Alcohol Intoxication

Acute intoxication

Acute alcohol intoxication is the most common of all poisonings, with thousands of cases occurring every month. Ordinary alcohol intoxication gradually progresses into alcohol poisoning without a specific threshold. About 5% of all adult men and 2% of women are alcohol-dependent. Approximately 300,000 people are estimated to have risky alcohol consumption, though some estimates suggest significantly higher numbers. About 20% of the population has occasional alcohol problems. These figures are approximate and relatively uncertain, as large variations exist across different estimates and scientific studies, including those from the Central Association for Alcohol and Narcotics Information (CAN), which publishes annual reports. Total alcohol consumption in Sweden has slightly decreased in recent years from a peak in 2004, when the average consumption was 10.5 liters of pure alcohol per person per year, to 9 liters of pure alcohol per person per year in 2016. Alcohol consumption is distributed as 42% wine, 37% strong beer, 21% spirits, 5% medium-strength beer, and 1% cider.

Risky alcohol consumption refers to the intake of alcohol that, over time, leads to medical and social complications. It is usually defined as the consumption of more than 14 standard drinks per week for men and 9 standard drinks per week for women. This corresponds to 56 cl of spirits or 2.2 bottles of wine for men, and 36 cl of spirits or 1.4 bottles of wine for women per week. One standard drink (or standard unit) corresponds to 12 g of alcohol, or one can of medium-strength beer (50 cl), one bottle of strong beer (33 cl), 12 cl of table wine, or 4 cl of spirits.

Binge drinking typically involves men consuming 5 standard drinks and women consuming 4 standard drinks or more at one time. One bottle of wine is considered to contain 6 standard units.

Mild and moderate alcohol intoxications (intoxication) are usually not subject to hospital care. Most patients who come to the hospital with alcohol intoxication also have injuries requiring medical treatment, such as abrasions, stab wounds, contusions, fractures, or lacerations. Other serious incidents, such as drowning, drug poisoning, smoke inhalation, assault, or hypothermia, are common in connection with acute alcohol intoxication . Hypothermia during mixed poisoning with drugs and alcohol can delay drug absorption, meaning that an intoxicated person may become increasingly drug-poisoned as they warm up. Vomiting and diarrhea are common with alcohol intoxication , sometimes leading to airway aspiration. Fluid and electrolyte disturbances are common during prolonged drinking. Hypokalemia, hyponatremia, and hypomagnesemia are relatively common in alcohol abuse. In acute care, these electrolyte imbalances should be monitored.

Pure alcohol intoxication may require hospital care if it is pronounced, is part of mixed intoxication, or affects young, debilitated, sick, or particularly sensitive individuals. Severe alcohol intoxication typically occurs with a blood alcohol content > 2.0 ‰, but there are significant individual differences depending on the degree of tolerance. It is generally possible to walk and stand steadily up to about 2 ‰. The most common cause of death due to alcohol intoxication is respiratory depression with hypoxia, lung atelectasis, and airway aspiration of stomach contents. Hypothermia is also common in fatal alcohol intoxication.

Approximately 150-200 people die each year from acute alcohol intoxication in Sweden, of which only 2-3 are under 30 years old. About 2,000 people die annually due to the effects of alcohol. The lethal dose of alcohol can be about 30-40 cl of pure alcohol (100%), which corresponds to 1-1.5 full bottles of spirits (75 cl, 40%) or 3.3-4.4 bottles of wine or 11-14 cans of strong beer consumed in a short time. At very high blood alcohol levels (> 3 ‰), it is usually spirits that have been consumed. Wine and beer take longer to drink, so the maximum concentration is rarely as high as after the consumption of spirits.

Moderate alcohol consumption has been described in several studies as having positive health effects. These positions are controversial and should be regarded as scientifically uncertain. Observational studies are limited by methodological problems, mainly confounding factors and misclassification. It is always difficult to prove causality, as opposed to correlations among groups with low alcohol consumption and stable social conditions.

Technical Alcohol

Various chemical alcohol solutions are used as fuel, cleaning agents, and solvents in technical alcohol. Common solutions of technical alcohol are T-red, T-blue, T-yellow, K-alcohol, and M-alcohol. Poisonings with these agents are not uncommon.

The alcohol content of technical alcohol varies between 70% and 95%. Technical alcohol generally contains denaturing additives to make the solution undrinkable, but some people, often degraded alcoholics or experimenting youths, still drink denatured alcohol.

