- Rate of ETOH elimination is 15-30mg/dL/hr (depending on degree of chronic alcohol intake)
- Classic Features
- Slurred speech
- Alcohol odor on breath
- Respiratory depression
- Other Features (if malnourished)
- Lactic acidosis
- Epigastric pain (pancreatitis)
- Impairment is greater at a given blood alcohol concentration when the level is rising than when it is falling. 
- Chloral hydrate
- Gamma hydroxybutyrate (GHB)
- Baclofen toxicity
- Toxic alcohols
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- CO2 narcosis
- Hypertensive Encephalopathy
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Vascular disease
- Hemispheric, brainstem
- CNS infections
- Nonconvulsive status epilepticus
- Postictal state
Clinical diagnosis. No specific workup required, but the following may be considered based on clinical picture/gestalt:
- Fingerstick glucose (recommended as minimum workup in all pts with AMS)
- Blood alcohol level (BAL)
- Correlates poorly with degree of intoxication
- Maintain low threshold for imaging in intoxicated patient with signs of trauma.
- Supportive care is mainstay of ED treatment and is based on clinical presentation.
- Manage ABCs
- Benzodiazepines or haloperidol for agitation.
- IV fluids are commonly used but do not hasten ETOH elimination or reduce length of stay
- Can be discharged once patient at baseline mental status, able to tolerate PO and ambulate without assistance.
- Alcohol Withdrawal
- Alcoholic ketoacidosis
- Beer Potomania Syndrome
- Altered mental status
- Wang MQ, Nicholson ME, Mahoney BS, et al. Proprioceptive responses under rising and falling BACs: a test of the Mellanby effect. Percept Mot Skills. 1993 Aug;77(1):83-8.
- Olson KN, Smith SW, Kloss JS, et al. Relationship between blood alcohol concentration and observable symptoms of intoxication in patients presenting to an emergency department. Alcohol Alcohol. 2013 Jul-Aug;48(4):386-9. doi: 10.1093/alcalc/agt042.
- Perez SR, Keijzers G, Steele M. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151.
- Li J, Mills T, Erato R. Intravenous saline has no effect on blood ethanol clearance. J Emerg Med. 1999 Jan-Feb;17(1):1-5.