Acute Alcohol Intoxication and Alcohol Excess

Acute alcohol intoxication is a common problem which has become more prevalent with the rise in alcohol consumption particularly by the young and women, both of whom have a lower tolerance of this popular social poison.

Whilst there may be some small health benefits from modest alcohol consumption as part of a healthy diet and lifestyle, the adverse effects of excessive alcohol intake both in the short and long terms are well documented.  This section deals with the nutritional care of those who are intoxicated.

For those who think that they may be drinking excessively in the long term please see the section on “Alcohol misuse” at NHS Direct www.nhsdirect.nhs.uk/articles/article.aspx?articleId=10

Severe intoxication may require medical treatment if the following problems are present:

• unconscious and not able to respond to commands
• vomiting if repeated or accompanied by reduced consciousness
• difficulty breathing or excessively rapid heart rate
• severe confusion
• marked unsteadiness and disordered eye movements with double vision (see below)

Nutritional Support for the Inebriated

Many of those with alcohol excess will benefit from:

• Adequate fluid replacement as alcohol acts as a diuretic and depletes the body of fluid
• Food, especially carbohydrate or sugar, as alcohol reduces the ability of the liver to maintain control of the sugar level in the blood.  However a large intake of sugar may worsen this problem.  The best option is a little sugar or carbohydrate followed by a balanced meal that has a good protein content.  This is particularly important in the morning after a night’s drinking.  Those who are very drunk or vomiting should not attempt to eat
• Foods and drinks that are rich in potassium such as fruit juice, fresh fruit and vegetables.  Potassium is easily lost by vomiting
• Supplements of vitamin B complex as these nutrients are needed for the metabolism of alcohol.  However alcohol reduces their absorption and increases their excretion and thus large doses may be needed several times per day
• Supplements of magnesium, which helps to activate the B vitamins and is easily depleted by alcohol.

For those who are going to go out drinking it is prudent to eat a good-size balanced meal several hours beforehand, which will help to reduce the immediate adverse nutritional effects of alcohol.

Alcohol, Vitamin B1 – Thiamine Deficiency and Brain Damage

Acute alcohol intoxication will typically produce unsteadiness, slurring of speech and mild confusion.  However the same picture may also result from severe deficiency of vitamin B1 - thiamine, which if not corrected can lead to permanent brain damage.  This is unlikely to happen as a result of a few episodes of intoxication and is more likely to occur in those who have been drinking regularly, especially large amounts of beer, are eating poorly and frequently miss meals are underweight or are otherwise unwell.

The syndrome of severe vitamin B1 – thiamine deficiency is termed Wernicke’s Encephalopathy, WE, which is impossible to differentiate from acute alcohol intoxication.  The persistence of confusion, unsteadiness or double vision 24-48 hours after ceasing drinking means that Wernicke’s Encephalopathy is a real possibility, which should be assessed by an experienced doctor. See Acute Thiamine Deficiency.

Important facts about alcohol-induced vitamin B1 deficiency:

• In the past it has often only been diagnosed at post-mortem and not during the person’s life
• Prompt treatment will prevent the brain damage that may often develop
• Blood tests do not always detect those at risk of deficiency

Wernicke’s Encephalopathy is often not recognised in life and studies have shown that as many as 90% of cases are only diagnosed at post-mortem.  Additionally repeated episodes of WE can lead to even more serious brain damage, Korsakoff’s Psychosis, which is characterised by a loss of memory for both recent and new events which the sufferer tries to cover by confabulating.  Such individuals are alert and orientated and thus initially appear quite normal.  As a rule they are unemployed/unemployable and have broken relationships. 

In view of the above the current widely accepted practice, nationally and internationally, is to administer parenteral (usually intravenous) replacement therapy to all high-risk patients undergoing treatment of alcohol withdrawal syndrome in inpatient settings, especially if they show signs of chronic malnutrition.  Such a situation is preventable by the prompt treatment of alcohol-induced vitamin B1 deficiency as well as alcohol abstention and attention to a better diet.

Sustained regular excessive drinking even without obvious nutritional deficiencies developing is associated with brain shrinkage and loss of intellectual and neurological function, which is not always reversible.

Medical intervention to aid alcohol withdrawal using drug treatment and psychological support is available from the NHS and is of benefit.  Attention to the person’s nutritional state is likely to be relevant and oral thiamine 100 mg three times daily with Vitamin B Compound Strong three times daily is often appropriate for those in primary care for as long as there is the possibility of malnutrition.

Folate supplements may also be required and those with macrocytosis on their Full Blood Count should have their folate status checked.

Maintenance with thiamine 50 mg one daily and Vitamin B Compound Strong two daily is also reasonable and may need to be continued indefinitely in those who continue to drink. www.cks.library.nhs.uk/alcohol_problem_drinking/view_whole_topic_review

Reference:

The Royal College of Physicians Report on Alcohol: Guidelines for Managing Wernicke’s Encephalopathy in the Accident and Emergency Department.  Thomson AD, Cook CCH, Touquet R, Henry JA.  Alcohol and Alcoholism Vol 37, No. 6, pp513-521, 2002.  See report here.
All doctors involved in the acute care of emergency patients should read the entire article.
Sgouros X et al.  Evaluation of a Clinical Screening Instrument to Identify State of Thiamine Deficiency in Inpatient with Severe Alcohol Dependence Syndrome.  Alcohol and Alcoholism Vol 39, No.3, pp227-232, 2004.   http://alcalc.oxfordjournals.org/cgi/content/full/39/3/227#TBL3