In addition to ethanol, technical alcohol contains methyl ethyl ketone, acetone, ethyl acetate, propanol, paraffins, and in some cases, Bitrex. Denatured alcohol is also found in many hand sanitizers, disinfectants, aftershaves, perfumes, and some medicinal solutions. In Sweden, methanol is not used as a denaturing agent, but it is found abroad.

Pharmacokinetics of Alcohol

Swallowed alcoholic beverages are quickly absorbed into the bloodstream from the mucous membranes of the duodenum and small intestine. Alcohol does not bind to proteins and is distributed throughout the body’s tissues. The apparent volume of distribution for alcohol (Vd) is 0.7 L/kg. The effect on the brain (“target site”) occurs within a few minutes after ingestion (approximately 60-90 seconds), which is well known to most regular consumers. Blood alcohol concentration can continue to rise for about an hour after ingestion.

A normal-sized adult male who drinks 3-4 cans of strong beer or 4-6 glasses of wine (12 cl, 12%) will reach an approximate blood alcohol concentration of 1 g/L, equivalent to 1 ‰. An adult female will reach the same blood alcohol concentration after consuming about 3 cans of strong beer or 3-5 glasses of wine (12 cl). One ‰ corresponds to 27 mmol/L of ethanol in the blood.

Conversion factor from mmol to ‰: mmol/L x 0.0376. The achieved blood alcohol concentration varies with body size, how quickly the alcohol is consumed, and concurrent food intake.

Ninety percent of alcohol is broken down by oxidation, the majority of which occurs in the liver. Ethanol is broken down at a relatively constant rate in the human body with the help of the enzyme alcohol dehydrogenase. Ethanol is converted to acetaldehyde, which is then quickly broken down into acetic acid and subsequently into carbon dioxide and water. The breakdown into acetaldehyde begins in the stomach but primarily occurs in the liver. Acetaldehyde (ethanal) is an intermediate product in the breakdown of alcohol. There is some evidence that acetaldehyde causes some of the classic hangover symptoms such as nausea, dizziness, headache, instability, and fatigue. Acetaldehyde is further broken down into acetic acid by the enzyme acetaldehyde dehydrogenase during peripheral respiration. The acetic acid is then further broken down into carbon dioxide and water in several steps.

The enzyme alcohol dehydrogenase, which breaks down alcohol, becomes saturated at a blood alcohol concentration (BAC) over 0.1%. Beyond this threshold, the breakdown rate remains constant, following zero-order kinetics. Approximately 90% of alcohol is eliminated by liver metabolism, while 10% is eliminated through breath, sweat, and urine. The ratio of alcohol in blood to exhaled air is about 2100:1. The normal rate of alcohol metabolism is approximately 0.1 g/kg body weight per hour, which translates to 5-10g of alcohol per hour for most people. This corresponds to 2-3 cl of spirits, 6-12 cl of wine, or 12-25 cl of beer per hour, roughly one “unit of alcoholic beverage” per hour. In an adult, the BAC is estimated to decrease by about 0.15 per hour. Alcohol in a light beer is broken down in about 15-30 minutes, while a strong beer typically takes 60-90 minutes. There are relatively large individual variations.

Tolerance

Alcohol tolerance varies greatly depending on age and habituation. The more frequently a person drinks, the higher the level of tolerance developed over time. Most people without alcohol problems have difficulty reaching blood alcohol levels above 2% ethanol.

Life-threatening intoxication is typically seen at BAC levels over 4.5% in women and over 5% in men, though lower concentrations can also be fatal. It’s difficult to reach these levels by drinking only beer or wine; large quantities of spirits are usually required. It’s not uncommon for alcoholics admitted to hospitals for acute intoxication to have BAC levels over 5%, sometimes reaching 7-8%, and in rare cases, even higher. Serious alcohol intoxication among youth occurs at levels above 2.5%. Severe alcohol intoxication is often associated with memory loss, hangover symptoms, and anxiety in the aftermath.

SYMPTOMS

Mild intoxication is considered to occur at a BAC of 0.5-1% (see the table above). At BAC levels between 1-1.5%, most adults feel moderately intoxicated (after a few strong beers or a bottle of wine), and over 1.5%, most feel heavily intoxicated (one to two bottles of wine). Young girls in their early teens may feel intoxicated after just one strong beer and exhibit clear signs of intoxication after two strong beers.

