see also:

• ethanol (alcohol and alcohol withdrawal)
• toxicology
• RCH guidelines - ethanol poisoning in children

• never assume that a patient is just drunk until you have considered all of the following:
  • hypoglycaemia
  • head injury - order a CT scan if decreased conscious state and possible head injury
  • post-ictal - eg. withdrawal seizures
  • acute poisoning / co-ingestants / opiates / GHB / etc
  • meningitis
  • sepsis / septicaemia
  • stroke (CVA)
  • hypothermia
  • heat illness and heat stroke
  • conditions more prevalent in alcoholics:
    • aspiration pneumonia
    • pneumococcal pneumonia
    • tuberculosis (TB)
    • cardac arrhythmia
    • cardiomyopathy
    • upper GIT bleeding
    • pancreatitis
    • hepatic encephalopathy
    • hypokalaemia
    • hypomagnesaemia
    • hypocalcaemia
    • acute kidney injury (AKI) / acute renal failure (ARF)
    • lactic_acidosis
    • alcoholic ketoacidosis
    • alcohol withdrawal and delirium tremens
    • Wernicke's encephalopathy
    • occult injury such as head, neck, fractured ribs, organ injury, ankle fractures
    • radial nerve palsy
    • aggressive behaviour

• strongly consider investigating for other causes or associated conditions:
  • vital signs including temperature and neuro obs
  • finger prick blood glucose
  • breathalyzer to document BAC
  • IV access and bloods for FBE, U&E, LFTs, lipase, CRP, ethanol and others as indicated
  • Group and hold / crossmatch / clotting profile if suspect major trauma or GIT bleed
  • targeted investigations:
    • CT brain if decreased GCS and suspicion of head injury or focal neurologic signs
    • trauma investigations (eg. CT Cx spine, CXR) if suspicion of trauma
    • serum ammonia if hepatic flap, etc
    • sepsis workup if high CRP, fever, hypothermia or other suspicion of sepsis
    • ECG especially if possible co-ingestants or chest pain
    • CXR if possible aspiration, sepsis or trauma
    • serum paracetamol if possible suicidal intent or self-poisoning
    • serum CK if possible rhabdomyolysis from prolonged collapse on ground
• adequate visual examination particularly looking for evidence of trauma, focal neurology and hepatic encephalopathy
• PR exam if suggestion of GIT bleed (eg. history dark stools, hypotension, or raised urea)
• bladder scan to exclude urinary retention especially if in pain or agitated
• supportive care
• manage airway if excessively sedated
• whilst in hospital, place on an alcohol withdrawal chart and prescribe 10-20mg oral diazepam 2-6hrly APP up to 60mg/d if GCS is not depressed.
  • do not discharge patient with diazepam - it is only for use whilst in hospital.
• all patients should be given iv thiamine ASAP (NOT oral as this is not absorbed well in alcoholics)
• when appropriate, offer information and referral for addiction medicine (alcohol and other substance use) to aid detoxification.