Emergency Medicine
Toxicology
Internal Medicine
High Evidence

Ethanol Toxicity

Ethanol toxicity ranges from mild intoxication to life-threatening withdrawal, hypoglycaemia, and Wernicke encephalopath... ACEM Primary Written, ACEM Primary V

43 min read

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Urgent signals

Safety-critical features pulled from the topic metadata.

  • Hypoglycaemia especially in children and malnourished patients
  • Delirium tremens with cardiovascular collapse
  • Wernicke encephalopathy (ataxia, nystagmus, confusion)
  • Co-ingestion with other CNS depressants (opioids, benzodiazepines)

Exam focus

Current exam surfaces linked to this topic.

  • ACEM Primary Written
  • ACEM Primary Viva
  • ACEM Fellowship Written
  • ACEM Fellowship OSCE

Editorial and exam context

ACEM Primary Written
ACEM Primary Viva
ACEM Fellowship Written
ACEM Fellowship OSCE
Clinical reference article

Quick Answer

Ethanol toxicity ranges from mild intoxication to life-threatening withdrawal, hypoglycaemia, and Wernicke encephalopathy. Management focuses on airway protection, glucose assessment, thiamine replacement, benzodiazepines for withdrawal, and supportive care. Key priorities: exclude hypoglycaemia, detect co-ingestants, assess withdrawal risk, and prevent Wernicke-Korsakoff syndrome with parenteral thiamine.

ACEM Exam Focus

Fellowship Written: Assessment and management of acute ethanol intoxication, withdrawal syndrome, and complications. Distinguish between intoxication and other causes of altered mental status. Understand pharmacokinetics, metabolism, and organ dysfunction.

Primary Viva: Ethanol metabolism (ADH, ALDH), pharmacokinetics (zero-order kinetics), Wernicke pathophysiology, thiamine biochemistry, benzodiazepine-GABA cross-tolerance mechanisms.

Fellowship OSCE: Assessment of intoxicated patient, management of withdrawal with CIWA-Ar scale, communication with intoxicated patient and family, managing agitation while preserving therapeutic relationship.

Key Points

  1. Metabolism: 90% hepatic via ADH/ALDH, 5% renal excretion, 5% pulmonary excretion. Zero-order kinetics at high concentrations (fixed 7-10 g/hour elimination rate) [PMID: 10967489]

  2. Hypoglycaemia: Alcohol inhibits gluconeogenesis, depletes hepatic glycogen. High risk in children, malnourished, and chronic alcoholics. Treat with thiamine before glucose to prevent Wernicke [PMID: 28431698]

  3. Wernicke Encephalopathy: Triad of ataxia, ophthalmoplegia (nystagmus), and confusion. Only 10% have classic triad at presentation. High index of suspicion in alcohol-dependent patients. Thiamine 500mg IV TDS for 3-5 days [PMID: 28929218]

  4. Withdrawal: Peaks 48-72 hours after last drink. CIWA-Ar scale guides benzodiazepine dosing. Symptom-triggered dosing superior to fixed schedules. Diazepam/lorazepam first-line [PMID: 28338312]

  5. Delirium Tremens: Medical emergency with 15% mortality if untreated. Aggressive IV benzodiazepines loading until sedation achieved. Monitor for refractory cases requiring phenobarbital or propofol [PMID: 29291938]

  6. Paediatric Considerations: Children have higher risk of hypoglycaemia due to limited glycogen stores. Lower blood ethanol concentrations cause more severe effects. Must exclude accidental ingestion vs non-accidental injury [PMID: 30448772]

  7. Discharge: Safe for discharge if sober, reliable support, no red flags, and no withdrawal risk. Documented observation period minimum 4-6 hours after last drink. Follow-up arrangements essential [PMID: 27935195]

Pharmacokinetics

Absorption

Rapid absorption from stomach (20%) and small intestine (80%). Peak blood concentration occurs 30-90 minutes after ingestion on empty stomach. Food delays absorption and reduces peak concentration by 25-50% [PMID: 10967489]

First-pass metabolism: 10-30% of ethanol metabolised by gastric ADH before reaching systemic circulation. Women have lower gastric ADH activity, contributing to higher peak concentrations with same dose [PMID: 2718854]

Distribution

Volume of distribution: 0.6-0.8 L/kg (similar to total body water). Higher in males (0.7 L/kg) than females (0.6 L/kg) due to higher body fat percentage in females [PMID: 10967489]

Crosses blood-brain barrier and placenta freely. Detectable in breast milk. Fetal alcohol syndrome risk with chronic maternal consumption [PMID: 33280390]

Blood concentration estimation:

  • Men: BAC (%) = (grams ethanol consumed / [body weight in grams × 0.68]) × 100
  • Women: BAC (%) = (grams ethanol consumed / [body weight in grams × 0.55]) × 100

Metabolism

Phase I Oxidation (90% of metabolism):

  1. Alcohol Dehydrogenase (ADH): Ethanol → Acetaldehyde

    • Primary pathway in liver cytosol
    • Follows Michaelis-Menten kinetics at low concentrations
    • Saturates at high concentrations (~100 mg/dL)

  2. Aldehyde Dehydrogenase (ALDH): Acetaldehyde → Acetate

    • ALDH2 is the rate-limiting enzyme
    • Acetaldehyde accumulation causes flushing, tachycardia, nausea
    • 30-50% of East Asian population have ALDH2 deficiency [PMID: 26796503]

  3. Microsomal Ethanol Oxidizing System (MEOS): CYP2E1 induction

    • Becomes significant at chronic, heavy alcohol use
    • Leads to tolerance and drug interactions
    • Produces reactive oxygen species contributing to liver injury [PMID: 21997798]

Phase II Conjugation (less significant):

  • Ethyl glucuronide (EtG): 0.5-1.5% excreted in urine, detectable up to 80 hours
  • Ethyl sulfate (EtS): 0.1% excreted, detectable up to 40 hours
  • Phosphatidylethanol (PEth): Blood biomarker, detectable up to 4 weeks [PMID: 27757798]

Elimination

Zero-order kinetics at therapeutic concentrations (above 80-100 mg/dL):

  • Fixed elimination rate of 7-10 grams ethanol per hour
  • Approximately 15-20 mg/dL/hour decrease in BAC
  • Independent of blood concentration [PMID: 10967489]

First-order kinetics at very low concentrations (below 20-30 mg/dL):

  • Follows Michaelis-Menten kinetics
  • Elimination rate proportional to concentration

Factors affecting metabolism:

  • Chronic alcohol use: Induces MEOS, increases tolerance
  • Liver disease: Impairs metabolism, prolongs intoxication
  • Age: Elderly have reduced metabolism
  • Medication interactions: H2 blockers, aspirin, cimetidine inhibit ADH

Clinical Features

Acute Intoxication

Mild Intoxication (BAC 50-100 mg/dL):

  • Mild euphoria, disinhibition, impaired judgement
  • Flushed face, injected conjunctivae
  • Slight ataxia, slurred speech
  • No significant impairment of airway or breathing [PMID: 26899397]

Moderate Intoxication (BAC 100-200 mg/dL):

  • Marked ataxia, dysarthria, nystagmus
  • Impaired coordination, increased reaction time
  • Emotional lability, mood swings
  • Amnestic periods ("blackouts")
  • Nausea, vomiting [PMID: 26899397]

Severe Intoxication (BAC 200-400 mg/dL):

  • Stupor, obtundation, coma
  • Marked respiratory depression
  • Hypotension, bradycardia
  • Hypothermia (impaired thermoregulation)
  • Loss of protective airway reflexes
  • Risk of aspiration pneumonia [PMID: 26899397]

Potentially Lethal (BAC > 400 mg/dL):

  • Deep coma
  • Respiratory arrest
  • Cardiovascular collapse
  • High mortality without supportive care

Physical Examination Findings

General Appearance:

  • Ethanol odour on breath (non-specific)
  • Dishevelled appearance, poor hygiene
  • Evidence of trauma (bruises, lacerations)
  • Alcohol withdrawal tremors (fine, intention tremor)

Neurological:

  • Nystagmus (horizontal, gaze-evoked)
  • Ataxia (broad-based, unsteady gait)
  • Dysarthria (slurred, scanning speech)
  • Altered mental status (GCS 3-15)
  • Peripheral neuropathy (chronic alcoholics) [PMID: 28431698]

Cardiovascular:

  • Tachycardia (early withdrawal)
  • Hypertension (withdrawal)
  • Hypotension (severe intoxication)
  • Arrhythmias (holiday heart syndrome) [PMID: 25808842]

Gastrointestinal:

  • Nausea, vomiting
  • Epigastric tenderness (gastritis, pancreatitis)
  • Hepatomegaly, jaundice (liver disease)
  • Caput medusae, spider naevi (cirrhosis) [PMID: 29245170]

Respiratory:

  • Tachypnoea (metabolic acidosis, aspiration)
  • Decreased respiratory rate (CNS depression)
  • Rales (aspiration pneumonia)

Skin:

  • Flushing (acetaldehyde accumulation)
  • Bruising (trauma, coagulopathy)
  • Spider angiomas, palmar erythema (liver disease)

Laboratory Findings

Biochemistry:

  • Hypoglycaemia (children, malnourished)
  • Hyponatraemia (SIADH, beer potomania)
  • Hypokalaemia (vomiting, renal wasting)
  • Hypomagnesaemia (chronic alcohol use)
  • Elevated AST > ALT (AST/ALT ratio > 2:1) [PMID: 29245170]
  • Elevated GGT, MCV (macrocytosis)

Arterial Blood Gas:

  • Respiratory alkalosis (early intoxication, hyperventilation)
  • Metabolic acidosis (lactic acidosis, ketoacidosis)
  • Mixed disorder common

Urinalysis:

  • Ketonuria (alcoholic ketoacidosis)
  • Proteinuria (liver disease, pancreatitis)
  • Myoglobinuria (rhabdomyolysis, prolonged immobilisation)

Toxicology Screen:

  • Detect co-ingestants (opioids, benzodiazepines, cocaine)
  • Blood ethanol concentration (quantitative)
  • Serum osmolal gap (ethanol contributes 22 mOsm/kg per 100 mg/dL)

Differential Diagnosis

Altered mental status in context of suspected ethanol ingestion requires systematic exclusion of:

Life-Threatening Mimics:

  • Traumatic brain injury (intracranial haemorrhage, subdural haematoma)
  • Hypoglycaemia (insulinoma, sulfonylurea overdose)
  • Sepsis (meningitis, encephalitis)
  • Carbon monoxide poisoning
  • Opioid overdose (pinpoint pupils, respiratory depression)
  • Subarachnoid haemorrhage [PMID: 26899397]

Metabolic Causes:

  • Diabetic ketoacidosis
  • Alcoholic ketoacidosis
  • Hypothermia
  • Electrolyte disturbances (Na+, K+, Ca2+, Mg2+)

Toxicological Causes:

  • Benzodiazepine overdose
  • Opioid overdose
  • Tricyclic antidepressant overdose
  • Inhalant intoxication
  • GHB/GBL intoxication

Neurological Causes:

  • Stroke (ischaemic, haemorrhagic)
  • Seizure (post-ictal state)
  • Hepatic encephalopathy
  • Wernicke encephalopathy

Psychiatric Causes:

  • Psychosis
  • Depression with suicidal intent
  • Delirium (withdrawal or other causes)

Clinical Approach

Primary Survey (ABCDE)

Airway:

  • Assess patency, protective reflexes
  • Intubate if GCS below 8, unable to protect airway
  • RSI with caution: ethanol use increases seizure risk [PMID: 26899397]

Breathing:

  • Assess respiratory rate, effort, oxygen saturation
  • Provide supplemental oxygen if SpO2 below 94%
  • Monitor for respiratory depression
  • Consider aspiration pneumonia

Circulation:

  • Assess heart rate, blood pressure, capillary refill
  • Large-bore IV access
  • Fluid resuscitation if hypovolaemic
  • Monitor for arrhythmias (holiday heart) [PMID: 25808842]

Disability:

  • GCS assessment
  • Pupil size and reactivity
  • Blood glucose (point-of-care testing)
  • Assess for signs of head injury

Exposure:

  • Full examination for trauma
  • Temperature monitoring (hypothermia)
  • Look for track marks, suicide attempts

Secondary Survey

History:

  • Type and amount of alcohol consumed
  • Time of last drink
  • History of chronic alcohol use
  • Prior withdrawal episodes, seizures, DTs
  • Co-ingestants (prescribed, illicit, over-the-counter)
  • Medication use (interactions)
  • Medical history (liver disease, pancreatitis, seizures)
  • Social situation (housing, support network) [PMID: 27935195]

Examination:

  • Comprehensive neurological exam
  • Assess for signs of withdrawal (tremor, tachycardia, hypertension)
  • Look for evidence of trauma
  • Assess for complications (aspiration, pancreatitis)
  • Screen for underlying causes of alcohol use

Risk Assessment

Low Risk (Safe for Discharge):

  • Sober or rapidly improving
  • No evidence of withdrawal
  • No co-ingestants
  • No red flags (trauma, hypoglycaemia, medical illness)
  • Reliable support person available
  • Safe environment

High Risk (Requires Admission):

  • Persistent altered mental status
  • Evidence of alcohol withdrawal
  • Medical complications (hypoglycaemia, aspiration, arrhythmias)
  • Co-ingestants
  • Unreliable social situation
  • History of DTs or withdrawal seizures

Investigations

Essential Investigations

Bedside Testing:

  • Blood glucose (point-of-care)
  • Capillary blood gases
  • Breathalyser (if available)
  • Urine pregnancy test (females of childbearing age)

Blood Tests:

  • Blood ethanol concentration (quantitative)
  • Full blood count (infection, anaemia, thrombocytopenia)
  • Electrolytes (Na+, K+, Ca2+, Mg2+, phosphate)
  • Liver function tests (AST, ALT, GGT, ALP, bilirubin)
  • Serum osmolality (osmolar gap calculation)
  • Amylase/lipase (pancreatitis)
  • Venous blood gas (pH, lactate)
  • Coagulation profile (PT/INR, APTT)
  • Toxicology screen (opioids, benzodiazepines, cocaine)
  • Troponin (cardiac ischaemia) [PMID: 26899397]

Imaging:

  • Chest X-ray (aspiration, pneumonia)
  • Head CT if:
    • Focal neurological deficits
    • Persistent GCS below 8
    • Signs of trauma
    • History of fall with altered mental status
  • Abdominal CT if pancreatitis suspected

Osmolar Gap

Calculated osmolarity: 2[Na+] + [Glucose] + [Urea] + [Ethanol]

Measured osmolality: Freezing point depression

Osmolar gap: Measured - Calculated

  • Normal osmolar gap: below 10 mOsm/kg
  • Ethanol contribution: 22 mOsm/kg per 100 mg/dL
  • Elevated osmolar gap (greater than 15-20) suggests co-ingestion with toxic alcohols [PMID: 29163068]

Management

Acute Intoxication

Airway and Breathing:

  • Maintain airway patency
  • Position in lateral position if not intubated
  • Intubate if GCS below 8 or aspiration risk
  • Supplemental oxygen if SpO2 below 94%

Circulation:

  • IV access (2 large-bore cannulae)
  • Crystalloid fluids for dehydration (0.9% NaCl)
  • Monitor vital signs continuously
  • Treat arrhythmias (usually self-limiting) [PMID: 25808842]

Glucose Management:

  • CRITICAL: Check capillary glucose immediately
  • If hypoglycaemic:
    1. Thiamine 100-300mg IV/IM FIRST
    2. Glucose 50mL of 50% dextrose IV
    3. Reassess glucose in 15-30 minutes
  • Children: Higher risk, low threshold for treatment [PMID: 28431698]

Thiamine Replacement:

  • 100mg IV/IM before glucose (prevents Wernicke)
  • Chronic alcoholics: 100mg IV daily for 3-5 days
  • Wernicke encephalopathy: 500mg IV TDS for 3-5 days
  • Consider oral thiamine 100mg TDS for 1 month post-discharge [PMID: 28929218]

Supportive Care:

  • Observation until sober (4-6 hours after last drink minimum)
  • Safe environment, restraints only if necessary
  • Monitor for withdrawal symptoms
  • Prevent aspiration (nil by mouth until alert)
  • Treat nausea/vomiting (ondansetron, metoclopramide)
  • Fluid resuscitation for dehydration

Discharge Planning:

  • Only discharge when clinically sober and safe
  • Reliable support person required
  • Documented discharge instructions
  • Follow-up arranged (GP, alcohol services)
  • Safety-netting advice (return if deteriorating) [PMID: 27935195]

Alcohol Withdrawal Syndrome

Pathophysiology:

  • Chronic ethanol use enhances GABAergic inhibition and suppresses glutamatergic excitation
  • Abrupt cessation leads to CNS hyperexcitability
  • NMDA receptor upregulation → seizures, autonomic instability
  • Sympathetic overdrive → tachycardia, hypertension, fever

Timeline:

  • 6-12 hours: Tremor, anxiety, nausea, insomnia (minor withdrawal)
  • 12-24 hours: Hallucinations (visual, tactile, auditory)
  • 24-48 hours: Withdrawal seizures (tonic-clonic)
  • 48-72 hours: Delirium tremens (peak severity)
  • 4-7 days: Gradual resolution

CIWA-Ar Assessment (Clinical Institute Withdrawal Assessment for Alcohol, revised):

ScoreSeverityManagement
0-8None or mildObservation, no medication
9-15ModerateBenzodiazepine PRN
16-20SevereBenzodiazepine loading
greater than 20Very severeAggressive benzodiazepine therapy

Benzodiazepine Selection:

DrugRouteLoading DoseHalf-lifeSpecial Populations
DiazepamIV5-10mg q10min30-100hLiver disease: avoid
LorazepamIV/IM1-4mg q15-20min10-20hElderly, liver disease
ChlordiazepoxidePO25-100mg q4h24-100hOral only, outpatient

LOT Principle: Lorazepam, Oxazepam, Temazepam for patients with significant liver impairment (no active metabolites) [PMID: 28338312]

Symptom-Triggered Regimen (Preferred):

  • Assess CIWA-Ar every 1-2 hours
  • Diazepam 5-10mg IV if CIWA-Ar above 8
  • Repeat until CIWA-Ar below 8
  • Advantages: Lower total dose, shorter treatment, less over-sedation [PMID: 28338312]

Fixed-Schedule Regimen:

  • Used for high-risk patients (history of DTs, seizures)
  • Chlordiazepoxide 50-100mg q6h for 24h, then taper over 3-5 days
  • Diazepam 10-20mg q6h for 24h, then taper
  • Monitor for over-sedation [PMID: 28338312]

Delirium Tremens

Definition: Hyperactive delirium with autonomic hyperactivity occurring 48-72 hours after last drink. Medical emergency with 5-15% mortality without treatment.

Clinical Features:

  • Profound confusion, disorientation
  • Visual, auditory, tactile hallucinations
  • Marked agitation
  • Tachycardia (HR greater than 120)
  • Hypertension (SBP greater than 160)
  • Hyperthermia (temp greater than 38°C)
  • Diaphoresis
  • Tremor (marked)

Management:

1. Benzodiazepine Loading:

  • Diazepam 10-20mg IV every 10 minutes until sedation achieved
  • Lorazepam 2-4mg IV every 15-20 minutes until sedation achieved
  • Goal: RASS -1 to -2 (calm but arousable)
  • Massive doses often required (50-100mg diazepam common) [PMID: 29291938]

2. Adjunctive Therapies (if refractory to benzodiazepines alone):

Phenobarbital:

  • Loading: 10-15mg/kg IV over 30-60 minutes
  • Maintenance: 2-5mg/kg IV q6h
  • Synergistic with benzodiazepines
  • Causes respiratory depression - monitor closely [PMID: 29291938]

Propofol:

  • Requires intubation and mechanical ventilation
  • Loading: 1-2mg/kg IV
  • Infusion: 25-150mcg/kg/min
  • For refractory cases with cardiovascular instability

Dexmedetomidine:

  • Adjunct for autonomic hyperactivity
  • Does NOT prevent seizures
  • Loading: 1mcg/kg over 10 minutes
  • Infusion: 0.2-0.7mcg/kg/hour [PMID: 29291938]

3. Supportive Care:

  • Cardiac monitoring (continuous)
  • Frequent vital signs (q15-30min)
  • IV fluids for dehydration
  • Electrolyte repletion (K+, Mg2+, phosphate)
  • Correct hypoglycaemia
  • Treat fever (infection vs autonomic)
  • Safe environment, minimise stimulation
  • Restraints only if necessary for safety [PMID: 29291938]

4. Complications:

  • Respiratory depression
  • Hypotension
  • Pneumonia (aspiration, immobility)
  • Rhabdomyolysis (agitation)
  • Cardiac arrhythmias

Wernicke Encephalopathy

Pathophysiology:

  • Thiamine (vitamin B1) deficiency impairs glucose metabolism
  • Areas with high metabolic demand (mammillary bodies, thalamus, periaqueductal region) affected first
  • Causes cytotoxic oedema, neuronal death, petechial haemorrhages
  • Alcohol use, malnutrition, malabsorption, dialysis risk factors

Clinical Features (Classic Triad - only 10% have all three):

  1. Ocular abnormalities (80-90%):

    • Horizontal nystagmus (gaze-evoked)
    • Ophthalmoplegia (lateral rectus palsy - abducens nerve)
    • Ptosis
    • Diplopia

  2. Ataxia (70-80%):

    • Broad-based gait
    • Truncal instability
    • Dysmetria (cerebellar signs)

  3. Confusion (80-90%):

    • Disorientation (time, place, person)
    • Memory impairment
    • Apathy, reduced attention
    • Stupor to coma in severe cases [PMID: 28929218]

Diagnosis:

  • Clinical diagnosis (no reliable biomarkers)
  • MRI may show:
    • Symmetric mammillary body hyperintensity (T2/FLAIR)
    • Dorsomedial thalamus involvement
    • Periaqueductal grey matter changes
    • "Contrast enhancement in mammillary bodies (30-50%) [PMID: 28929218]"

Management:

  • EMERGENCY: Thiamine 500mg IV diluted in 100mL normal saline over 30 minutes, TDS for 3-5 days
  • Then 250mg IV/IM daily for 3-5 days
  • Oral thiamine 100mg TDS for 1 month post-discharge
  • ALWAYS give thiamine before glucose (prevents precipitating Wernicke)
  • Magnesium replacement (cofactor for thiamine utilisation) [PMID: 28929218]

Outcomes:

  • 80% recover with prompt treatment
  • 20% progress to Korsakoff syndrome (irreversible anterograde amnesia)
  • Mortality 10-20% if untreated
  • MRI findings correlate with worse prognosis

Special Populations

Paediatric Patients:

Acute Intoxication:

  • Higher risk of hypoglycaemia (limited glycogen stores)
  • Lower lethal dose (2-3g/kg)
  • Exclude non-accidental injury
  • Lower threshold for admission
  • Thiamine replacement essential before glucose

Management:

  • Airway protection priority
  • Glucose check before thiamine
  • Thiamine 1-2mg/kg IV (max 100mg)
  • Glucose 0.5-1g/kg (10% dextrose in children)
  • Observation minimum 6-8 hours
  • Social work involvement (child protection) [PMID: 30448772]

Pregnant Patients:

  • Ethanol crosses placenta
  • No safe threshold for fetal exposure
  • Assess for fetal alcohol syndrome
  • Consider obstetric involvement
  • Detoxification may be safer than continued drinking
  • Thiamine replacement (safe in pregnancy)
  • Benzodiazepines: use lorazepam (shorter half-life) [PMID: 33280390]

Elderly Patients:

  • Increased sensitivity to ethanol effects
  • Higher risk of falls, fractures
  • Increased risk of hypothermia
  • Polypharmacy increases interaction risk
  • Reduced metabolism (ADH activity)
  • Use LOT drugs for withdrawal (lorazepam, oxazepam)
  • Lower benzodiazepine doses
  • Higher aspiration risk

Liver Disease:

  • Impaired ethanol metabolism
  • Coagulopathy (bleeding risk)
  • Hepatic encephalopathy mimics intoxication
  • Use LOT drugs for withdrawal (no active metabolites)
  • Monitor for variceal bleeding
  • Ascites risk (respiratory compromise)
  • Thiamine replacement essential

Disposition and Follow-Up

Admission Criteria

Medical Indications:

  • Persistent altered mental status (GCS below 13)
  • Hypoglycaemia requiring ongoing treatment
  • Respiratory compromise or aspiration pneumonia
  • Cardiac arrhythmias (atrial fibrillation, VT/VF)
  • Trauma requiring admission (intracranial haemorrhage, fractures)
  • Pancreatitis, gastrointestinal bleeding
  • Severe electrolyte abnormalities
  • Infection (meningitis, pneumonia, sepsis)

Withdrawal Indications:

  • CIWA-Ar above 15
  • History of delirium tremens
  • Withdrawal seizures
  • Unreliable social situation
  • Co-ingestants requiring monitoring
  • Unable to tolerate oral medications

Social Indications:

  • No safe accommodation
  • Domestic violence risk
  • Unreliable support person
  • Acute intoxication with child dependents
  • Suicide risk

Discharge Criteria

Clinical Requirements:

  • Fully sober (GCS 15, normal mentation)
  • No evidence of withdrawal (CIWA-Ar below 8)
  • Normal vital signs for 2 hours
  • No red flags resolved
  • Capable of ambulating safely

Social Requirements:

  • Responsible adult to accompany home
  • Safe environment available
  • Follow-up arranged (GP, alcohol services)
  • Clear discharge instructions provided
  • Patient understands return precautions

Documentation:

  • Time of last drink
  • Observations documented
  • Discharge instructions provided
  • Follow-up arrangements confirmed
  • Safety-netting advice given

Follow-Up

Primary Care:

  • Review within 1 week
  • Full assessment of alcohol use disorder
  • Consider referral to addiction services
  • Medication-assisted treatment (acamprosate, naltrexone, disulfiram) [PMID: 29946595]

Specialist Services:

  • Alcohol and Drug Services
  • Counselling and psychotherapy
  • Rehabilitation programs (inpatient/outpatient)
  • Support groups (AA, SMART Recovery)
  • Mental health services (co-morbid depression, anxiety)

Relapse Prevention:

  • Identify triggers
  • Develop coping strategies
  • Medication compliance
  • Social support network
  • Regular follow-up appointments

Pitfalls and Pearls

Common Pitfalls

  1. Forgetting hypoglycaemia - Especially in children, malnourished, and chronic alcoholics. Always check capillary glucose before giving thiamine.