Polydrug Intoxication

Simultaneous use of medications such as sleeping pills or painkillers (opioids) potentiates alcohol’s toxic effects. In particular, the combination of alcohol with opioids, benzodiazepines, neuroleptics, barbiturates, or certain antidepressants poses significant risks. A BAC over 2%, combined with flunitrazepam, opioids, or other respiratory depressants, is considered life-threatening. Moderate alcohol intoxication can become life-threatening when combined with moderate or high doses of sedatives or painkillers. The combination of alcohol and energy drinks makes people feel more alert and less aware of their intoxication, leading to a higher risk of overconsumption and increased intoxication, often accompanied by memory loss.

Technical Alcohol

The symptoms of poisoning with denatured alcohol are similar to those of intoxication with “regular” ethanol-based beverages: varying degrees of intoxication, altered consciousness, impaired balance, hyperventilation, nausea, and vomiting. A characteristic acetone-like odor from the breath is often present. There is a significant risk of metabolic acidosis, nausea, and vomiting.

INVESTIGATION

• S-Ethanol
• S-Methanol
• S-Acetone
• Pulse and blood pressure
• Oxygen saturation with pulse oximetry (SaO₂)
• Drug screening for illicit substances (urine test)
• Arterial blood gas (ABG) to assess acid-base status
• Calculate the anion gap
• Infection parameters (CRP, ESR, Procalcitonin)
• Hb, glucose, Na, K, Mg
• Optional: Alcohol markers such as B-PEth (phosphatidylethanol), S-CDT (carbohydrate-deficient transferrin)
• Optional: U-Ethylglucuronide (EtG), U-Ethylsulfate (EtS) (detects alcohol consumption in the last 3 days)
• Liver function tests
• ECG
• Temperature
• Assess neurological status, palpate the skull, rule out trauma. If unconscious or suspect trauma, perform a head CT scan to exclude epidural or subdural hematoma, as well as other intracranial bleeding or stroke.
• If airway aspiration is suspected, order a chest X-ray.
• In case of poisoning with illegal alcohol or moonshine, check for methanol and ethylene glycol in serum and calculate the anion and osmolal gaps.

Electrolyte Disorders

Beware of the risk of electrolyte imbalances. Hyponatremia, hypokalemia, and hypomagnesemia are common in alcohol intoxication and alcohol abuse.

• Severe hyponatremia increases the risk of cerebral edema and impaired consciousness. Acute hyponatremia usually results in significant somnolence. Severe hyponatremia (< 120 mmol/L) with mild cognitive impairment indicates chronic hyponatremia. Chronic hyponatremia must be corrected slowly over several days. Rapid correction can lead to myelin damage in brain cells (myelinolysis), causing serious neurological damage. Hyponatremia is most commonly seen
  
  in beer drinkers but also poses an increased risk in those taking SSRIs (antidepressants).
• Hypokalemia causes fatigue and increases the risk of cardiac arrhythmias.
• Hypomagnesemia increases the risk of cardiac arrhythmias (especially atrial fibrillation) and seizures.

Other abnormalities in routine tests

Note the presence of anemia and hypoglycemia.

Biological Alcohol Markers

A good assessment of high alcohol consumption can include EtG, CDT, and B-PEth. One could say that EtG reflects high alcohol consumption over the past few days, B-PEth over the past few weeks, and CDT over the past few months. It likely takes about a week of excessive alcohol consumption for B-PEth to rise, but a high value clearly indicates high alcohol consumption, i.e., the value has high specificity.

• EtG (days)
• B-PEth (weeks)
• CDT (months)

U-Ethyl Glucuronide (EtG) and U-Ethyl Sulfate (EtS)

Indicates alcohol consumption in the past 3 days. EtG is a direct metabolite of ethanol and therefore a specific marker for ethanol consumption. EtG and EtS are eliminated significantly slower than ethanol and can be detected in urine for many hours up to a few days after alcohol intake, with the detection time primarily depending on the amount of alcohol consumed. EtG and EtS can be detected as early as one hour after alcohol intake. EtG is the more quantitatively significant of the two, and the concentration in urine is on average about twice as high as EtS.

Ethyl Glucuronide can also be measured in hair strands to determine alcohol intake over the past 6 months, for example in preparation for a transplant evaluation. Normally, the value is negative (< cutoff value 0.5 mg/L).

B-PEth (Phosphatidylethanol)

B-PEth is a collective name for a group of phospholipids formed from phosphatidylcholine in the presence of alcohol. B-PEth reflects alcohol consumption over the past few weeks. B-PEth values lower than 0.05 µmol/L indicate no or sporadic alcohol consumption. Values above 0.30 µmol/L may suggest more extensive, regular alcohol intake. 0.50 µmol/L corresponds to approximately 25 units of alcohol per week. Values above 1.0 µmol/L indicate significantly increased consumption according to WHO and often AUD. Values between 2–3 µmol/L are not uncommon in patients with chronic alcoholism. The B-PEth test should be used as a complement to other information about drinking habits.

