European Review for Medical and Pharmacological Sciences 2020; 24: 9121-9128 Role of first aid in the management of acute alcohol intoxication: a narrative review A. PICCIONI1, C. TARLI2, S. CARDONE1, M. BRIGIDA1, S. D’ADDIO2, M. COVINO1, C. ZANZA1, G. MERRA3, V. OJETTI1, A. GASBARRINI2, G. ADDOLORATO2-4, F. FRANCESCHI1 1Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy 2Institute of Internal Medicine and Gastroenterology, Università Cattolica del Sacro Cuore, Rome, Italy 3Nutritional Sciences Department, University of Tor Vergata, Rome, Italy 4Department of Internal Medicine and Gastroenterology, Internal Medicine and Alcohol Related Disease Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy Abstract. – OBJECTIVE: Acute alcohol intox- require the use of drugs; they can benefit from a ication is actually a common admission cause clinical observation, with a clinical course often in the Emergency Department and represents completed within 24 hours with a favorable out- an increasing public health burden, in particular come. Clinical observation with vital signs control among adolescents. It involves possible and sig- is necessary also to evaluate the possible devel- nificant illness and injury, which can quickly get opment of the alcohol withdrawal syndrome (that worse and may need to be managed in the emer- involves a specific treatment) and to evaluate also gency room. possible pathological complications of the organ- MATERIALS AND METHODS: We conducted ism, above all acute liver damage. a narrative review of the literature regarding the CONCLUSIONS: Patients affected by acute al- effectiveness of first aid role of the Emergency cohol intoxication are the best candidates to ap- Department setting. ply the rules of the Temporary Observation Unit RESULTS: This review included eighteen stud- in the Emergency Department, because of a clini- ies about alcohol intoxication management in the cal course often completed within 24 hours, a fa- Emergency Department; most of all highlights the vorable outcome and without the need for hos- emerging phenomenon in Europe and around the pitalization. In many cases, hospitalization could world of acute alcohol intoxication management be not necessary, but the patient affected by Al- in first aid. cohol Use Disorder must be referred to an Alco- The treatment of acute alcohol intoxication hol Addiction Unit for the follow-up, to reduce the depends on general clinical conditions of the pa- risk of alcohol relapse and complications relat- tient, vital signs, hemodynamic stability, cognitive ed to alcohol abuse, and financial costs of hos- state, alcohol-related complications, which are pitalization. closely related to the blood alcohol concentration. At the same time, symptoms could be extremely Key Words: variable due to individual differences in alcohol Acute alcohol intoxication, Temporary Observation metabolism. In case of mild-moderate intoxication Unit, Emergency Department. (blood alcohol concentration < 1 g/L), no drugs are necessary. In case of severe intoxication (blood alcohol concentration > 1 g/L), it is necessary to support with intravenous fluids, treat hypogly- Introduction cemia, hypotension, hypothermia and electrolyte imbalance, administer complex B and C vitamins and accelerate alcohol elimination from blood Acute alcohol intoxication is a common and with metadoxine. Unlike adults, adolescents are increasing public health burden that causes sig- more exposed to the toxic effect of alcohol (be- nificant illness and injury in the Emergency De- cause of their immature hepatic alcohol dehydro- partment (ED)1,2. genase activity), and then, acute alcohol-related According to the fifth edition of the Diagnos- complications are more frequent and dangerous tic and Statistical Manual (DSM-5) alcohol abuse in young people than in adult population. In many and alcohol dependence (repeated use) are inte- cases, patients affected by acute alcohol intoxica- tion referring to an Emergency Department have grated into a single disorder called Alcohol Use mild-moderate transitory symptoms that do not Disorder (AUD). Corresponding Author: Andrea Piccioni, MD; e-mail: [email protected] 9121 A. Piccioni, C. Tarli, S. Cardone, M. Brigida, S. D’Addio, et al Frequently, patients affected by AUD who re- porary Observation Unit (TOU) in ED, because fer to ED are not known to the territorial services the clinical course is often resolved within 24 and are not followed up for the specific disease; in hours with a favorable outcome and the hospital- this context, ED plays a first aid role3. ization might not be necessary. Excessive alcohol consumption represents We undertook a narrative review about the ef- one of the principal