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Approach to the Critical Patient
Immediate priorities
First look stabilization
Airway protection concern
GCS 8 or less with loss of protective reflexes
Recurrent emesis with inability to protect airway
Copious secretions or aspiration concern
Breathing compromise
RR less than 8 or apneic episodes
SpO2 less than 92% on room air
Suspected aspiration pneumonitis
Circulatory instability
SBP less than 90 mmHg after positioning
Shock index greater than 1
Active bleeding or major trauma concern
Immediate bedside tests
Capillary glucose
Core temperature
Monitoring and access
Continuous pulse oximetry
Supplemental oxygen if hypoxemic
High flow or NIV only if airway reflexes intact
Cardiac monitoring
Dysrhythmia triggers
QT prolongation triggers
IV access
Two large bore IVs if trauma or hypotension
IO access if unable to obtain IV and unstable
Frequent reassessment interval
Every 5 to 15 minutes if unstable
Every 30 to 60 minutes if improving
High risk features
Red flag features
Head trauma or anticoagulant use
New focal neurologic deficit
Persistent altered level of consciousness
Co-ingestion concern
Suspected opioids
Suspected sedative hypnotics
Metabolic or infectious alternative
Fever
Meningismus
Severe toxidrome
Seizure
Severe agitation with hyperthermia
Immediate triggers for escalation
Escalation triggers
If hypoglycemia, then immediate dextrose protocol
Glucose less than 3.0 mmol/L
Recheck glucose in 10 minutes
If suspected opioid co-ingestion, then naloxone protocol
Bradypnea or apnea
Pinpoint pupils with hypoventilation
If refractory vomiting or aspiration, then airway management pathway
Inability to tolerate positioning
SpO2 decline despite oxygen
If severe agitation, then chemical sedation pathway
Threat to staff safety
Unable to complete essential evaluation
Key concepts
Clinical framing
Alcohol intoxication is a diagnosis of exclusion until dangerous alternatives addressed
Ethanol level poorly predicts clinical impairment in tolerant patients
Altered mental status requires glucose check before attributing to ethanol
History
Focused intoxication history
Exposure details
Time of last known normal
Time of last drink
Time of first symptoms
Amount and type of alcohol
Spirits versus beer versus mixed drinks
Homemade or non beverage alcohol concern
Route and context
Drinking games or binge pattern
Possible assault or drink spiking concern
Co-ingestion risks
Opioids
Prescription access
Witnessed pill use
Sedative hypnotics
Benzodiazepines
Z drugs
Stimulants
Cocaine
Amphetamines
Toxic alcohols
Antifreeze exposure
Windshield washer fluid exposure
Medical risk context
Baseline health
Diabetes
Insulin use
Prior severe hypoglycemia
Seizure disorder
Antiepileptic adherence
Recent seizures
Liver disease
Variceal bleeding history
Hepatic encephalopathy history
Psychiatric risk
Intentional ingestion concern
Suicidal thoughts screening when able
Trauma and environment
Falls
Head strike
Loss of consciousness
Exposure
Cold exposure
Immobility duration
Withdrawal risk
Alcohol use pattern
Daily heavy use
Morning drinking
Prior withdrawal symptoms
Prior severe withdrawal
Withdrawal seizure history
Delirium tremens history
Last drink timing
Less than 8 hours
Greater than 8 to 24 hours
Physical Exam
Primary survey findings
Airway and aspiration
Gag and cough reflexes
Pooling secretions
Gurgling respirations
Emesis evidence
Oropharyngeal debris
Vomit on clothing
Respiratory status
Work of breathing
Accessory muscle use
Hypoventilation
Lung exam
New crackles
Wheeze after aspiration
Circulation and perfusion
Skin perfusion
Capillary refill
Cool clammy skin
Heart rate rhythm
Irregularly irregular rhythm
Tachycardia out of proportion
Neurologic and toxidrome assessment
Mental status
GCS components
Eye opening
Verbal response
Motor response
Orientation and attention
Able to follow commands
Fluctuating course
Pupils and eye findings
Size and reactivity
Pinpoint pupils
Fixed dilated pupils
Nystagmus
Horizontal nystagmus
Vertical nystagmus concern for alternate tox
Motor and cerebellar
Ataxia
Unable to ambulate safely
Truncal instability
Focal deficits
Facial droop
Unilateral weakness
Trauma and complications
Head and neck
Scalp hematoma
Basilar skull signs
Facial fractures
C spine tenderness
Midline pain
Neurologic symptoms
Skin and temperature
Hypothermia signs
Core temperature less than 35.0 C
Shivering absent in severe hypothermia