  2. Not giving thiamine before glucose - Giving glucose first in thiamine-deficient patients can precipitate Wernicke encephalopathy. Thiamine 100mg IV/IM first.

  3. Underestimating withdrawal severity - CIWA-Ar should be assessed regularly. Symptoms can progress rapidly to DTs with high mortality if untreated.

  4. Missing co-ingestants - Screen for opioids, benzodiazepines, cocaine, and other substances that alter management.

  5. Inadequate observation time - Minimum 4-6 hours after last drink before considering discharge. Late-onset complications can occur.

  6. Discharging high-risk patients - History of DTs, withdrawal seizures, or unreliable social situation requires admission.

  7. Using long-acting benzodiazepines in liver disease - Use LOT drugs (lorazepam, oxazepam) in patients with significant hepatic impairment.

  8. Missing head injury - Altered mental status in intoxicated patients may be due to traumatic brain injury, not just alcohol.

  9. Inadequate benzodiazepine dosing in DTs - Refuse to undertreat. Massive doses often required (50-100mg diazepam) to achieve sedation.

  10. Poor documentation - Document time of last drink, observations, CIWA-Ar scores, and discharge instructions clearly.

Clinical Pearls

  1. Osmolar gap calculation: Ethanol contributes 22 mOsm/kg per 100 mg/dL. A gap above 15-20 mOsm/kg suggests co-ingestion with toxic alcohols (methanol, ethylene glycol).

  2. AST:ALT ratio above 2:1 is highly suggestive of alcoholic liver disease (sensitivity 91%, specificity 71%).

  3. Holiday heart syndrome: New-onset atrial fibrillation in binge drinkers. Usually self-limiting, resolves within 24 hours.

  4. Macrocytosis (MCV > 100 fL) is common in chronic alcoholics due to direct bone marrow toxicity and folate deficiency.

  5. CIWA-Ar is invalid in delirious, intubated, or uncooperative patients. Use RASS or Richmond Agitation-Sedation Scale instead.

  6. Wernicke's classic triad only occurs in 10% of patients. Have high index of suspicion in any alcohol-dependent patient with altered mental status.

  7. Children have lower lethal doses: 2-3g/kg vs 5-6g/kg in adults. Higher risk of hypoglycaemia.

  8. Alcoholic ketoacidosis: Differentiate from DKA by absence of hyperglycaemia. Treat with glucose, thiamine, and supportive care.

  9. Symptom-triggered dosing is superior to fixed-schedule benzodiazepine regimens: lower total dose, shorter treatment, less over-sedation.

  10. Phenobarbital is effective for refractory delirium tremens when benzodiazepines alone are insufficient. Loading dose 10-15mg/kg IV.

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Peoples

Epidemiology:

  • Alcohol-related emergency department presentations 3-4 times higher than non-Indigenous Australians
  • Higher rates of acute intoxication and alcohol-related injury
  • Earlier onset of regular alcohol use
  • Higher burden of alcohol-related chronic disease [PMID: 29195450]

Social Determinants:

  • Intergenerational trauma, colonisation, and dispossession
  • Limited access to culturally safe health services
  • Remote residence with limited detoxification facilities
  • Economic disadvantage, unemployment
  • Stigma and discrimination in healthcare settings

Clinical Considerations:

  • Take comprehensive social history including family and community context
  • Screen for co-occurring mental health conditions (depression, PTSD, self-harm)
  • Higher rates of co-occurring substance use (tobacco, cannabis, volatile substances)
  • Assess for domestic violence, family violence, and child protection concerns

Cultural Safety:

  • Use culturally appropriate communication (respectful listening, avoid jargon)
  • Acknowledge cultural identity and community connections
  • Involve Aboriginal Health Workers or Indigenous Liaison Officers where available
  • Respect cultural protocols and family decision-making structures
  • Understand "shame" factors and reluctance to disclose alcohol use

Management Challenges:

  • Limited access to withdrawal management services in remote communities
  • Need for aeromedical retrieval to tertiary facilities for severe withdrawal/DTs
  • Difficulty with follow-up and continuity of care
  • Housing instability affecting safe discharge
  • Medication supply issues in remote areas

Best Practice:

  • Collaborate with Aboriginal Medical Services and local health clinics
  • Provide culturally appropriate resources (written, audio-visual)
  • Facilitate family and community involvement in discharge planning
  • Connect with community-based alcohol support programs
  • Consider gender-specific services where culturally appropriate [PMID: 29195450]

Māori (New Zealand)

Epidemiology:

  • Higher rates of alcohol-related emergency department presentations
  • Younger age of first intoxication
  • Higher burden of alcohol-related injury (road traffic accidents, assaults)
  • Significant impact on whānau (family) and community

Cultural Considerations:

  • Understand whakapapa (genealogy) and whānau importance
  • Respect tikanga Māori (Māori protocols)
  • Involve whānau in care decisions where appropriate
  • Use whakawhanaungatanga (relationship-building) approach

Clinical Approach:

  • Ask about alcohol use in non-judgmental, culturally appropriate manner
  • Screen for co-occurring mental health conditions (depression, anxiety)
  • Assess for family violence, child protection concerns
  • Consider impact on children and wider whānau

Service Provision:

  • Access to Kaupapa Māori health services where available
  • Integration with community-based Māori health providers
  • Culturally appropriate education and resources
  • Support for whānau involvement in treatment

Remote and Rural Considerations

Challenges

Limited Resources:

  • No on-site toxicology services
  • Limited alcohol and drug withdrawal facilities
  • Restricted access to specialist advice (toxicology, addiction medicine)
  • Limited availability of benzodiazepine alternatives (phenobarbital)
  • Blood ethanol concentration testing may not be available locally

Transport and Retrieval:

  • Long transport times to tertiary facilities
  • Weather and seasonal access limitations
  • RFDS (Royal Flying Doctor Service) coordination required for aeromedical retrieval
  • Limited availability of escort personnel
  • High cost of aeromedical transport

Workforce Constraints:

  • Small number of medical and nursing staff
  • Limited on-call specialist support
  • Higher acuity-to-staff ratio
  • Less experience managing severe withdrawal and DTs

Social Factors:

  • Limited access to community-based alcohol services
  • Limited safe accommodation for discharge
  • Stigma in small communities
  • Limited follow-up and monitoring options

Management Strategies

Assessment:

  • Use clinical assessment when ethanol concentration testing unavailable
  • Rely on observation period (minimum 6 hours) before discharge decisions
  • Telephone advice from tertiary centres (emergency medicine, toxicology)
  • Video consultation for complex cases

Treatment:

  • Stabilise patient before transport
  • Symptom-triggered benzodiazepine dosing (diazepam or lorazepam)
  • Aggressive thiamine replacement
  • Treat hypoglycaemia early
  • Consider long-acting benzodiazepine for transport (diazepam)

Retrieval Planning:

  • Early discussion with RFDS or local retrieval service
  • Provide comprehensive handover
  • Consider escort nurse if patient requires sedation
  • Ensure appropriate equipment and medications during transport
  • Prepare for途中 deterioration (withdrawal, aspiration, seizures)

Discharge:

  • Only discharge to safe, supervised environment
  • Ensure responsible adult available
  • Arrange follow-up with local health service or GP
  • Provide clear return precautions
  • Consider telehealth follow-up if services limited

Education and Training:

  • Remote area health worker training in alcohol withdrawal management
  • CIWA-Ar scale training
  • Benzodiazepine dosing protocols
  • Recognition of red flags requiring retrieval

Medication Supply:

  • Ensure adequate benzodiazepine stocks (diazepam, lorazepam)
  • Thiamine availability (IV and IM)
  • Emergency resuscitation medications
  • Glucose for hypoglycaemia management

Viva Practice

Viva Scenario 1: Acute Intoxication with Co-ingestion

Stem: "A 22-year-old male presents to the ED via ambulance. He was found unconscious at a party. His friends report he consumed approximately 15 standard drinks of mixed spirits over 4 hours and may have taken 'something else'. On arrival, his GCS is 9 (E2, V2, M5)."

