Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Alcohol Intoxication

—

In one line

·Alcohol shuts down the brain in top-to-bottom order: first judgment and coordination fail, then memory blacks out, then consciousness fades, and finally the brainstem stops telling the lungs to breathe.

—

Normal physiology

·A healthy brain keeps a precise balance between glutamate (the brain's main go signal) and GABA (the brain's main stop signal). This balance keeps judgment, coordination, memory, consciousness, and breathing all in normal range.

—

What goes wrong

·Alcohol enhances GABA (the brain's main brake signal) and blocks glutamate (the brain's main go signal), so the whole brain slows down in a predictable top-to-bottom sequence. The higher thinking areas shut down first, and the life-support areas in the brainstem shut down last.

—

Hallmark signs

·Disinhibition and impaired judgment
·Slurred speech (dysarthria)
·Loss of coordination (Ataxia) (unsteady walk, poor balance)
·Involuntary eye jerking (Nystagmus) (jerky, back-and-forth eye movements)
·Anterograde amnesia (blackout—can't form new memories)
·Nausea and vomiting
·Flushed skin and feeling warm
·Altered mental status progressing to stupor or coma

—

Red flags · escalate now

·Breathing rate below 8 breaths per minute or pauses between breaths
·Glasgow Coma Scale score of 8 or lower (won't open eyes even to pain, or no response at all)
·Known or suspected head injury, seizure, or fall—risk of brain bleed
·Vomiting while unconscious or very drowsy—can breathe vomit into the lungs and cause aspiration pneumonia
·Core body temperature below 95 °F (35 °C) or skin feels cold and clammy
·Fingerstick blood glucose below 60 mg/dL

—

Workup

·Blood alcohol concentration (BAC), serum
·Fingerstick or serum glucose
·Comprehensive metabolic panel (CMP): sodium, potassium, chloride, bicarbonate, blood urea nitrogen (BUN), creatinine, and glucose
·Serum or urine toxicology screen (comprehensive drug screen including opioids, benzodiazepines, amphetamines, cocaine, tricyclic antidepressants, acetaminophen, and salicylates)
·Serum osmolality and calculated osmolal gap
·Creatine kinase (CK), serum
·Arterial or venous blood gas (with lactate) if the patient is very drowsy, breathing slowly, or has abnormal vital signs
·Head CT scan (computed tomography, a detailed X-ray of the brain) if there is any concern for head trauma, focal neurologic signs (weakness or numbness on one side, unequal pupils, new slurred speech), or if the person does not wake up as expected

—

Treatment

·Protect the airway with endotracheal intubation if the Glasgow Coma Scale (GCS) is 8 or lower, or if the person cannot protect the airway (no gag reflex, continuous vomiting, or witnessed aspiration)
·Give thiamine 100 mg intravenously (IV) or intramuscularly (IM) BEFORE giving any glucose or dextrose; follow with IV fluids (0.9% normal saline or lactated Ringer solution) at 100–200 mL per hour, plus folic acid 1 mg IV or by mouth daily, and a multivitamin
·Give dextrose 25–50 grams IV (one amp of D50W, which is 50% dextrose in water) if the fingerstick or serum glucose is below 70 mg/dL
·Give naloxone 0.4 to 2 mg IV, intramuscularly (IM), or by intranasal spray if opioid co-ingestion is suspected (clues: pinpoint pupils, breathing rate below 10 breaths per minute, deeply unresponsive, and not waking to loud voice or sternal rub)
·Give fomepizole 15 mg per kilogram (mg/kg) IV as a loading dose over 30 minutes if toxic alcohol ingestion (methanol or ethylene glycol) is confirmed or strongly suspected based on osmolal gap above 10 mOsm/kg, anion-gap metabolic acidosis (acid building up in the blood), visual symptoms (methanol), or known ingestion history
·Give a benzodiazepine—lorazepam 1–2 mg IV or by mouth, or diazepam 5–10 mg IV—if signs of alcohol withdrawal appear during observation: tremor (shaking hands), heart rate above 100 beats per minute, high blood pressure (systolic above 140 mmHg), heavy sweating, agitation, hallucinations (seeing bugs or shadows that are not there), or a seizure
·Before discharge, perform a brief intervention (5–15 minute structured conversation using the SBIRT framework: Screening, Brief Intervention, and Referral to Treatment) and refer to addiction medicine, psychiatry, or a primary care provider who can start medication-assisted treatment: naltrexone 50 mg by mouth once daily, or monthly injection (Vivitrol 380 mg IM); or acamprosate 333 mg tablets, two tablets three times daily (total 1998 mg per day); or disulfiram 250 mg by mouth once daily. Also connect the patient with social work or a care coordinator for housing assistance, mental health therapy (cognitive-behavioral therapy, CBT; or motivational enhancement therapy, MET), job or school support, and peer recovery support groups (such as Alcoholics Anonymous, AA; SMART Recovery; Refuge Recovery)