Injection marks
Fresh puncture sites
Cellulitis
PITFALLS
Common misses
Intracranial hemorrhage attributed to intoxication
Persistent AMS despite falling ethanol level
New headache or repeated vomiting
Hypoglycemia attributed to intoxication
Diaphoresis
Seizure
Toxic alcohol ingestion mislabeled as ethanol
High anion gap metabolic acidosis
Visual complaints when awake
Differential Diagnosis
Life threats and mimics
Altered mental status differentials
Hypoglycemia
ICD-10 E16.2
SNOMED 302866003
Opioid toxicity
ICD-10 T40.2X1A to T40.4X1A
SNOMED 55680006
Intracranial hemorrhage
ICD-10 I61.9
SNOMED 274100004
Ischemic stroke
ICD-10 I63.9
SNOMED 422504002
CNS infection
ICD-10 G00.9
SNOMED 7180009
Sepsis
ICD-10 A41.9
SNOMED 91302008
Alcohol related conditions
Alcohol intoxication and toxicity
Uncomplicated acute ethanol intoxication
ICD-10 F10.129
SNOMED 191772003
Alcohol poisoning toxic effect of ethanol
ICD-10 T51.0X1A
SNOMED 295995006
Alcohol ketoacidosis
ICD-10 E87.2
SNOMED 190502000
Wernicke encephalopathy
ICD-10 E51.2
SNOMED 20496006
Co-ingestions and metabolic
Sedative hypnotic intoxication
Benzodiazepine toxicity
ICD-10 T42.4X1A
SNOMED 406506008
Z drug toxicity
ICD-10 T42.6X1A
SNOMED 293010000
Toxic alcohol ingestion
Methanol
ICD-10 T51.1X1A
SNOMED 13732003
Ethylene glycol
ICD-10 T52.3X1A
SNOMED 13732003
Hypercapnia from hypoventilation
ICD-10 R06.89
SNOMED 271825005
Laboratory Tests
Bedside and core labs
Immediate screening labs
Point of care glucose
Hypoglycemia threshold less than 3.0 mmol/L
Recheck after treatment in 10 minutes
Serum ethanol concentration
Trend with clinical course rather than absolute value
Consider delayed peak with continued absorption
Electrolytes and renal function
Sodium
Potassium
Venous blood gas
pH
pCO2 in mmHg
Metabolic complication evaluation
Anion gap and bicarbonate
High anion gap metabolic acidosis triggers toxic alcohol workup
Low bicarbonate triggers ketone evaluation
Serum beta hydroxybutyrate
Alcohol ketoacidosis support
DKA alternative consideration
Serum lactate
Seizure or hypoperfusion signal
Sepsis alternative consideration
Toxic alcohol and osmolar evaluation
Osmolar assessment
Serum osmolality measured
Osmolar gap supports toxic alcohol concern
Gap may normalize late in course
Toxic alcohol surrogate markers
Calcium oxalate crystals in urine for ethylene glycol
Visual symptoms for methanol when awake
Co-ingestion labs as indicated
Acetaminophen level
Intentional ingestion screening
Repeat per nomogram timing if early
Salicylate level
Tinnitus
Hyperventilation with mixed acid base
Additional labs by scenario
Trauma and rhabdomyolysis
Creatine kinase
Immobilization concern
Dark urine concern
Urinalysis
Heme positive with few RBCs
Myoglobinuria support
Hepatic and bleeding risk
AST ALT
Hepatic injury
Baseline liver disease
INR
Coagulopathy assessment
Head trauma threshold lowering
Pregnancy
Beta hCG
Females of reproductive potential
Imaging selection impact
Interpretation pitfalls
Limitations
Ethanol level correlation limitations
Tolerance produces fewer signs at high levels
Severe impairment at low levels in naive patients
Urine drug screen limitations
False positives
Misses synthetic opioids depending on assay
Diagnostic Tests
Scoring Systems
Structured assessment tools
Glasgow Coma Scale
Trend over time is key
Persistent low score triggers airway and head CT consideration
Richmond Agitation Sedation Scale
Guides sedation titration
Target calm cooperative range 0 to minus 1 when feasible
CIWA Ar for withdrawal risk when awake
Symptom triggered benzodiazepine strategy support
Not valid in severe AMS
MRI
MRI brain considerations
Indications
Persistent focal deficits with negative CT
Suspected posterior circulation stroke
Limitations
Limited availability in unstable patient
Motion artifact with agitation
Alternative diagnoses
Demyelination
Encephalitis patterns
CT
CT indications in intoxication
CT head without contrast
Head trauma with LOC or amnesia
Persistent AMS not improving as expected
CT cervical spine
Midline neck tenderness
Neurologic deficit
CT chest if aspiration complication concern
Severe hypoxemia
Suspected pneumonia complications
CT abdomen pelvis if pancreatitis or trauma concern
Severe abdominal pain
Peritonitis
Ultrasound
Bedside ultrasound applications
Lung ultrasound for aspiration or edema
B lines patterns
Consolidation with dynamic air bronchograms
FAST exam if trauma concern
Hypotension with unclear source
