Emergency physicians must be well versed in the management of the intoxicated patient. Emergency departments have become the “drunk tank” and the health care safety net for American society. In order to properly manage the alcohol impaired patient, the EP must understand several important clinical and medical-legal principles. This is a high risk presentation, and the EP must be extremely diligent in order to provide the highest quality of patient care, diagnose co-existing life threatening disorders, and protect the patient’s constitutionally protected rights.

A review of the literature indicates that there are no clear cut guidelines for the EP’s management of the intoxicated patient. These patients present to the ED with an altered mental status, often express suicidal ideation, and at times are belligerent and physically violent. Often times, police, family or friends bring these patients into the Emergency Department against their wishes, and patients refuse medical care. This presents the EP with very difficult “refusal of care” issues.

The alcohol impaired patient often lacks insight into his condition; thereby, making it difficult for the physician to accurately diagnose and treat underlying medical illness. In order to ensure patient and staff safety, the emergency physician must be prepared to apply physical or chemical restraint and isolation when warranted. An understanding the medical and legal issues will assist the EP in acting confidently and competently, providing optimal patient care, and protecting against the risk of patient injury and subsequent litigation.

The following issues will be discussed: (1) whether blood alcohol levels are required in all patients; (2) general management of the intoxicated patient; (3) “against medical advice” in the “alcohol impaired patient”; (4) physician use of restraint and forced treatment; (5) clinically clearing patients for discharge; (6) high risk cases and risk management