—

NCLEX trap

·Every patient with suspected alcohol intoxication needs a blood alcohol level (the amount of alcohol in the blood, measured in mg/dL), serum glucose (blood sugar level), a basic metabolic panel (tests for electrolytes like sodium and potassium, plus kidney function), and a urine drug screen to rule out co-ingestion (taking other drugs at the same time) of opioids, benzodiazepines, or other sedatives. A patient who is too sleepy for their blood alcohol level—for example, unconscious at 150 mg/dL when most people are awake at that level—is poisoned by another substance and needs a different treatment plan. Current CDC, ACEP (American College of Emergency Physicians), and toxicology guidelines require laboratory evaluation to detect low blood sugar (hypoglycemia) (blood sugar below 70 mg/dL), electrolyte abnormalities, and polysubstance use before discharge.
·Alcohol intoxication causes pupils to remain normal in size and reactive to light, or to dilate (get bigger) slightly because alcohol relaxes smooth muscle in the iris (the colored ring in your eye that controls pupil size). Pinpoint pupils (miosis, pupils smaller than 2 mm—about the size of a pen tip) indicate opioid co-ingestion or pontine bleeding (hemorrhage) (bleeding in the pons, a part of the brainstem). In pure alcohol intoxication, pupils stay round, equal, and brisk (respond quickly to light) unless there is severe brainstem depression or head trauma. This is consistent with current ACEP and AAN (American Academy of Neurology) guidelines on pupillary assessment in altered mental status.
·Unconscious plus alcohol intoxication equals inability to protect the airway (keep vomit and saliva out of the windpipe). Vomit will be aspirated into the lungs (breathed into the airways), causing aspiration pneumonia (lung infection from stomach contents) or acute respiratory distress syndrome (severe lung injury with low oxygen). Respiratory depression (breathing rate too slow or too shallow) can worsen as alcohol continues to be absorbed from the stomach and small intestine. Every unconscious patient with alcohol intoxication needs hospital observation, IV access, airway positioning in the left lateral decubitus or recovery position (lying on the left side so vomit drains out), thiamine (vitamin B1, 100 mg IV) and dextrose (sugar, IV) if blood glucose is low, continuous monitoring of respiratory rate and oxygen saturation, and intubation equipment (breathing tube supplies) at the bedside. This reflects current ACEP and AHA (American Heart Association) guidelines on airway management in toxicology emergencies.
·Alcohol inhibits gluconeogenesis (the liver making new glucose from amino acids and lactate—like the liver's emergency sugar factory shutting down). Low blood sugar (Hypoglycemia) (blood glucose less than 70 mg/dL) causes confusion, agitation, seizures (sudden uncontrolled electrical activity in the brain), and altered mental status (change in awareness or thinking) that mimic or worsen alcohol intoxication but require immediate IV dextrose (D50 or D10, sugar given through the vein). Always check point-of-care glucose (bedside fingerstick blood sugar test) within the first 5 minutes of evaluating any patient with altered mental status or suspected alcohol intoxication. Current ADA (American Diabetes Association), ACEP, and Cochrane evidence support universal glucose screening in altered mental status to prevent neurologic injury and death from untreated low blood sugar.
·Vomiting in alcohol intoxication is the body's protective reflex to expel the poison from the stomach—like your body hitting the eject button. Suppressing vomiting with ondansetron or promethazine (antiemetic medications) masks the warning sign and increases aspiration risk because the patient may vomit silently while sedated and not alert staff. Instead, position the patient on the left side in left lateral decubitus (lying on the left side), keep suction (machine to clear vomit from the mouth) and airway equipment at the bedside, keep the patient NPO (nothing by mouth, no food or liquids) until vomiting stops and mental status clears, and allow vomiting to occur safely. Current ACEP and toxicology consensus statements recommend against routine antiemetics in alcohol intoxication to preserve airway protective reflexes.

—

Install Maldek by Hill as an app — studies work even offline