Acute Ethanol Intoxication

An increased reaction time, diminished fine motor control, impulsivity, and impaired judgment become evident when the concentration of ethanol in the blood is 20-30 mg/dL. More than 50% of persons are grossly intoxicated by a concentration of 150 mg/dL. In fatal cases, the average concentration is -400 mg/dL, although alcohol-tolerant individuals often can withstand comparable BALs. The definition of intoxication varies by state and country. In the U.S., most states set the ethanol level defined as intoxication at 80 mg/dL. There is increasing evidence that lowering the limit to 50-80 mg/dL can reduce motor vehicle injuries and fatalities significantly. While alcohol can be measured in saliva, urine, sweat, and blood, measurement of levels in exhaled air remains the primary method of assessing the level of intoxication.

Many factors, such as body weight and composition and the rate of absorption from the GI tract, determine the concentration of ethanol in the blood after ingestion of a given amount of ethanol. On average, the ingestion of three standard drinks (42 g ethanol) on an empty stomach results in a maximum blood concentration of 67-92 mg/dL in men. After a mixed meal, the maximal blood concentration from three drinks is 30-53 mg/dL in men. Concentrations of alcohol in blood will be higher in women than in men consuming the same amount of alcohol because, on average, women are smaller than men, have less body water per unit of weight into which ethanol can distribute, and have less gastric ADH activity than men. For individuals with normal hepatic function, ethanol is metabolized at a rate of one standard drink every 60-90 minutes.

The characteristic signs and symptoms of alcohol intoxication are well known. Nevertheless, an erroneous diagnosis of drunkenness may occur with patients who appear inebriated but who have not ingested ethanol. Diabetic coma, for example, may be mistaken for severe alcoholic intoxication. Drug intoxication, cardiovascular accidents, and skull fractures also may be confused with alcohol intoxication. The odor of the breath of a person who has consumed ethanol is due not to ethanol vapor but to impurities in alcoholic beverages. Breath odor in a case of suspected intoxication can be misleading because there can be other causes of breath odor similar to that after alcohol consumption. BALs are necessary to confirm the presence or absence of alcohol intoxication.

The treatment of acute alcohol intoxication is based on the severity of respiratory and CNS depression. Acute alcohol intoxication can be a medical emergency, and a number of young people die every year from this disorder. Patients who are comatose and who exhibit evidence of respiratory depression should be intubated to protect the airway and to provide ventilatory assistance. The stomach may be lavaged, but care must be taken to prevent pulmonary aspiration of the return flow. Since ethanol is freely miscible with water, ethanol can be removed from blood by hemodialysis.

Acute alcohol intoxication is not always associated with coma, and careful observation is the primary treatment. Usual care involves observing the patient in the emergency room for 4-6 hours while the patient metabolizes the ingested ethanol. BALs will be reduced at a rate of -15 mg/dL/hr. During this period, some individuals may display extremely violent behavior. Sedatives and antipsychotic agents have been employed to quiet such patients, but great care must be taken when using sedatives to treat these patients because of possible synergistic CNS depressant effects.

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