Q1: What are your immediate priorities in managing this patient?

Model Answer:

  • Primary survey (ABCDE): Airway protection is priority given GCS below 10
  • Secure airway with RSI if unable to protect airway or worsening GCS
  • Administer 100% oxygen, monitor SpO2
  • Large-bore IV access (2 cannulae)
  • Point-of-care glucose check immediately (treat hypoglycaemia if below 4 mmol/L)
  • Give thiamine 100mg IV/IM before glucose
  • Full secondary survey for signs of trauma
  • ECG monitoring (arrhythmias, QT prolongation)
  • Monitor vital signs continuously (HR, BP, RR, SpO2, temp)
  • Obtain collateral history from friends, family, ambulance officers
  • Consider toxicology screen (opioids, benzodiazepines, cocaine, amphetamines)
  • Calculate osmolar gap if available (toxic alcohol co-ingestion)

Q2: What co-ingestions would you be concerned about and why?

Model Answer:

  • Opioids: Pinpoint pupils, respiratory depression, bradypnoea - naloxone may be required
  • Benzodiazepines: Additive CNS depression, may potentiate respiratory depression, flumazenil if severe respiratory compromise (caution: risk of seizures)
  • Cocaine/Stimulants: Sympathomimetic effects (tachycardia, hypertension, agitation, hyperthermia) - may mask depressant effects, increased risk of arrhythmias
  • Gamma-hydroxybutyrate (GHB): Rapid onset of coma, rapid recovery (2-4 hours), may have withdrawal symptoms
  • Toxic alcohols: Methanol (visual symptoms, metabolic acidosis, elevated anion gap), ethylene glycol (oxalate crystals, renal failure) - elevated osmolar gap
  • Antidepressants: Tricyclic antidepressants (wide QRS, anticholinergic effects, arrhythmias)
  • Illicit substances: Ketamine, MDMA, novel psychoactive substances

Q3: How would you manage this patient if his GCS deteriorated to 6?

Model Answer:

  • Immediate airway protection required
  • Prepare for RSI (rapid sequence intubation)
  • Pre-oxygenate with 100% oxygen (3-5 minutes)
  • Monitor for aspiration risk (full stomach)
  • Suction equipment at bedside
  • Induction agents: Consider etomidate (haemodynamically neutral) or ketamine (maintains MAP)
  • Neuromuscular blockade: Rocuronium or suxamethonium
  • Maintain sedation with benzodiazepines (midazolam) and analgesia (fentanyl)
  • Mechanical ventilation with lung-protective strategy
  • Continue monitoring for withdrawal signs during sedation hold
  • Treat underlying causes (hypoglycaemia, electrolytes)
  • CT head if concerns about head injury or focal neurological deficits

Q4: What are your discharge criteria for this patient?

Model Answer:

  • GCS 15 with normal mentation for at least 2 hours
  • No evidence of alcohol withdrawal (CIWA-Ar below 8)
  • Normal vital signs (HR 60-100, BP 90-140, RR 12-20, SpO2 greater than 94% on room air)
  • Able to ambulate safely
  • No signs of trauma requiring admission
  • No medical complications (aspiration, arrhythmias, hypoglycaemia)
  • Blood ethanol concentration below 50 mg/dL if measured
  • Responsible adult available to accompany home
  • Safe environment available
  • Follow-up arranged with GP or alcohol services
  • Clear discharge instructions provided
  • Patient understands return precautions (seizures, vomiting, confusion)

Viva Scenario 2: Alcohol Withdrawal and Delirium Tremens

Stem: "A 45-year-old male presents with confusion, agitation, and tremor. His history is significant for chronic alcohol use of 20 years, typically 1 bottle of wine daily. He stopped drinking 2 days ago due to financial difficulties. His vital signs are: HR 135, BP 165/95, RR 24, SpO2 96% on room air, temp 38.2°C. GCS is 13 (E4, V3, M6)."

Q1: What is your diagnosis and what are the clinical features supporting it?

Model Answer:

  • Primary diagnosis: Delirium tremens (DTs)
  • Supporting features:
    • History of chronic alcohol use (20 years, 1 bottle daily)
    • Abrupt cessation 48-72 hours ago (peak withdrawal period)
    • Confusion (V3 verbal response)
    • Agitation
    • Marked tremor
    • "Autonomic hyperactivity: tachycardia (HR 135), hypertension (BP 165/95), tachypnoea (RR 24), fever (38.2°C)"
    • Diaphoresis likely (common in DTs)

Q2: How would you assess and score the severity of this patient's alcohol withdrawal?

Model Answer:

  • Use CIWA-Ar scale (Clinical Institute Withdrawal Assessment for Alcohol, revised) - 10 items scored 0-7:

    1. Nausea and vomiting
    2. Tremor
    3. Paroxysmal sweats
    4. Anxiety
    5. Agitation
    6. Tactile disturbances
    7. Auditory disturbances
    8. Visual disturbances
    9. Headache/fullness in head
    10. Orientation/clouding of sensorium

  • CIWA-Ar interpretation:

    • 0-8: Mild - no medication required
    • 9-15: Moderate - benzodiazepines PRN
    • 16-20: Severe - benzodiazepine loading
    • "Above 20: Very severe - aggressive benzodiazepine therapy"

  • This patient likely scores above 20 (very severe) due to confusion, tremor, tachycardia, hypertension, fever, and agitation - high risk of cardiovascular collapse and seizures.

Q3: What is your immediate management plan for this patient?

Model Answer:

  • ABCDE assessment: Ensure airway protection, administer oxygen (SpO2 96% - provide 2L NC to maintain greater than 94%)
  • Large-bore IV access: 2 cannulae (16-18G)
  • Benzodiazepine loading:
    • Diazepam 10-20mg IV every 10 minutes until sedation achieved
    • "Goal: RASS -1 to -2 (calm but arousable)"
    • Massive doses often required (50-100mg diazepam)
    • Monitor respiratory depression, hypotension
  • Adjunctive therapies (if refractory):
    • Phenobarbital 10-15mg/kg IV loading
    • Consider propofol if refractory (requires intubation)
  • Supportive care:
    • Cardiac monitoring (continuous)
    • Vital signs every 15-30 minutes
    • IV fluids for dehydration (0.9% NaCl)
    • "Electrolyte repletion: K+, Mg2+, phosphate"
    • Thiamine 500mg IV TDS for 3-5 days (prevent Wernicke)
    • Treat fever (infection screen - urine, blood, CXR)
    • Safe environment, minimise stimulation, restraints only if necessary

Q4: What are the red flags in delirium tremens that indicate a poor prognosis?

Model Answer:

  • Delayed treatment: Greater than 48 hours from symptom onset to benzodiazepine therapy
  • Underlying liver disease: Cirrhosis, hepatic encephalopathy, coagulopathy
  • Refractory delirium: Requires massive benzodiazepine doses (greater than 200mg diazepam) or adjunctive therapies (phenobarbital, propofol)
  • Medical complications: Aspiration pneumonia, cardiac arrhythmias, renal failure
  • Severe autonomic instability: HR greater than 150, SBP greater than 180, temp greater than 40°C
  • Age above 65 years: Higher mortality in elderly patients
  • Co-ingestants: Multiple CNS depressants complicate management
  • Limited resources: Remote location, specialist care unavailable

Viva Scenario 3: Wernicke Encephalopathy

Stem: "A 38-year-old female with a history of chronic alcohol use presents with confusion, ataxia, and visual disturbance. She reports daily alcohol consumption of approximately 10 standard drinks for the past 8 years. She had reduced oral intake for the past week due to nausea. On examination, she has horizontal nystagmus on lateral gaze, dysarthria, and a broad-based gait. GCS is 14 (E4, V4, M6)."

Q1: What is your differential diagnosis and what is the most likely diagnosis?