S-GT (Gamma-Glutamyltransferase)

S-GT is a membrane protein mainly found in the liver and becomes elevated with chronic alcohol consumption. Some medications can induce increased GT levels in plasma. Elevated GT levels are seen, among other things, in bile duct obstruction. GT can also be elevated in diabetes, obesity, liver metastases, primary liver cancer, acute pancreatitis, pancreatic cancer, and biliary diseases. GT in cases of severe alcohol consumption can exceed 10 µkat/L. The normal value for adults is less than 2 µkat/L.

Moderately elevated GT is seen in infectious hepatitis and liver steatosis, in diabetes, overweight, high alcohol consumption, and with treatment with certain medications.

S-CDT (Carbohydrate-Deficient Transferrin)

S-CDT (carbohydrate-deficient transferrin) increases after a few weeks of heavy alcohol consumption and can indicate chronically high alcohol intake. CDT has high specificity for determining high alcohol consumption. CDT is used as a long-term alcohol marker and reflects alcohol intake over the past few weeks to a little over a month. The normal value is < 2.0%. Normally, CDT constitutes a small part (< 2.0%) of the total transferrin in serum, but with high alcohol consumption or abuse over a longer period, CDT values over 2.0% are often, but not always, observed.
The diagnostic sensitivity is therefore not sufficient to completely rule out overconsumption of alcohol (i.e., false-negative CDT results do occur).

However, the diagnostic specificity is high (i.e., false-positive CDT results are rare), and CDT is considered a very specific alcohol marker since values over 2.0%, apart from alcohol, are only seen in rare congenital glycosylation disorders (CDG syndromes) and occasionally in galactosemia or fructosemia. Additionally, the CDT value may approach the cutoff toward the end of pregnancy.

Vitamin Deficiency

Be especially aware of the risk of acute B vitamin deficiency. Vitamin K and B often need to be substituted with intramuscular injections for three days.

Withdrawal

Be aware of the risk of severe withdrawal symptoms during the detoxification process, with the potential for delirium and generalized myoclonic seizures.

Acidosis

Metabolic acidosis is commonly seen in intoxication from both alcoholic beverages and technical alcohol. If the measured arterial blood gas pH is below 7.1, the poisoning is considered life-threatening. A base excess of less than -10 mmol/L indicates a cause other than standard ethanol intake.

Treatment of alcohol intoxication

All patients, including those intoxicated with alcohol, have the right to good general care and to be treated with respect. Interact calmly and confidently with the patient. General supervision to prevent traumatic injuries and disruptive behavior is the primary concern.

The treatment of acute alcohol intoxication is mainly symptomatic, as there is no specific antidote. Determine the appropriate level of care, but keep in mind that consciousness and breathing may fluctuate suddenly.

In uncomplicated alcohol intoxication , a sick bag, fluids, sleep under observation, and antacids may be sufficient. Avoid placing the patient in a high position on the bed or examination table to reduce the risk of falls. Resting on a mattress on the floor may be an alternative. In cases of agitation and anxiety, administer diazepam (Stesolid) 2.5-5 mg intravenously with caution or orally. Substitute B vitamins and vitamin K in alcoholics:

• Neurobion 3 ml x 1 IM for 3 days
• Konakion 1 ml x 1 IV (10 mg/ml)

In more severe cases of intoxication or when complicating factors are present, the situation is different:

• Closely monitor consciousness and breathing.
• Administer oxygen.
• Suction the mouth and throat if there is an increase in mucus.
• Support breathing and circulation as needed (ensure a clear airway, treat hypoxia/hypercapnia, fluids, and inotropic drugs if circulatory failure occurs, etc. See details below). If paradoxical breathing is present, better airway conditions are needed, and intubation is usually required.
• Monitor body temperature.
• Treat acute confusion and motor agitation.
• Administer fluids, either orally or intravenously. Poisoned patients typically need rehydration with IV fluids. Administer buffered glucose solutions. If necessary, correct electrolyte imbalances.
• In case of hypothermia, provide warming.
• If airway aspiration is suspected, order a chest X-ray and administer antibiotics for a respiratory infection (cefotaxim (Zinacef) 1.5 g x 3 IV). In cases of severe aspiration: intubation, suctioning, and mechanical ventilation with PEEP.
• Consider prophylaxis for delirium and generalized seizures (e.g., carbamazepine (Hermolepsin, Tegretol) 200 mg 1×3 PO). Rule out status epilepticus.
• Gastric lavage and activated charcoal are administered only in cases of mixed poisoning with medication when the patient arrives within 1 hour of ingestion.

