Last reviewed: March 2026
Contents
MDM Templates
Alcohol Intoxication — Mild
Patient presents with altered mental status, slurred speech, and sluggish behavior consistent with alcohol intoxication. Airway intact, protecting airway. No focal neurologic deficits, no signs of trauma.
Presentation consistent with acute alcohol intoxication with expected clinical trajectory. Not consistent with intracranial hemorrhage (no focal deficits, no mechanism), opioid co-ingestion (normal respiratory rate, normal pupils), sepsis (afebrile, no localizing source), hypothyroidism, or hypoglycemia (POC glucose normal).[1]
Plan: Serial reassessments demonstrating improving mental status consistent with metabolism of alcohol. Patient ambulating without difficulty and tolerating oral intake. Discharge with safe ride and return precautions. Alcohol cessation counseling and resources provided.
Alcohol Intoxication — Severe / Obtunded
Patient with unknown PMH presents obtunded with altered mental status. Clinical picture consistent with severe alcohol intoxication but differential must be broadened given depth of AMS.
Severe obtundation from alcohol alone is a diagnosis of exclusion in patients without a reliable history. Differential includes intracranial hemorrhage, polysubstance ingestion, hypoglycemia, sepsis, hypothyroidism, hypothermia, and post-ictal state. Workup performed to exclude dangerous alternative diagnoses. AMS improving on serial exams consistent with metabolic clearance of alcohol.[1]
Plan: Airway monitoring with low threshold for intervention. CT head if mechanism for trauma or if mental status does not improve on expected trajectory. Acetaminophen and salicylate levels to evaluate for co-ingestion. Serial reassessments. Once at baseline, ambulating, and tolerating oral intake, discharge with safe ride. Return for any recurrent symptoms.
If not improving as expected: Broaden workup. Consider CT head, LP, additional labs, and toxicology consultation. Alcohol intoxication alone should show progressive improvement — failure to improve mandates evaluation for an alternative or concurrent diagnosis.
Clinical Education
Approach to the Intoxicated Patient
The biggest danger in managing the intoxicated patient is anchoring on alcohol. Alcohol intoxication is the most common diagnosis for AMS in the ED, but it must be a diagnosis of improvement. If the patient is not progressively improving, reassess and broaden the differential.[1]
POC glucose is mandatory in every altered patient. Hypoglycemia mimics intoxication perfectly and is immediately treatable. There is no excuse for missing it.
IV NS does not decrease ED length of stay in uncomplicated alcohol intoxication. Fluids are indicated for dehydration or concurrent illness but do not “sober up” the patient faster. Time and metabolism are the only treatments for intoxication itself.
Consider withdrawal risk at disposition. A patient presenting intoxicated today may be withdrawing tomorrow. Assess chronicity of use and history of withdrawal complications before discharge.
Vitamin Deficiency Syndromes
Chronic alcoholics are at risk for multiple vitamin deficiencies. These can present acutely and should be considered in any chronic drinker with unusual symptoms:
| Deficiency | Presentation | Treatment |
| Thiamine (B1) — Wernicke | Ataxia, confusion, ophthalmoplegia | Thiamine 500 mg IV over 30 min, magnesium, admit |
| Thiamine (B1) — Beriberi | Heart failure (wet) or peripheral neuropathy (dry) | Thiamine 100 mg IV/IM daily x 7-14 days, magnesium |
| Niacin (B3) — Pellagra | Diarrhea, dermatitis (photosensitive), dementia | Niacin 100 mg PO TID-QID |
| Vitamin C — Scurvy | Perifollicular petechiae, bruising, corkscrew hair, gingival bleeding | Vitamin C 300 mg PO daily or 1 g IV daily |
| Vitamin A | Night blindness, recurrent falls in low light | Vitamin A 30,000 IU PO daily x 1 week |
Magnesium must be repleted alongside thiamine. Hypomagnesemia makes the patient resistant to thiamine administration. Always give both together.[2]
Wernicke Encephalopathy
Wernicke encephalopathy is underdiagnosed. The classic triad of ataxia, confusion, and ophthalmoplegia is present in only ~10% of cases. Any one or two of these findings in a chronic alcoholic should trigger treatment. When in doubt, give thiamine — the treatment is safe and the disease is devastating if missed.[2]
Thiamine dose for suspected Wernicke is 500 mg IV, not 100 mg. The 100 mg dose is a maintenance/prophylactic dose. Acute Wernicke requires high-dose IV thiamine (500 mg IV over 30 minutes, TID for 2-3 days, then 250 mg IV daily for 3-5 days). Oral thiamine has unreliable absorption in alcoholic patients.
Give thiamine BEFORE glucose. Dextrose administration without thiamine can precipitate or worsen Wernicke encephalopathy by consuming remaining thiamine stores in glucose metabolism. This is the same principle as in AKA management.
Disposition Pitfalls
Do not discharge an intoxicated patient who cannot demonstrate safe ambulation. Falls, aspiration, and exposure are significant risks. The patient must be able to walk, talk, and demonstrate judgment before discharge.[1]
Ensure a safe ride home. Discharging an intoxicated patient to drive themselves is a liability and a safety failure. Document the discharge plan including mode of transportation.
Screen for suicidal ideation in every intoxicated patient. Alcohol intoxication both lowers inhibitions and is a risk factor for suicide attempt. Ask directly. If positive, the patient needs psychiatric evaluation before discharge.
Disposition
Discharge: Improving mental status on serial exams. Ambulating without difficulty. Tolerating oral intake. No signs of withdrawal. No concurrent medical pathology identified. Safe ride arranged. Alcohol cessation counseling and resources provided. PCP follow-up recommended.
Admit: Failure to improve on expected trajectory (concern for alternative diagnosis). Severe intoxication requiring prolonged airway monitoring. Concurrent medical pathology (pneumonia, GI bleed, pancreatitis). Concern for withdrawal in patient with history of complicated withdrawal. Wernicke encephalopathy suspected. Unsafe for discharge (no ride, no safe environment, suicidal ideation).
tydotphrase.com 