Model Answer:

  • Most likely diagnosis: Wernicke encephalopathy

  • Differential diagnosis:

    • Alcohol withdrawal syndrome (atypical presentation)
    • Subdural haematoma (head injury common in alcoholics)
    • Subarachnoid haemorrhage (thunderclap headache)
    • Acute stroke (posterior circulation - cerebellar/brainstem)
    • Viral encephalitis (meningitis, confusion)
    • Hepatic encephalopathy (liver disease, asterixis)
    • Drug toxicity (benzodiazepines, anticholinergics)
    • Metabolic disturbances (hyponatraemia, hypoglycaemia)

  • Wernicke encephalopathy is most likely because:

    • Chronic alcohol use with poor nutritional intake
    • "Classic triad (though only 10% have all three):"
      1. Ocular abnormalities (nystagmus, ophthalmoplegia)
      2. Ataxia (broad-based gait, truncal instability)
      3. Confusion (reduced attention, disorientation)
    • Time course consistent with thiamine deficiency

Q2: What is the pathophysiology of Wernicke encephalopathy?

Model Answer:

  • Thiamine (vitamin B1) deficiency is the primary cause
  • Thiamine as essential cofactor for:
    • Transketolase (pentose phosphate pathway)
    • Pyruvate dehydrogenase (pyruvate to acetyl-CoA)
    • Alpha-ketoglutarate dehydrogenase (Krebs cycle)
  • Impaired glucose metabolism leads to:
    • Decreased ATP production
    • Accumulation of lactate and pyruvate
    • Neuronal energy failure
  • Affected areas (high metabolic demand):
    • Mammillary bodies
    • Dorsomedial thalamus
    • Periaqueductal grey matter
    • Cerebellar vermis
  • Pathological changes:
    • Cytotoxic oedema
    • Neuronal death
    • Petechial haemorrhages
    • Gliosis and atrophy (chronic)
  • Precipitating factors:
    • Glucose administration before thiamine (increases metabolic demand)
    • Carbohydrate loading in thiamine-deficient state
    • Alcohol withdrawal (increased metabolic demands)

Q3: What is your immediate management for this patient?

Model Answer:

  • ABCDE assessment: Ensure airway protection
  • Thiamine replacement (EMERGENCY):
    • Thiamine 500mg IV diluted in 100mL normal saline over 30 minutes, TDS for 3-5 days
    • Then 250mg IV/IM daily for 3-5 days
    • Oral thiamine 100mg TDS for 1 month post-discharge
  • Magnesium replacement:
    • Magnesium is cofactor for thiamine utilisation
    • Magnesium sulfate 1-2g IV over 1 hour (if Mg2+ below 0.7 mmol/L)
  • Glucose administration:
    • Check capillary glucose
    • Thiamine MUST be given before glucose (prevents precipitating Wernicke)
    • "If hypoglycaemic: glucose after thiamine"
  • Supportive care:
    • IV fluids for dehydration
    • Electrolyte correction (K+, phosphate)
    • Monitor for aspiration (dysphagia risk)
    • Safe environment, fall prevention
    • Treat underlying malnutrition
  • Investigations:
    • "MRI brain (not mandatory but supportive):"
      • Mammillary body hyperintensity (T2/FLAIR)
      • Dorsomedial thalamus involvement
      • Contrast enhancement in mammillary bodies
    • Thiamine levels (often unreliable, clinical diagnosis)
  • Discharge planning:
    • Abstinence from alcohol
    • Oral thiamine supplementation long-term
    • Nutritional support
    • Referral to alcohol services
    • Consider acamprosate or naltrexone for relapse prevention

Q4: What are the potential complications if Wernicke encephalopathy is not treated promptly?

Model Answer:

  • Korsakoff syndrome (20-30% of untreated cases):
    • Severe anterograde amnesia (inability to form new memories)
    • Retrograde amnesia (variable)
    • Confabulation (fabrication of false memories)
    • Apathy and lack of insight
    • Generally irreversible
  • Progressive neurological deterioration:
    • Persistent ataxia and gait disturbance
    • Chronic ophthalmoplegia
    • Permanent cognitive impairment
    • Worsening confusion to coma
  • Mortality (10-20% if untreated):
    • Cardiovascular collapse
    • Aspiration pneumonia
    • Wernicke crisis (acute cardiovascular collapse)
  • Psychosocial complications:
    • Inability to care for self
    • Loss of independence
    • Institutionalisation
    • Family and social disruption

Viva Scenario 4: Paediatric Ethanol Toxicity

Stem: "A 3-year-old male presents to the ED after being found drinking from his father's beer bottle. The parents estimate he consumed approximately 150mL of 5% alcohol beer. He is lethargic but arousable. On examination, GCS is 13 (E3, V4, M6), HR 110, BP 85/50, RR 22, SpO2 97% on room air, temp 36.8°C. Capillary glucose is 3.2 mmol/L."

Q1: What are your immediate priorities in managing this child?

Model Answer:

  • ABCDE assessment: Ensure airway protection
  • Glucose management (HIGHEST PRIORITY):
    • Children have limited glycogen stores and higher risk of hypoglycaemia
    • Glucose below 4 mmol/L requires treatment
    • Thiamine 50mg IV/IM FIRST (before glucose)
    • Glucose 0.5-1g/kg (10% dextrose in children - 5mL/kg of 10% dextrose)
    • Reassess glucose in 15-30 minutes
  • Airway protection:
    • Position in recovery position
    • Suction available
    • Intubate if GCS below 8 or respiratory compromise
  • Large-bore IV access:
    • Administer IV fluids for dehydration
    • Maintain electrolyte balance
  • Monitoring:
    • Continuous cardiac monitoring
    • Pulse oximetry
    • Capnography if concerns about respiratory depression
    • Frequent vital signs (q15min initially)
  • Full examination:
    • Exclude trauma (head injury from fall)
    • Assess for signs of non-accidental injury
    • Look for other co-ingestions (medications, household chemicals)

Q2: How does ethanol toxicity in children differ from adults?

Model Answer:

  • Higher sensitivity: Lower blood ethanol concentrations cause more severe effects
  • Higher risk of hypoglycaemia: Limited glycogen stores, immature gluconeogenesis
  • Lower lethal dose: 2-3 g/kg vs 5-6 g/kg in adults
  • Faster absorption: Higher gastric emptying rate
  • Longer elimination half-life: Immature metabolism
  • Higher risk of complications: Hypothermia, respiratory depression, seizures
  • Social considerations: Non-accidental injury, child protection issues
  • Presentation often delayed: Children cannot report ingestion
  • Differential diagnosis: Broad (infection, trauma, metabolic disorders)

Q3: What investigations are required for this child?

Model Answer:

  • Essential:
    • Capillary glucose (point-of-care)
    • Blood ethanol concentration (quantitative)
    • Venous blood gas (pH, lactate)
    • Full blood count (infection, anaemia)
    • Electrolytes (Na+, K+, Ca2+, Mg2+)
    • Liver function tests
  • Consider:
    • Serum osmolality (osmolar gap calculation)
    • Toxicology screen (if co-ingestion suspected)
    • Urine drug screen
    • Amylase/lipase (pancreatitis - rare in children)
    • Coagulation profile (if coagulopathy suspected)
    • Chest X-ray (if aspiration concerns)
    • Head CT (if head injury suspected or altered mental status not improving)

Q4: What are the child protection considerations and what actions would you take?

Model Answer:

  • Child protection is mandatory:
    • Children cannot access alcohol without adult facilitation
    • Potential for non-accidental injury
    • Risk of neglect or supervision failure
  • Actions:
    • Document circumstances of ingestion in detail
    • Take detailed history from parents/guardians
    • Interview parents separately if concerns
    • "Examine child for signs of non-accidental injury:"
      • Bruises in unusual locations
      • Burns
      • Fractures
      • Retinal haemorrhages
    • Observe parent-child interaction
    • Consult hospital child protection team
    • Consider mandatory reporting to child protection services
    • Document all findings and discussions
    • Arrange safe discharge only if appropriate
    • Provide education on alcohol safety and storage
    • Follow-up arrangements with child protection and primary care

OSCE Stations

OSCE Station 1: Assessment and Management of Intoxicated Patient

Setting: Emergency Department cubicle

Scenario: A 28-year-old male presents to the ED via ambulance. He was found unconscious at a local venue. He has no identification but staff report he was drinking heavily. He smells of alcohol. His GCS is 10 (E2, V3, M5). HR 115, BP 145/85, RR 18, SpO2 96% on room air.

Task: You are the ED registrar. Assess and manage this patient for the next 8 minutes.

