilepticus, complications with signs of severity suggesting a life-threatening situation)
  • Independently, an ethanol level > 4 g/L should prompt discussion about monitoring under observation and medical supervision for at least 24 hours.
• Hospitalization:
  • Any other cases for minor patients (in case of disagreement from parents: have them sign a waiver or contact the on-duty magistrate in cases of complicated intoxication or suspicion of abuse)
  • Other complicated ethanol intoxications
• Keep the patient in the emergency department / "observation" unit for a few hours until an adequate level of contact is restored in cases of uncomplicated acute ethanol intoxication but with inappropriate behavior
• Discharge in other cases, after obtaining blood glucose and ethanol levels

Note that a request for hospitalization for withdrawal through the emergency department, even in cases of acute ethanol intoxication, is generally not a valid reason for hospitalization (marginal success rate under such circumstances), unless there is contrary psychiatric advice. In cases of chronic etilism or problematic consumption, refer the patient to their primary care physician or appropriate outpatient facilities.

Author

Dr Shanan Khairi, MD

Bibliography

Cowan E et al., Ethanol intoxication in adults, UpToDate, 2021

EMC, Traité de médecine AKOS, Elsevier, 2018