I wonder if there is an Emergency Department out there that has never dealt with an intoxicated patient. My guess is no. When a patient smells like booze and is acting a fool it is easy to put them in a box and early anchor on alcohol intoxication as the diagnosis. These patients can be challenging. They can be aggressive towards you and your staff. Your staff may not care for these patients like other patients because maybe the patient is rude, disheveled or smells bad. Chronic alcoholics who repeatedly visit the ED can be viewed by staff as abusing the system. No matter how hard the situation gets it is your job to be an advocate for the patient.
Approaching an intoxicated patient should be no different than approaching any other patient. Start with a critical differential diagnosis.
Critical Differential
BHT with Intracranial hemorrhage
Meningitis Encephalitis -esp important if the patient is altered and febrile.
Hypoglycemia
Infection
Intoxication
Having a strong critical differential diagnosis will allow you to pick up potentially life-threatening conditions that are potentially confounded by the intoxicated state of the patient.
Your critical differential diagnosis will guide your history and physical exam.
Make sure to look for blunt head trauma. Look for signs of basal skull fractures (Raccoon eyes, Battle sign, etc).
You will remember to check for neck stiffness and fever which would represent meningitis.
You will check the eyes and the axilla (the tox handshake) to ensure that there isn’t evidence of a toxidrome.
You don’t want to put a patient in the drunk tank only to find out hours later that he was hit by a car and has intraabdominal bleeding or has some other life-threatening condition. That would be an automatic ticket to the M&M show.
Do I Need To Order Labs
No. If you were able to rule out all the diagnoses on your critical differential via history and physical exam then you do not need to order any labs. Also getting an alcohol level is not necessary. If the patient is obviously intoxicated you don’t need a number to make you feel better that he or she is intoxicated. If there is any doubt that the patient has alcohol intoxication then you can consider getting an alcohol level. This way if the level comes back zero then you know you have to go fishing for another cause of the patient’s altered mental status.
So You’ve Ruled Out Something Bad Now What
Technically you can’t discharge a patient until they are sober. Clinical sobriety is determined by a patient’s ability to walk, answer questions appropriately, and appear in general to be sober. Chronic alcoholics have GABA receptor modulation and as a result, they will be clinically sober even when their alcohol level is above zero. If you wait for a chronic alcoholics alcohol level to return to zero they will withdraw which opens up a whole new pandora’s box.
So How Long Will It Take For Your Patient To Become Sober?
In general, alcohol is cleared at a Zero Order rate which means nothing you do will cause a person to sober faster. Although it is difficult to study the rate of metabolism is believed to be around 25 mg/dl/hour. Caffeine, IVFs, nothing will clear alcohol faster.
So with that knowledge let’s go over the intoxication profile of patients (understanding that everyone is different)
So every 4 hours we would hope for an appreciable improvement in the patient’s mental status. If this does not happen you need to go back to your critical differential diagnosis. Make sure the patient doesn’t have an epidural.
Be An Advocate For Your Patient
It’s important to be a steward of your patient. If they are intoxicated, elope from the ED, and get hit by a car, you are responsible for the patient’s injuries. If the patient is starting to become agitated, you may need to sedate him or her until they are clinically sober. Always take control of the situation before it’s too late.
And with all of this, you should now have the framework to work with alcohol-intoxicated patients.
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