📝ED #Order for suspected Ethanol poisoning

Imp: suspected ethanol poisoning
Cond: urgency
Diet: NPO temporary
Positioning: Place patient in lateral decubitus position to reduce aspiration risk if vomiting occurs, unless spinal precautions are indicated.

▪️C.V.S q15min until stable then q1h
▪️POM and CM
▫️Administer oxygen via nasal cannula at 2-4 L/min to maintain SpO2 > 92%; escalate to non-rebreather mask if needed.
▫️If GCS < 8 or respiratory rate < 10 breaths/min, prepare for endotracheal intubation.

▪️Establish peripheral IV line stat (18-20 gauge)
▫️Administer 0.9% Normal Saline (NS) 500 mL IV bolus over 30 minutes as necessary.
*if hypotensive (SBP < 90 mmHg) or dehydrated, then maintenance at 100 mL/hour.
Note: IV fluids do not accelerate ethanol clearance but address dehydration or hypotension.

▪️ECG stat if indicated
*in cases of severe intoxication, abnormal vital signs, suspected co-ingestions, or underlying cardiac risk factors

▪️Check BS glucometer
▫️Dextrose: If fingerstick glucose < 70 mg/dL, administer Dextrose 50% (D50) 50 mL IV push stat, recheck glucose in 15 minutes.

▪️Check CBC, BUN, Cr, Na, K, Mg, P, Ca, BS, LFT, VBG, serum ethanol, urine drug screen(esp in altered mental status for opioid and benzodiazepines ),
*Laboratory studies are usually unnecessary in patients with an isolated mild ethanol intoxication.

▪️Head CT (non-contrast) if indicated
*If trauma suspected, altered mental status persists despite expected BAC decline, or focal neurological deficits present.

▪️Amp Naloxone 0.4 mg IV stat, may repeat every 2-3 minutes up to 2 mg total as necessary.
*If suspected opioid co-ingestion or unresponsive to stimulation.

▪️Benzodiazepines (for agitation or seizures):
*Attempt verbal de-escalation first for agitated patient

▫️Amp Lorazepam 2 mg IV stat for severe agitation or witnessed seizure, may repeat every 10 minutes PRN (max 8 mg total).
*Monitor respiratory status closely post-administration.

▫️Alternative for agitation(if benzodiazepines are contraindicated (e.g., respiratory depression).

Olanzapine 2.5-10mg IM, may repeated in 2h and 6h if needed.
or
Haloperidol 5 mg IM

🔺Benzodiazepines are preferred for agitation in ethanol intoxication, but use cautiously in severe respiratory depression. Avoid antipsychotics in severe intoxication due to seizure risk.

▪️Amp Thiamine 100 mg IV stat as necessary.
▫️Patients presenting with coma secondary to ethanol intoxication should receive at least 100 mg of parenteral thiamine to prevent or treat Wernicke's encephalopathy, along with dextrose(especially in chronic alcohol users , malnourished patients or neurological signs)

▫️Wernicke’s Encephalopathy Suspicion: If ocular abnormalities (nystagmus, ophthalmoplegia), ataxia, or confusion persist beyond expected intoxication, increase thiamine to 500 mg IV every 8 hours for 2-3 days.

▫️Patients at high risk for WE include those with chronic alcohol use, malnutrition (from any cause), GI absorption issues, critical illness, or TPN dependency

🔺If toxic alcohol poisoning is possible or suspected but the exact alcohol is unknown, especially in the presence of a metabolic acidosis, it is reasonable to empirically administer all three cofactors.(Folic acid + thiamine + pyridoxine)

▪️ Gastric Decontamination: Not indicated unless co-ingestion of other substances within 1 hour of presentation is confirmed.
🔺activated charcoal and gastric lavage are generally not helpful because of the rapid rate of absorption of ethanol from the gastrointestinal tract

▪️Risk factors for (ICU) admission.
abnormal vital signs (eg, hypotension, tachycardia, fever, and hypothermia), hypoxia, hypoglycemia, and the need for parenteral sedation.


▪️Disposition and Follow-Up

▫️Observation: Admit to observation unit if BAC > 0.2%(serum ethanol >200 mg/dL)
, GCS < 15, or hemodynamic instability persists after 4-6 hours.
▫️Discharge Criteria: BAC < 0.08%, GCS 15, ambulatory, no vomiting, and sober responsible adult available to accompany patient home.

🔹Consider Suspect Methanol Mixed Ethanol Intoxication