Alcohol or drug intoxication - Quick reference

• This is a Quick Reference article. See also the main article Poisonings caused by inebriating substances (alcohols, drugs) .

Alcohol (ethanol) intoxication

Clinical examination

• Level of consciousness and intoxication; circulatory status; abdominal status; check for any asymmetry, neck stiffness, signs of injury; temperature
• An alcohol concentration below 2.5 ‰ alone does not explain unconsciousness in an adult.
• Polysubstance use (alcohol, sedatives, narcotics) complicates assessment.
• Remember the risk of injuries and cerebral haemorrhage.

Tests

• Blood glucose and, if possible, potassium, sodium
• If infection is suspected, CRP
• If use of surrogate alcohol is suspected, acid-base balance
• If the cause of evident intoxication is unclear, take:
  • blood sample for intoxication
  • urine sample for urine drug screen
  • blood and urine in store for subsequent tests.

Treatment

• Medicinal charcoal can be given to patients with drug or polysubstance intoxication.
• In alcohol intoxication, medicinal charcoal is ineffective and gastric aspiration only effective immediately after drinking.
• Monitor the patient at an outpatient clinic, if
  • the breathalyzer result exceeds 3 ‰ in a patient with a lowered level of consciousness
  • speech contact is not possible
  • the breathalyzer result is inconsistent with the patient's state.
• If no need for treatment or monitoring is observed, the intoxicated person can be discharged if he/she is capable of taking care of him-/herself or if someone else will take care of him/her (an accompanying person who is able to function, or monitoring at a sobering-up station).
• Hospital monitoring is warranted for children, patients who are deeply unconscious and patients with respiratory or circulatory symptoms.
• Remember to make sufficient entries in the medical record.

Other alcohols

• Isopropanol (anti-freeze agents, carburettor cleaner, windscreen washer fluid): treatment as for ethanol intoxication
• Methanol (adulterated alcohol, windscreen washer fluid, paint strippers)
  • Even small doses may be lethal.
  • Symptoms may not occur until 12–24 hours after ingestion.
  • In addition to normal symptoms of intoxication, dyspnoea or hyperventilation (metabolic acidosis), eye symptoms ("seeing snow", blindness, fixed, dilated pupils, papilloedema)
  • Always treat at a central hospital with dialysis facilities.
• Ethylene glycol (car radiator fluids, antifreeze agents)
  • Small doses may be lethal.
  • Symptoms and treatment otherwise as for methanol intoxication but there are no eye symptoms
  • Hyperglycaemia and renal symptoms (haematuria and proteinuria) possible

Illicit drugs

• The effects of drugs may be
  • stimulating, excitatory (amphetamine, crack, ecstasy, cocaine)
  • depressant (heroin, gamma, hydroxybutyrate, fentanyl derivatives)
  • variable (cannabis).
• Heroin
  • Risk of fatal overdose particularly after i.v. use
  • Symptoms: respiratory depression followed by hypoxia, bradycardia, pinpoint pupils (but dilated in a life-threatening state)
  • The antagonist is naloxone.
    • Dose 0.08 mg i.v. at intervals of 15–30 seconds until spontaneous respiration is resumed (up to 2 mg), subsequently more slowly until the patient wakes up (approx. 10 min); 0.4–0.8 mg is often needed.
    • Can also be given s.c. or i.m., in which case the single dose is 0.8 mg.
  • Ensure patent airway if oxygenation is not rapidly restored or there is loud stertor.
• Amphetamine and other stimulants
  • Cocaine: severe cardiac symptoms (arrhythmias, myocardial infarction), convulsions
  • Ecstasy: severe dehydration, electrolyte imbalance, hyperthermia
  • Risk of sudden death: arrhythmias / precordial pain (ECG!), severe agitation
  • Treatment
    • Sufficient fluid administration
    • Sedation with 5–10 mg diazepam i.v.
    • 20–50 mg labetalol (alpha and beta blocker) i.v. for the treatment of hypertension (not just a beta blocker; risk of hypertensive crisis)
• Cannabis
  • Effects include a pleasurable feeling, increased appetite, passiveness, fits of laughter, relaxation, dry mouth, bloodshot conjunctivae. Impairs coordination and balance.
  • No cases of fatal overdose are known to have occurred.
• Designer drugs
  Modified from existing intoxicants with effects resembling the original agents
  • Dozens of new designer drugs are launched every year.
  • The largest groups include various amphetamine derivatives and synthetic cannabinoids.
  • Most designer drugs cannot be detected by drug screens in emergency situations.
  • Examples of designer drugs and their effects
    • Gamma hydroxybutyrate (GHB) and its precursor gamma butyrolactone (GBL)
      • Cause tiredness, an overdose may rapidly lead to coma
      • Short half-life
      • Effects resemble alcohol poisoning
      • Mild bradycardia is a characteristic symptom
      • Rarely requires intubation
      The amphetamine derivatives MDMA (ecstasy) and MDPV with effects resembling cocaine, mephedrone
    • Cannabinoids: JWH, smoked and sedative like cannabis Gamma hydroxybutyrate (GHB) and its precursor gamma butyrolactone (GBL), cause tiredness, an overdose may rapidly lead to coma. Short half-life.