causes of preventable death fective role of TOU in ED to improve manage- around the world. ment of acute alcohol and drugs intoxication. The most frequent clinical presentation of al- cohol intoxication is a cognitive impairment, but it hides complex pathological states of the organism Materials and Methods caused by the action of a substance that depends on type of substance, dosage, time of elimination, We conducted a narrative review of the liter- comorbidity. ature regarding the effectiveness of first aid role It is a dynamic process that can quickly get of the ED setting, using the following key terms: worse and lead to life-threatening complications; alcohol, alcohol dependence, alcohol abuse, Alco- it includes acute illness such as hepatitis, liver cir- hol Use Disorder, acute alcohol intoxication, and rhosis, cancer, respiratory disease and can rapid- emergency department. ly develop to hepatic insufficiency or respiratory Electronic database searches of Med- arrest even death. In addition to this, acute alco- line-PubMed, Web of Science, Scopus, Cochrane hol intoxication induces behavioral alterations Central Register of Controlled Trial (CENTRAL) such as euphoria, dysphoria, social disinhibition, were conducted for English-language articles sleepiness, belligerence and aggressiveness (until published between 2002 and 2019. The studies lethargy, stupor and coma) that could provoke ac- selected were preferentially randomized place- cidents and violence, reducing the quality of life bo-controlled studies, case-control studies, ret- or resulting potentially fatal4,5. rospective and prospective observational studies, Nowadays, acute alcohol intoxication prev- systematic reviews. alence is increased, in particular among adoles- cents with the pattern of binge drinking6. Binge drinking is defined as the consumption of five or Results more drinks (12 grams of ethanol each one) in a single occasion, reaching so quickly cognitive im- Eighteen studies3,4,6,9-23 about alcohol intoxica- pairment6. Acute alcohol intoxication represents tion management in ED were included. the most frequent cause of hospitalization for Table I describes the type of study, year of children under 16 years of age5; 17% of all ED vis- publication, number of patients evaluated and its for acute alcohol intoxication are adolescents < principal findings. Studies were generally lim- 14 years old7. ited to individuals older than 18 years, with the This scenario emerges in a period in which exception of four studies5,6,18,20 that surveyed ado- World Health Organization has long recommend- lescents and young adults. ed total alcohol and drugs abstinence for ado- Most studies highlight the emerging phenome- lescents up to 16 years old: who starts drinking non in Europe and around the world of acute alco- before 16 years old has a four-fold increased risk hol intoxication management in first aid. to develop addiction in adulthood, compared with All studies agree on the need to urgently treat people who begin no earlier than 21 years old8. patients affected by acute alcohol intoxication in This high burden of alcohol-related injury ED, to stabilize the patient’s vital signs, and to and disease indicates a need to increase aware- prevent mid- and long-term alcohol-related com- ness of AUD and its effective treatment options9. plications. It is necessary to underline the importance of an The first goal is to monitor and support vital appropriate and timely management and treat- functions and keep the patient under observation ment of the alcohol disease referring to territo- also for the onset of alcohol withdrawal symp- rial services and Alcohol Addiction Unit also to toms, mainly for people affected by severe Alco- reduce the ED access and the financial costs of hol Use Disorder. hospitalization. Symptoms are usually related to blood alcohol Patients affected by acute alcohol intoxication concentration (BAC) and are extremely variable are the best candidates to apply the rules of Tem- due to individual differences in its metabolism11 9122 Role of first aid in the management of acute alcohol intoxication Table I. Studies analyzed for this narrative review. Authors Type Year of No. of Findings publication patients Bouchery et al Research 2011 / US National databases from 2006 were analyzed in [1] support order to assess the economic costs of excessive drinking: the impact was about 750$ per person, most of it related to binge drinking. The overall burden in 2006 was $223.5 billion Mullins et al Retrospective 2017 / A national retrospective review conducted in [2] study Washington concerning ED visits for alcohol intoxication in adults from 2001 to 2011 showing that these are increasing at a greater