Free Airway

The airway may be partially or fully obstructed in alcohol intoxication. Securing a free airway is the highest priority. Suction the mouth and throat if there is an increase in mucus. Nasal or oropharyngeal airways are the first-line devices. Be aware that nasal airways may cause severe nosebleeds, and the risk of nosebleeds is increased in alcohol intoxication (due to alcohol’s vasodilating effect). Therefore, use plenty of gel when inserting the nasal airway.

The patient’s position should be in the recovery position, with the tongue pulled forward through a firm jaw thrust. Patients who cannot maintain a free airway in the supine position or are unresponsive should be monitored in an intensive care unit.

Endotracheal intubation is necessary if the airway cannot be adequately maintained, if there is hypoxia, or if there is carbon dioxide retention.

Breathing

Avoid hypoxia and hypercapnia by administering liberal amounts of oxygen. If breathing is inadequate, consider endotracheal intubation and mechanical ventilation in the intensive care unit. Suction the airway of any mucus.

Circulation

Treat hypotension with intravenous fluids and, if necessary, with vasopressor drugs (e.g., ephedrine, phenylephrine, dopamine, or norepinephrine).

Confusion and Aggression

Agitated and aggressive patients may require sedation to prevent self-harm or harm to others.

This type of sedation is challenging and difficult to manage correctly. The treatment itself poses risks such as hypotension or sudden decreased consciousness, with difficulties in maintaining a free airway and respiratory depression. Sedatives must therefore be used with caution and under supervision. Treatment requires the ability to take over the patient’s breathing with controlled ventilation and mechanical ventilation if necessary.

Suitable agents include haloperidol (Haldol) 1-5 mg IV, midazolam (Dormicum) 1-5 mg IV, or propofol (Diprivan, Propofol) 20-100 mg IV. Propofol should only be used by an experienced anesthesiologist who can handle airway issues, as there is a significant risk of hypotension and apnea. Haldol should not be used in patients with seizures or a history of seizures.

Hangover

The hangover is characterized by nausea, dizziness, fatigue, instability, anxiety, and headache. It occurs when the BAC is near zero. The severity of the hangover is primarily determined by the amount of alcohol consumed, but also by the speed at which it was consumed and the type of alcoholic beverages ingested. Colored beverages such as whiskey are believed to cause worse hangovers compared to clear spirits. Red wine often causes more hangovers than white wine. Drinking alcohol during dehydration increases the risk of hangovers and headaches, so alcoholic beverages should not be used as thirst quenchers. The hangover is partly explained by acetaldehyde, though not entirely. New theories suggest an inflammatory component as a cause of the hangover. The sensitivity to hangovers is individual, but most people who reach a BAC of over 1.5% experience hangover symptoms. About 25% of the population experiences little to no hangover symptoms.

The symptoms are also due to relative dehydration and the intake of substances known as congeners. Congeners are by-products formed during the fermentation of alcohol and include furfural, tannins, and fusel oils. Whether drinking water after alcohol consumption can prevent hangovers is scientifically unclear, although many people report positive personal experiences with this practice.

The main cause of nausea and the general feeling of discomfort is due to acetaldehyde, which is produced during the breakdown of alcohol. Treatment for hangovers is symptomatic, focusing on rehydration, rest, sleep, simple analgesics, and antacids.

FOLLOW-UP

For severe alcohol misuse, patients should be followed up with psychiatry, addiction medicine, and social services. Any potential co-occurring mental health disorders (comorbidity) should be assessed and treated.

ICD-10 Diagnosis Codes

• Mental and behavioral disorders due to alcohol, acute intoxication F10.0
• Ethanol T51.0
• Mild alcohol intoxication Y91.0
• Moderate alcohol intoxication Y91.1
• Severe alcohol intoxication Y91.2
• Very severe alcohol intoxication Y91.3

Sick Leave

Links to the National Board of Health and Welfare’s insurance medical decision support:

F10 Mental and behavioral disorders caused by alcohol

References

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7. Ramstedt M, Lindell A & Raninen J (2013a). Talking about Alcohol – A Statistical Annual Report from the Monitor Project. SoRAD. Stockholm University.
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