Unreliable history
Cardiac POCUS if shock
Pericardial effusion
Gross LV function
Disposition
Level of care decisions
Discharge eligibility
Clinical sobriety
Alert and oriented to baseline
Ambulates safely
Stable vitals
SpO2 92% or higher on room air
Normothermia
Safe supervision plan
Responsible adult escort
No driving plan
Observation or admission indications
Persistent altered mental status
Not improving with time and supportive care
Concern for alternate diagnosis
Complications
Aspiration pneumonia concern
Rhabdomyolysis concern
Co-ingestion or intentional overdose concern
Psychiatric evaluation required
Toxicology consultation required
Higher acuity and transfer
ICU indications
Airway intervention required
Intubated
Recurrent apnea
Severe acid base disturbance
pH less than 7.1
Rising pCO2 with hypoventilation
Refractory agitation requiring infusion
Continuous sedative infusion
Persistent hyperthermia
Withdrawal pathway disposition
High risk withdrawal
Prior delirium tremens
Prior withdrawal seizures
Medically complicated withdrawal
Severe electrolyte derangements
Concurrent infection or GI bleed
Treatment
Supportive care
Core supportive measures
Positioning and airway protection
Lateral decubitus positioning if vomiting risk
Suction readiness
Temperature management
Passive rewarming for mild hypothermia
Active rewarming if core temperature less than 32.0 C
Fluids
Isotonic crystalloid 500 mL bolus if hypotension
Repeat bolus to MAP 65 mmHg if volume responsive
Consider alternate shock cause if no response
Avoid routine fluids solely for ethanol clearance
No proven acceleration of sobriety
Volume overload risk in frail patients
Hypoglycemia and nutrition
Glucose and thiamine strategy
Thiamine IV 100 mg
Give before or with dextrose when malnutrition risk
Chronic alcohol use
Poor oral intake
Repeat daily while inpatient if risk persists
Ongoing malnutrition
Concern for Wernicke
Dextrose for hypoglycemia
Dextrose 10% IV 150 mL
Recheck glucose in 10 minutes
Repeat if glucose remains less than 4.0 mmol/L
If no IV, then glucagon 1 mg IM
Less effective in depleted glycogen states
Bridge until IV access obtained
Nausea and vomiting
Antiemetic options
Ondansetron 4 mg IV
Repeat 4 mg in 15 to 30 minutes if persistent
QT prolongation caution
Metoclopramide 10 mg IV
Dystonia risk
Avoid in suspected obstruction
Aspiration prevention adjuncts
NPO until awake and swallowing intact
Consider NG suction only if airway protected and severe gastric distention
Agitation and behavioral control
Nonpharmacologic de-escalation
Low stimulation environment
Dim lights
Reduce crowding
One to one observation
Fall risk
Elopement risk
Chemical sedation for severe agitation
Droperidol 2.5 mg to 5 mg IM or IV
Repeat 2.5 mg to 5 mg every 15 minutes as needed
Target calm cooperative state
Avoid oversedation with rising ethanol level
QT monitoring if high cumulative dose or risk factors
Baseline QT prolongation
Concurrent QT prolonging drugs
Haloperidol 2 mg to 5 mg IM or IV
Repeat 2 mg to 5 mg every 20 to 30 minutes as needed
Extrapyramidal symptom risk
Consider diphenhydramine rescue if dystonia
Avoid as sole agent for withdrawal seizures risk
Does not treat withdrawal physiology
Lowers seizure threshold
Midazolam 2 mg IM or IV
Repeat 1 mg to 2 mg every 5 to 10 minutes as needed
Respiratory depression risk with ethanol
Continuous monitoring required
Avoid large front loading in older adults
Delirium risk
Prolonged sedation
Respiratory depression and co-ingestion
Naloxone pathway when indicated
Naloxone 0.04 mg IV
Escalate to 0.4 mg IV if no response
Escalate to 2 mg IV if persistent apnea
Titrate to adequate ventilation not full arousal
Consider infusion if repeated boluses required
Infusion rate two thirds of effective wake up dose per hour
Monitor for renarcotization
Wernicke encephalopathy and severe deficiency
High suspicion treatment
Thiamine IV 500 mg
Every 8 hours for 2 to 3 days if Wernicke concern
Ophthalmoplegia or nystagmus
Ataxia
Then thiamine IV 250 mg daily for 3 to 5 days
Transition to oral thiamine when eating
Add magnesium repletion if low
Alcohol withdrawal overlap
Withdrawal treatment if emerging
Diazepam 10 mg PO or IV
Repeat 10 mg every 10 to 20 minutes to symptom control
Aim for CIWA guided control when awake
Monitor respiratory status closely
Avoid in severe liver disease if prolonged sedation risk
Prefer lorazepam
Dose reduction
Lorazepam 2 mg IV
Repeat 1 mg to 2 mg every 10 to 20 minutes as needed