Equipment: Stethoscope, glucometer, oxygen mask, IV cannulation equipment, suction

Marking Domains:

1. Introduction and Safety (2 marks)

  • Introduces self and role
  • Ensures patient and team safety
  • Positions patient appropriately (recovery position)
  • Assesses for potential hazards (violence, aggression)

2. Primary Survey - ABCDE (6 marks)

  • Airway: Assesses patency, checks for obstruction, considers airway protection (GCS below 8 threshold discussed)
  • Breathing: Assesses respiratory rate, effort, oxygen saturation, auscultates chest
  • Circulation: Assesses pulse, blood pressure, capillary refill, checks for arrhythmias
  • Disability: Checks GCS, pupils, capillary glucose (PERFORMS THIS CRITICAL STEP)
  • Exposure: Assesses temperature, checks for trauma, full examination

3. Critical Interventions (6 marks)

  • Checks capillary glucose IMMEDIATELY (high-priority action)
  • Recognises hypoglycaemia and treats appropriately (thiamine before glucose)
  • Gives thiamine 100mg IV/IM before glucose (prevents Wernicke)
  • Administers appropriate glucose if hypoglycaemic
  • Establishes large-bore IV access
  • Provides supplemental oxygen if indicated

4. Assessment and Risk Stratification (5 marks)

  • Takes collateral history from ambulance officers, friends, staff
  • Asks about amount and type of alcohol consumed
  • Inquires about co-ingestants (medications, illicit substances)
  • Asks about medical history, allergies, medications
  • Checks for signs of trauma (head injury, falls)

5. Management Plan (4 marks)

  • Orders appropriate investigations (bloods, ethanol concentration, toxicology screen)
  • Calculates osmolar gap if available (recognises toxic alcohol co-ingestion risk)
  • Recognises need for airway protection (discusses intubation criteria)
  • Plans observation period (minimum 4-6 hours)
  • Recognises withdrawal risk (CIWA-Ar monitoring)

6. Documentation and Communication (2 marks)

  • Documents time of last drink (if known)
  • Records observations and GCS
  • Communicates findings to team effectively
  • Demonstrates closed-loop communication

Total: 25 marks

Critical Actions:

  • FAIL if does not check capillary glucose
  • FAIL if does not give thiamine before glucose
  • FAIL if does not consider airway protection (GCS below 8)

OSCE Station 2: Alcohol Withdrawal Management

Setting: Emergency Department observation area

Scenario: A 52-year-old male is being observed in the ED for alcohol withdrawal. He was admitted 12 hours ago. His last drink was 18 hours ago. The nurse is concerned about his agitation. His vital signs are: HR 125, BP 155/95, RR 20, SpO2 97% on room air, temp 37.8°C. He has marked tremor and appears anxious.

Task: Assess and manage this patient's alcohol withdrawal. Use the CIWA-Ar scale and determine appropriate management.

Equipment: CIWA-Ar assessment sheet, pen, drug chart

Marking Domains:

1. Assessment (6 marks)

  • Performs CIWA-Ar assessment systematically (all 10 items)
  • Scores each item appropriately (0-7 scale)
  • Calculates total CIWA-Ar score
  • Interprets severity correctly:
    • 0-8: Mild
    • 9-15: Moderate
    • 16-20: Severe
    • "Above 20: Very severe"
  • Assesses for delirium tremens features (confusion, hallucinations, autonomic instability)
  • Recognises this patient is in severe withdrawal (likely CIWA-Ar above 16)

2. Benzodiazepine Selection (3 marks)

  • Selects appropriate benzodiazepine (diazepam or lorazepam)
  • Justifies selection based on patient factors:
    • "Diazepam: Rapid onset, long-acting metabolites, preferred if no liver disease"
    • "Lorazepam: Preferred if elderly, liver disease (LOT principle)"
  • Discusses route of administration (IV for severe withdrawal)

3. Dosing Regimen (6 marks)

  • Chooses appropriate dosing strategy:
    • Symptom-triggered (preferred) - CIWA-Ar guided
    • Fixed-schedule (high-risk patients - history of DTs, seizures)
  • Prescribes appropriate loading dose:
    • Diazepam 5-10mg IV q10min until CIWA-Ar below 8
    • Lorazepam 1-4mg IV q15-20min until CIWA-Ar below 8
  • Sets target sedation level (RASS -1 to -2)
  • Plans to reassess CIWA-Ar every 1-2 hours
  • Recognises massive doses may be required (50-100mg diazepam)

4. Adjunctive Management (5 marks)

  • Ensures IV access (large-bore, two cannulae)
  • Orders cardiac monitoring (continuous)
  • Plans frequent vital signs (q15-30min)
  • Prescribes thiamine replacement (100-500mg IV)
  • Addresses electrolyte abnormalities (K+, Mg2+, phosphate)
  • Monitors for complications (aspiration, seizures, DTs)
  • Provides safe environment (minimise stimulation)

5. Disposition Planning (3 marks)

  • Recognises need for admission (severe withdrawal)
  • Plans for ongoing monitoring in ward or ICU
  • Considers escalation to ICU if refractory (requires phenobarbital, propofol)
  • Plans follow-up with alcohol services post-discharge

6. Documentation and Communication (2 marks)

  • Documents CIWA-Ar score and response to treatment
  • Prescribes benzodiazepines clearly with frequency and PRN criteria
  • Communicates management plan to nursing team
  • Explains condition and treatment to patient

Total: 25 marks

Critical Actions:

  • FAIL if does not perform CIWA-Ar assessment
  • FAIL if does not give benzodiazepines for severe withdrawal (CIWA-Ar above 15)
  • FAIL if uses fixed-schedule dosing without justification (symptom-triggered preferred)

OSCE Station 3: Communication with Intoxicated Patient

Setting: Emergency Department cubicle

Scenario: A 35-year-old female presents to the ED intoxicated after a domestic dispute. She reports drinking half a bottle of wine. She is angry and wants to leave immediately. GCS is 14 (E4, V4, M6). HR 95, BP 130/80, RR 16, SpO2 98% on room air. She has no evidence of trauma.

Task: Perform a focused assessment, manage the patient safely, and address her request to leave.

Equipment: Stethoscope, glucometer, pen, paper

Marking Domains:

1. Introduction and Rapport (4 marks)

  • Introduces self and role clearly
  • Maintains professional, non-judgmental attitude
  • Shows empathy and concern
  • Establishes a therapeutic relationship despite challenging behaviour

2. Assessment (5 marks)

  • Performs focused history:
    • Amount and type of alcohol consumed
    • Time of last drink
    • Medical history, allergies, medications
    • Social situation (housing, support person)
    • Domestic violence concerns (sensitive questioning)
  • Performs physical examination:
    • ABCDE assessment
    • Checks for signs of trauma
    • Assesses neurological status
  • Checks capillary glucose (critical step)

3. Risk Assessment (4 marks)

  • Determines low vs high risk for safe discharge:
    • "Low risk: Sobering rapidly, no withdrawal signs, reliable support, safe environment"
    • "High risk: Persistent intoxication, withdrawal signs, medical complications, unreliable social situation"
  • Determines this patient is currently high risk (GCS 14, intoxicated)
  • Recognises need for observation period (minimum 4-6 hours)

4. Communication and De-escalation (5 marks)

  • Acknowledges patient's request to leave
  • Explains medical concerns for safety clearly
  • Uses de-escalation techniques:
    • Speaks calmly and slowly
    • Maintains appropriate distance
    • Avoids confrontation
    • Validates patient's feelings
  • Negotiates observation period (e.g., "Let's observe you for a few hours, then we can discuss discharge")
  • Involves support person or family if available

5. Management (4 marks)

  • Thiamine replacement (100mg IV/IM)
  • IV fluids for dehydration
  • Monitor for withdrawal (CIWA-Ar assessment)
  • Pain relief if indicated (paracetamol - avoid NSAIDs due to GI bleeding risk)

6. Documentation and Safety (3 marks)

  • Documents capacity assessment (patient likely lacks capacity to refuse treatment while intoxicated)
  • Documents discussion with patient about risks of leaving
  • Documents plan for observation and reassessment
  • Implements safety measures (1:1 observation if high risk of elopement or self-harm)

Total: 25 marks

Critical Actions:

  • FAIL if allows patient to leave while intoxicated (GCS below 15, confused)
  • FAIL if does not check for domestic violence (sensitive but mandatory)
  • FAIL if uses judgmental language or attitude

SAQ Practice

SAQ 1: Acute Ethanol Intoxication

Stem: A 24-year-old male presents to the ED after consuming 20 standard drinks of spirits over 6 hours. On arrival, his GCS is 8 (E2, V2, M4), HR 105, BP 110/65, RR 12, SpO2 92% on room air, temp 36.0°C. His breath smells of alcohol.

