Acute alcohol intoxication (10–24 years) — Frequently asked questions (FAQ)
1) What does this algorithm cover?
This algorithm guides the approach to acute alcohol intoxication in adolescents and young adults (10–24 years) in the emergency department, from ABCDE assessment and identification of severity signs to the decision between observation, targeted investigation, admission or discharge. It also includes a post-discharge assessment block for risky drinking and referral when indicated.
2) What are the main severity signs in alcohol intoxication?
The following should be valued: altered level of consciousness (Glasgow < 15 or AVPU ≠ A), respiratory depression or hypoxaemia, haemodynamic instability, seizures, hypoglycaemia, hypothermia, significant trauma or suspected head injury, and disproportionate clinical presentation suggesting co-ingestion. The presence of any of these criteria implies management as moderate to severe acute alcohol intoxication.
3) Why is capillary blood glucose mandatory?
Hypoglycaemia may occur in alcohol intoxication, especially in adolescents with reduced food intake, vomiting, low body weight or fasting. Blood glucose should be assessed on admission and reassessed according to severity, because hypoglycaemia may explain altered mental status and increase the risk of seizures and depressed sensorium.
4) When can intoxication be considered “mild”?
Mild acute alcohol intoxication is considered when there are typical behavioural changes — euphoria, disinhibition, excessive talkativeness — with AVPU = A, stable vital signs, neurological examination without deficits and no trauma or other complications. In these cases, management consists of observation, hydration and periodic reassessment, and laboratory testing is not usually required beyond glucose measurement.
5) When should co-ingestion of other substances be suspected?
Suspicion of co-ingestion should be raised when the clinical presentation is disproportionate to the reported alcohol intake, when there is unexpected deterioration, marked autonomic changes, extreme agitation, atypical neurological signs or lack of expected recovery. The presence of miosis and respiratory depression should prompt consideration of opioids.
6) What is the role of naloxone?
Naloxone should be considered only when there is clinical suspicion of opioid intoxication, namely miosis and respiratory depression that are not compatible with the degree of alcohol intoxication or that do not respond to basic supportive measures. It should be administered according to local protocol, while maintaining stabilisation and airway protection in parallel.
7) Which tests should be requested and when?
For most patients with mild acute alcohol intoxication, no tests are required beyond blood glucose. In moderate to severe cases or when there is diagnostic uncertainty, targeted investigation should be performed and may include electrolytes and renal function, blood gas analysis if there are respiratory abnormalities/acidosis, blood alcohol concentration if there is clinical uncertainty or a medico-legal need, and toxicology screening if co-ingestion is suspected. Cranial CT should be considered in suspected trauma, focal deficits, neurological deterioration or lack of expected recovery.
8) Does gastrointestinal decontamination have any role?
In isolated ethanol intoxication, gastrointestinal decontamination is not indicated. Measures such as activated charcoal or gastric lavage are only exceptionally considered in selected, very early co-ingestions with a protected airway, and should follow local protocols and risk–benefit assessment.
9) When should thiamine be administered?
Thiamine should be administered in patients with chronic alcohol use disorder, nutritional risk or marked altered consciousness, to reduce the risk of vitamin-deficiency encephalopathy. Correction of hypoglycaemia should not be delayed; when nutritional risk is present, thiamine may be administered early, ideally before or at the same time as glucose.
10) What are the criteria for admission/prolonged observation?
Admission or prolonged observation should be considered in the presence of persistent altered consciousness or abnormal vital signs, respiratory depression, focal neurological deficits, recurrent/persistent hypoglycaemia, significant dehydration — vomiting/polyuria —, relevant co-ingestion, severe trauma/suspected head injury, suicide attempt or inability to ensure safe supervision, including situations of neglect or an unfavourable social/family context.
11) What are the criteria for safe discharge?
Discharge may be considered when there is complete recovery of consciousness to baseline, stable vital signs, normal blood glucose, absence of complications — aspiration, relevant trauma, co-ingestion — and assurance of safe supervision and adequate social conditions. Clear guidance on warning signs and the need for reassessment should be provided.
12) What does post-discharge assessment include and when should referral be made?
After resolution of the acute episode, an assessment of the alcohol consumption pattern should be performed, identifying habitual/risky drinking and screening for associated psychopathology. In the presence of habitual drinking or significant risk, referral to addiction services should be considered. If relevant psychopathology or risk of self-harm is suspected, prompt referral for specialist assessment should be considered according to the local care network.