Better in hepatic impairment
Less active metabolites
Evidence and guideline notes
Evidence aligned practice points
Airway protection and ventilation in poisoning is consistent with resuscitation consensus
ACLS airway and breathing principles support early airway control in failure
Class I recommendation for airway and ventilation when indicated
Routine IV fluids do not reliably hasten ethanol clearance
Use fluids for hypovolemia or hypotension not for sobriety speed
ACEP Level C consensus aligned practice point
Special Populations
Pregnancy
Pregnancy considerations
Maternal stabilization priority
Airway and oxygenation targets to avoid fetal hypoxia
Left lateral positioning if late pregnancy
Fetal risk context
Binge exposure risk counseling when sober
Domestic violence screening when safe
Medication considerations
Ondansetron use risk benefit discussion when needed
Benzodiazepines only when clear indication
Geriatric
Older adult considerations
Higher risk of intracranial hemorrhage
Lower threshold for CT head after fall
Anticoagulant and antiplatelet review
Lower physiologic reserve
Increased aspiration risk
Hypothermia risk
Medication sensitivity
Lower initial sedative doses
Avoid prolonged restraint and oversedation
Pediatrics
Pediatric considerations
Weight based dosing required
Dextrose 10% 5 mL per kg for hypoglycemia
Ondansetron 0.15 mg per kg IV maximum 8 mg
Alternate diagnosis emphasis
Ingestion is nonaccidental injury concern
Hypoglycemia and seizures more common
Safeguarding and reporting
Child protection involvement when indicated
Unsafe home environment concern
Background
Epidemiology
Frequency and burden
Common ED presentation for altered mental status
High association with trauma and aspiration
High association with polysubstance use
High risk groups
Adolescents and young adults binge patterns
Older adults with falls
Mortality drivers
Airway compromise and aspiration
Co-ingestions and hypothermia
Pathophysiology
Ethanol effects
CNS depression via GABA and NMDA modulation
Dose dependent sedation
Impaired airway reflexes at high levels
Hypoglycemia mechanisms
Inhibits gluconeogenesis
Higher risk with poor nutrition and prolonged fasting
Alcohol ketoacidosis mechanism
Starvation state with increased ketogenesis
Often with vomiting and volume depletion
Therapeutic Considerations
Treatment principles
Supportive care is primary therapy
Time and monitoring for most uncomplicated cases
Treat complications rather than ethanol itself
Thiamine for deficiency prevention and treatment
Low risk intervention
High benefit when Wernicke risk present
Sedation strategy
Use lowest effective dose
Prefer agents with predictable onset for acute agitation
Patient Discharge Instructions
copy discharge instructions
Discharge guidance
No driving or operating machinery for 24 hours
Arrange safe ride home
Avoid being alone if still drowsy
Hydration and nutrition
Oral fluids as tolerated
Light meal when nausea resolves
Avoid mixing substances
No opioids or sedatives
No additional alcohol today
Return to ED immediately
Worsening confusion or inability to wake fully
New trouble breathing
Repeated vomiting
New severe headache or weakness
Vision changes
Seizure
Chest pain or severe abdominal pain
Black stools or vomiting blood
Persistent fast heartbeat
Follow up and support
Primary care follow up within 1 week if recurrent episodes
Discuss alcohol use and safety planning
Screening for withdrawal risk
Community support options if desired
Addiction services referral
Counseling resources
References
Clinical guidelines and evidence sources
Emergency medicine toxicology references
ACEP clinical policy framework for evidence levels
Level A strongest evidence
Level B moderate evidence
Toxicology society position statements on airway management in poisoning
Early airway control when protective reflexes lost
Continuous monitoring after sedatives
Resuscitation guidance
AHA ACLS principles for airway and ventilation in poisoned patients
Class I support for oxygenation and ventilation when indicated
Continuous monitoring after opioid reversal
Coding references
ICD-10 and SNOMED mapping
Alcohol intoxication ICD-10 F10.129
Alcohol dependence ICD-10 F10.20 when relevant
Toxic effect of ethanol ICD-10 T51.0X1A for poisoning
SNOMED alcohol intoxication 191772003
SNOMED Wernicke encephalopathy 20496006
SNOMED hypoglycemia 302866003
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.