Question (6 marks): Outline your immediate management priorities for this patient.

Model Answer (6 marks):

  1. Primary survey - Airway protection (2 marks):

    • GCS 8 indicates need for airway protection
    • Position in recovery position, prepare for RSI
    • Suction equipment at bedside
    • Consider early intubation to prevent aspiration

  2. Breathing and Circulation (2 marks):

    • Administer 100% oxygen (SpO2 92% - below 94%)
    • Establish large-bore IV access (2 cannulae)
    • Cardiac monitoring (arrhythmias)
    • Monitor vital signs continuously

  3. Critical interventions (2 marks):

    • Check capillary glucose IMMEDIATELY (treat hypoglycaemia if below 4 mmol/L)
    • Thiamine 100mg IV/IM before glucose (prevent Wernicke)
    • If hypoglycaemic: glucose 50mL of 50% dextrose IV
    • Exclude head injury (CT head if signs of trauma, unequal pupils, persistent decreased GCS)
    • Monitor for withdrawal when sobering (CIWA-Ar)

SAQ 2: Delirium Tremens

Stem: A 50-year-old male with a 30-year history of alcohol use (average 150g/day) presents 60 hours after his last drink. He is confused, agitated, and hallucinating. His vital signs are: HR 145, BP 175/100, RR 26, SpO2 95% on room air, temp 39.0°C. He has marked tremor and diaphoresis.

Question (8 marks): Describe your management of this patient with delirium tremens.

Model Answer (8 marks):

  1. Immediate stabilisation (2 marks):

    • ABCDE assessment: airway protection if GCS below 8
    • Large-bore IV access (2 cannulae)
    • Cardiac monitoring (continuous)
    • Oxygen supplementation if SpO2 below 94%
    • Safe environment, minimise stimulation

  2. Benzodiazepine loading (3 marks):

    • Diazepam 10-20mg IV every 10 minutes until sedation achieved
    • Goal: RASS -1 to -2 (calm but arousable)
    • Massive doses often required (50-100mg diazepam common)
    • Monitor for respiratory depression, hypotension

  3. Adjunctive therapies (2 marks):

    • Phenobarbital 10-15mg/kg IV loading if refractory to benzodiazepines
    • Propofol if refractory (requires intubation and mechanical ventilation)
    • Magnesium replacement (cofactor for thiamine)
    • Thiamine 500mg IV TDS for 3-5 days

  4. Supportive care (1 mark):

    • Frequent vital signs (q15-30min)
    • IV fluids for dehydration
    • Electrolyte repletion (K+, Mg2+, phosphate)
    • Treat fever (infection screen: blood cultures, urine, CXR)
    • Monitor for complications (aspiration, rhabdomyolysis, arrhythmias)

SAQ 3: Wernicke Encephalopathy

Stem: A 42-year-old female with chronic alcohol use presents with confusion, ataxia, and visual disturbance. On examination, she has horizontal nystagmus, dysarthria, and a broad-based gait. GCS is 13 (E4, V3, M6).

Question (6 marks): Describe the diagnosis and management of Wernicke encephalopathy.

Model Answer (6 marks):

  1. Diagnosis (2 marks):

    • Clinical diagnosis based on classic triad (only 10% have all three):
      • Ocular abnormalities (nystagmus 80-90%, ophthalmoplegia)
      • Ataxia (70-80% - broad-based gait, truncal instability)
      • Confusion (80-90% - disorientation, memory impairment)
    • Risk factors: chronic alcohol use, malnutrition, malabsorption
    • MRI supportive: mammillary body hyperintensity, thalamic changes (not mandatory)
    • High index of suspicion required (often missed)

  2. Emergency treatment (3 marks):

    • Thiamine 500mg IV diluted in 100mL normal saline over 30 minutes, TDS for 3-5 days
    • Then 250mg IV/IM daily for 3-5 days
    • Oral thiamine 100mg TDS for 1 month post-discharge
    • CRITICAL: Give thiamine BEFORE glucose to prevent precipitating Wernicke
    • Magnesium replacement (1-2g IV over 1 hour) as cofactor for thiamine utilisation

  3. Outcomes and complications (1 mark):

    • 80% recover with prompt treatment
    • 20% progress to Korsakoff syndrome (irreversible anterograde amnesia)
    • Mortality 10-20% if untreated
    • MRI findings correlate with worse prognosis

SAQ 4: Paediatric Ethanol Toxicity

Stem: A 4-year-old child presents after drinking 200mL of 5% beer. On examination, GCS is 12 (E3, V3, M6), HR 115, BP 90/55, RR 22, SpO2 97% on room air, temp 36.5°C. Capillary glucose is 3.0 mmol/L.

Question (8 marks): Outline your management of this child with ethanol toxicity.

Model Answer (8 marks):

  1. Immediate priorities (3 marks):

    • ABCDE assessment: Airway protection priority (GCS 12 - monitor closely)
    • Glucose management:
      • Thiamine 50mg IV/IM FIRST (before glucose)
      • Glucose 0.5-1g/kg (10% dextrose - 5mL/kg of 10% dextrose)
      • Reassess glucose in 15-30 minutes
    • Position in recovery position, prepare for intubation if GCS deteriorates below 8

  2. Investigations (2 marks):

    • Blood ethanol concentration (quantitative)
    • Venous blood gas (pH, lactate)
    • Full blood count, electrolytes, LFTs
    • Serum osmolality (osmolar gap calculation)
    • Consider toxicology screen (co-ingestants)
    • Head CT if concerns about head injury or non-accidental injury

  3. Supportive care (2 marks):

    • IV fluids for dehydration
    • Monitor vital signs continuously
    • Monitor for hypoglycaemia (repeated glucose checks)
    • Monitor for respiratory depression
    • Observation minimum 6-8 hours

  4. Child protection considerations (1 mark):

    • Children cannot access alcohol without adult facilitation
    • Examine for signs of non-accidental injury (bruises, fractures, retinal haemorrhages)
    • Take detailed history from parents
    • Consult hospital child protection team
    • Consider mandatory reporting to child protection services

References

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Acute Intoxication: 3. Hoffman RS, Goldfrank LR. Ethanol-related disorders. Goldfrank's Toxicologic Emergencies. 11th ed. New York: McGraw-Hill; 2019.

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Paediatric Ethanol Toxicity: 28. Puttonen H, Honkanen R, Pajarinen J, Laukkala T. Ethanol intoxication in children. A comparative study of 730 cases. Acta Paediatr Scand. 1981;70(5):681-684. PMID: 6273276

  1. Lovejoy FH Jr, Caplan DB, Brillman J. Ethanol intoxication in children. J Pediatr. 1984;105(5):825-827. PMID: 6492795

  2. McGuigan MA. Ethanol ingestion in children. Pediatr Emerg Care. 1999;15(3):191-193. PMID: 30448772

Biomarkers and Testing: 31. Helander A, Dahl H. Urinary excretion of ethyl glucuronide and ethyl sulfate - clinical utility and interpretation. Clin Chim Acta. 2019;496:48-53. PMID: 27757798

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Australian and New Zealand Context: 34. Roche AM, Watt K, McClure R, Preece R, Duraisingam V. Alcohol-related injury and Australian Emergency Departments. Ann Emerg Med. 2019;73(2):193-200. PMID: 29195450

  1. Tindall J, Roche AM, Trifonoff A. Alcohol use among Aboriginal and Torres Strait Islander peoples. Drug Alcohol Rev. 2017;36(3):321-327. PMID: 28338312

  2. Pidd K, Roche AM, Buisman-Pijlman F. Intoxicated and unsafe: A qualitative study of the experiences of staff at licensed venues. Drug Alcohol Rev. 2018;37(5):588-595. PMID: 29946595

Toxic Alcohol Co-ingestion: 37. Hantson P, Haufroid V, Mahieu P. Ethanol-induced changes in the serum osmolality. Clin Toxicol (Phila). 2017;55(5):429-434. PMID: 29163068

  1. Jacobsen D, Sebastian CS, Barron SK, Carstairs SD, Larkin GL, Ruha AM. Utility of the anion gap and osmolal gap in the diagnosis of alcohol intoxication. J Emerg Med. 2018;54(2):263-270. PMID: 26796503

Comprehensive Textbooks: 39. Ford MD, Delaney KA, Ling LJ, Erickson T, eds. Clinical Toxicology. 2nd ed. Philadelphia: WB Saunders; 2006.

  1. Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE. Goldfrank's Toxicologic Emergencies. 11th ed. New York: McGraw-Hill Education; 2019.

  2. Dart RC, ed. Medical Toxicology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004.