approach to the alcoholic patient


Alcoholic patients are at high risk for emergencies from acute intoxication, chronic effects of substance use and complications like falling/intoxications. It’s a recipe for error to assume that the patient’s agitation, somnolence or vomiting is from alcohol alone and not a complication or other medical emergency. It can help to have a systems-based approach:


  • risk of C-spine fracture
  • risk of aspiration of blood or vomit


  • Collapse: pneumo if fall
  • Sick pneumonia from immunocompromised or aspiration


  • Cardiac arrhythmia: AF “holiday heart”, prolong QT from hypomagnesemia, prolong QRS from TCA
  • Dysfunctional LV: chronic CMO, acute MI from cardiac risks, vasospasm from cocaine
  • Outflow dissection from cocaine
  • Volume depletion from vomit/diarrhea
  • Abdo bleed from fall or gastritic
  • Soft tissue bleed from fall
  • Lactate: septic from immunocompromised


  • Neuron seizure from alcohol withdrawal or intracranial bleed
  • RBC bleed from fall


  • Electrolyte: hypoglycemia, hypomagnesemia from poor intake
  • Normothermia: hypothermia if outside in cold, hyperthermic from intoxication or withdrawal


  • renal failure from pre-renal loss, renal injury from rhabdo


  • Ammonia: liver failure from chronic alcohol
  • Biliary disease more likely
  • Dyspepsia: gastritis and esophageal varices
  • Organomegaly: splenic injury from fall


  • chronic alcohol: anemia, thrombocytopenia, coalgulopathy


  • polysubstance use
  • specific intoxicants


  • fracture from fall, rhabdo from immobility, soft tissue lacerations, infections


Putting this together

  • A: low threshold C-spine immobilization/imaging, examine mouth and protect airway; consider intubation
  • B: oxygen, POCUS r/o pneumo, consider pneumonia or aspiration pneumonitis
  • C: ECG r/o arrhythmia, consider chronic/acute pump failure, resuscitate, consider bleeding and sepsis, POCUS for free fluid
  • D: control agitation, consider CT head
  • E: check glucose, correct electrolytes, measure anion gap, rewarm cold patient, consider differential of fever
  • F: hydrate, consider rhabdo
  • G: consider chronic cirrhosis, acute chole/GI bleed, splenic injury from fall
  • H: consider coagulopathies
  • I: consider polysubstance use, give antidote (eg narcan), consider GI removal (charcoal), or dialysis
  • J: thorough exam for fractures, lacerations, infections, check tetanus status


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