Consider the following:

1. If there is any indication for a blood alcohol level, get one. Indications would include altered mental status, severe alcohol intoxication, and: coma; respiratory arrest; and the inability to get patient cooperation with a breath analysis.

2. In cases where the patient presents intoxicated, but is awake and alert, and there are no apparent confounding factors such as trauma or other apparent co-existing medical problem, it is within the standard of care to let the patient "come up" (i.e. metabolize the blood alcohol over a period of observation) without obtaining an alcohol level. When the patient is ambulatory, has a normal mental status and a normal neurologic examination, and is thus deemed functionally competent by the EP, the EP may discharge that patient from the hospital. Prior to that point, if the patient refuses care and attempts to leave, the patient should be restrained for his own protection.

3. In cases where the patient presents intoxicated, but is awake and alert, and there are no apparent confounding factors such as trauma or other apparent co-existing medical problem, and the EP elects to obtain an alcohol level, the conservative risk managed approach is to work with that level. When possible, repeat the levels and observe the patient in the ED until the blood alcohol is less than the legal limit of intoxication in your jurisdiction, or you've discharged the patient to home or out of harms way with a reliable family member or friend. If using blood alcohol levels, it is probably not necessary to have a level documented below the legal limit, as long as the last level was close to the limit, and the value has probably reached the legal limit with the passage of time.

Be aware that, even if the alcohol level is above the legal limit, once the patient has a normal neurologic examination and a normal mental status and can give an informed refusal of care, that patient has the legal right to leave the emergency department. The patient may compromise that right, if he or she intends to get into an automobile, or in some other fashion became a danger to himself or others. In these cases, the emergency staff may have to restrain, or contact local law enforcement for assistance.

4. Patient Follow-up. In each case provide the patient with a referral or a list of resources for alcohol detox and treatment.

5. Alcohol impaired patients often expresses suicidal or homicidal ideation. It is appropriate to reassess the patient’s psychiatric status after the patient’s return to sobriety. If the patient does not express suicidal or homicidal ideation at that time, a psychiatric consultation is not necessary.

6. Prepare a department protocol addressing the management of the intoxicated patient. Inservice the entire staff on all related issues, including quality management, medical-legal concerns, and patient rights.

7. Perform a routine quality review in order to assure compliance with the essential aspects of patient management.