See also Alcohol poisoning (Alcohol poisoning) and Treatment of poisoning (Treatment of poisoning).

Physical examination

• Examine level of consciousness and intoxication; respiratory and circulatory status; abdominal status; check for any asymmetry, neck stiffness, signs of injury; temperature
• An alcohol concentration below 2.5‰ alone does not explain unconsciousness in an adult.
• Polysubstance use (alcohol, sedatives, narcotics) complicates assessment.
• Remember the risk of injuries and cerebral haemorrhage.

Tests

• Plasma glucose and, if possible, K, Na
• If infection is suspected, CRP
• If use of surrogate alcohol is suspected, acid-base balance
• If the cause of evident intoxication is unclear:
  • take blood sample for intoxication analysis
  • take urine sample for urine drug screen (rapid screen)
  • store blood and urine for subsequent tests.

Treatment

• Medicinal charcoal can be given to patients with drug or polysubstance intoxication.
• In alcohol intoxication, medicinal charcoal is ineffective and gastric aspiration only effective immediately after drinking.
• Monitor the patient at an outpatient clinic, if
  • the breathalyzer result exceeds 3‰ in a patient with a lowered level of consciousness
  • speech contact is not possible
  • the breathalyzer result is inconsistent with the patient's state.
• If no need for treatment or monitoring is observed, the intoxicated person can be discharged if they are capable of taking care of themselves or if someone else will take care of them (an accompanying person who is able to function, or monitoring at an alcohol recovery centre).
• Hospital monitoring is warranted for children, patients who are deeply unconscious and patients with respiratory or circulatory symptoms.
• Remember to make sufficient entries in the medical record and child welfare notification for any minors.

• Isopropanol (anti-freeze agents, carburettor cleaner, windscreen washer fluid): treatment as for ethanol intoxication
• Methanol (contaminated or adulterated alcohol, windscreen washer fluid, paint strippers)
  • Even small doses may be lethal.
  • Symptoms may not occur until 12–24 hours after ingestion.
  • In addition to normal symptoms of intoxication, dyspnoea or hyperventilation (metabolic acidosis), eye symptoms ("seeing snow", blindness, fixed, dilated pupils, papilloedema)
  • Always treat in specialized care with dialysis facilities.
• Ethylene glycol (car radiator fluids, antifreeze agents)
  • Small doses may be lethal.
  • Symptoms and treatment otherwise as for methanol intoxication but there are no eye symptoms
  • Hyperglycaemia and renal symptoms (haematuria and proteinuria) possible

• See also (Identification of illegal drug overdose and diagnosis of illegal drug poisoning).
• The effects of narcotics may be
  • stimulating, excitatory (amphetamine, crack, ecstasy, cocaine)
  • depressant (heroin, gamma-hydroxybutyrate, fentanyl derivatives)
  • variable (cannabis)

Heroin

• Risk of fatal overdose particularly after i.v. use
• Symptoms: respiratory depression followed by hypoxia, bradycardia, pinpoint pupils (but dilated in a life-threatening state)
• The antagonist is naloxone.
  • Dose 0.08 mg at a time intravenously at 1-minute intervals, until spontaneous respiration is resumed.
  • If respiration does not improve in a few minutes, repeat the dose every 2–3 minutes with increasing doses, as necessary (single doses of 0.2–0.4 mg).
  • If there is no response to 10 mg, the cause may be something other than opioid intoxication.
  • Can also be given i.m., in which case the single dose is 0.4 mg.
• Ensure patent airway if oxygenation is not rapidly restored or there is loud stertor.

Amphetamine and other stimulants

• Symptoms and findings: tachycardia, chest pain, anxiety, confusion, hallucinations, motor restlessness, dehydration, convulsions, hyperthermia
• Treatment
  • Sufficient fluid administration
  • Sedation with 5–10 mg diazepam i.v.
  • Labetalol for the treatment of hypertension (an alpha- and beta-blocker; due to risk of hypertensive crisis, not just a beta-blocker)

Cannabis

• Effects include a pleasurable feeling, increased appetite, passiveness, fits of laughter, relaxation, dry mouth, bloodshot conjunctiva. Impairs coordination and balance.
• The treatment is symptomatic.
• Cannabis is of vegetable origin and rarely causes acute intoxication requiring treatment, but synthetic cannabinoid receptor agonists may cause similar intoxication symptoms as stimulants.

Designer drugs

• Dozens of new designer drugs are launched every year.
• The largest groups include various amphetamine derivatives and synthetic cannabinoids.
• Most designer drugs cannot be detected by drug screens in emergency situations.
• The treatment is usually symptomatic.
• Examples of designer drugs and their effects
  • Gamma-hydroxybutyrate (GHB), precursor gamma-butyrolactone (GBL)
    • Produces fatigue, an overdose may lead to coma.
    • Short half-life
    • Resembles alcohol intoxication
    • Typical symptom mild bradycardia
    • Intubation rarely needed
  • Amphetamine derivatives MDMA (ecstasy: severe dehydration, electrolyte imbalance, hyperthermia), MDPV (with effects resembling amphetamine and cocaine), mephedrone (with effects resembling amphetamine and cocaine)