Intoxication—most commonly due to alcohol but also from drugs, toxins, and metabolic disorders—is one of the most frequent presentations in the emergency department. Although many cases seem straightforward, serious, life-threatening conditions can mimic simple intoxication.
This guide simplifies the assessment and management of intoxicated patients using the framework from your uploaded chart.
Why Intoxication Evaluation Matters
Patients appearing “drunk” may actually have:
- Intracranial hemorrhage (ICH)
- Hypoglycemia
- Hypothermia
- Stroke
- Sepsis
- Trauma
Therefore, emergency clinicians must never assume alcohol is the sole cause of altered behavior.
The First 4 Mandatory Steps (From Chart)
Before labeling a patient as intoxicated, complete these four priority assessments:
1. Fingerstick glucose (FS)
Rule out hypoglycemia — a reversible life-threatening mimic.
2. Undress and examine completely
Subtle trauma, bleeding, infections, hypothermia, or skin signs may be hidden.
3. Evaluate for signs of trauma
If trauma is possible:
→ Low threshold for CT head
4. Check for epigastric tenderness
If present:
→ Low threshold for pancreatitis workup
These initial steps prevent misdiagnosis and missed emergencies.
Key Decision: Are You Confident It’s ONLY Alcohol?
The chart centers on the critical decision:
Does the patient appear intoxicated ONLY from alcohol?
Indicators supporting alcohol intoxication:
- Alcohol smell on breath
- Patient admits to drinking
- History of frequent alcohol visits
- No red flags
If YES, manage as isolated alcohol intoxication.
If NO, broaden to the Altered Mental Status (AMS) differential (AEIOU TIPS).
Pathway 1: Confident It’s Alcohol Intoxication (Left Side of Chart)
Treatment & Management
1. Give IM/IV thiamine (± folate)
Prevents Wernicke’s encephalopathy in chronic alcohol users.
2. Observe until sobriety
Patient must become:
- Alert & oriented (A&O ×3)
- Walking with a steady gait
3. If not waking → CT head
Failure to improve suggests occult trauma or intracranial bleeding.
4. Severely intoxicated patients
Monitor closely:
- Pulse oximetry
- Capnography
- Use nasal trumpet if needed
- Cardiac monitoring
5. Reassess every 1–2 hours
Track improvement in mentation and vitals.
6. Once sober
Evaluate for:
- Suicidal ideation (SI)
- Homicidal ideation (HI)
- Safety before discharge
Pathway 2: NOT Confident It’s Alcohol (Right Side of Chart)
If the presentation is not perfectly consistent with alcohol, consider other causes of AMS.
Expand diagnostic evaluation using:
- Alcohol level
- ASA level
- Acetaminophen (APAP) level
- Urine toxicology
- Electrolytes
- CT head
- Infectious workup
- AEIOU TIPS (Alcohol, Electroytes, Insulin, Opiates, Uremia, Trauma, Toxins, Tumor, Thyroid, Infection, Polypharmacy, Stroke)
Examples where you must broaden evaluation:
- No smell of alcohol
- Patient denies drinking
- Abnormal vitals
- Focal neurological deficits
- Unequal pupils
- Seizure activity
- Unusual behavior for intoxication
- Elderly or anticoagulated patients
- No improvement over time
If there is failure to sober appropriately, escalate to full AMS workup.
Pearls & Pitfalls (Directly from the Chart)
✔ Beware of intoxication mimics
Conditions that closely resemble alcohol intoxication:
- Intracranial hemorrhage (ICH)
- Hypoglycemia
- Hypothermia (especially outdoors)
✔ Watch for developing withdrawal
Alcohol withdrawal can begin hours after the last drink and may progress to delirium tremens.
✔ Alcohol level is NOT a measure of sobriety
A high ethanol level does not mean the patient must appear profoundly intoxicated — and vice versa.
Therefore: Do NOT routinely check ethanol levels to determine readiness for discharge.
Diagnostic Considerations in Alcohol Intoxication
While many cases are straightforward, clinicians should look for:
1. Trauma
A big concern because intoxicated patients:
- Fall easily
- Forget events
- Underreport pain
- Show unreliable neurological exams
Thus → Low threshold for CT imaging
2. Hypoglycemia
Must be ruled out immediately because:
- Alcohol suppresses gluconeogenesis
- Symptoms mimic drunkenness
- Delayed treatment causes brain injury
3. Pancreatitis
Alcohol is a classic cause.
Clue → Epigastric tenderness
4. Co-ingestion
Look for:
- Sedatives
- Opioids
- Stimulants
- Toxic alcohols
- Acetaminophen overdose
5. Hypothermia
Intoxicated individuals may be exposed to cold environments.
Withdrawal Considerations
While the focus is intoxication, withdrawal is important.
Look for:
- Tremors
- Tachycardia
- Anxiety
- Sweating
- Seizures
- Hallucinations
If withdrawal is suspected → benzodiazepines + supportive care.
Disposition & Reassessment
Before discharge, the patient must be:
- Alert and oriented (A&O ×3)
- Steady gait
- No focal neurological deficits
- No new complaints
- Clinically sober
Reassess regularly during observation.
Documentation Essentials (From Chart)
General/Neurologic
- GCS
- Exams consistent with intoxication
- Reassessment notes
History
- Pattern of alcohol use
- Witness accounts
- EMS notes
HEENT
- Signs of trauma
- Pupils equal & reactive (PERRL)
Abdominal
- Epigastric tenderness (pancreatitis clues)
Skin
- Cellulitis
- Abrasions
- Lacerations
Before discharge
Document:
- A&O ×3
- Steady gait
- No focal deficits
- No new complaints
This ensures safe discharge and medico-legal protection.
FAQs About Intoxication
1. When is intoxication dangerous?
When it hides trauma, hypoglycemia, hypothermia, or intracranial bleeding.
2. Do all intoxicated patients need CT scans?
No, but any suspicion of trauma → get a CT head.
3. Why give thiamine?
Prevents Wernicke’s encephalopathy in chronic alcohol users.
4. How do we know a patient is “clinically sober”?
They are alert, oriented, coherent, and can walk steadily.
5. Should we check blood alcohol levels routinely?
No — levels do not correlate with mental status or readiness for discharge.
6. What if the patient isn’t improving?
Consider alternative diagnoses (AEIOU TIPS) and escalate evaluation.
7. Why is pancreatitis screening important?
Alcohol is a common cause; delayed diagnosis can be fatal.
