See also

Poisoning – Guidelines for initial management
Resuscitation

Key points

1. Clarify if the type of alcohol ingested is ethanol or toxic alcohol as toxic alcohol (methanol/ethylene glycol) can cause severe toxicity in small doses
2. Exploratory ethanol ingestion (as opposed to toxic alcohol) by children less than 6 years of age typically results in minor symptoms
3. Infants and young children are prone to profound hypoglycaemia, coma, and hypothermia, despite ingesting relatively small amounts of ethanol
4. Even with a raised blood alcohol level, always consider potentially more dangerous contributors to decreased conscious state (including head Injury ingestion of other drugs)

For 24 hour advice, contact the Poisons Information Centre 13 11 26

Background

In adolescents, binge drinking and other forms of ethanol abuse are common problems. There are variety of forms of alcohol which children may ingest. Ethanol is available in a multitude of alcoholic beverages, but also concentrated in household products, eg vanilla extract, mouthwash, perfume, or cologne (See Ethanol containing preparations table below) 

Blood alcohol concentration (BAC)
BAC can be expressed using a variety of units
eg 0.05% = 0.05 g / 100 mL blood = 11 mmol/L

Pharmacokinetics
Peak BAC occurs 90 minutes after ingestion (although alcohol is often not ingested as a single dose)

The rate at which BAC decreases varies between individuals.  In most cases, BAC decreases by 0.01% to 0.02% per hour after ingestion via zero order elimination through a process of metabolism and elimination in urine.  

Children requiring assessment

All patients presenting with a history of alcohol ingestion, or with signs and symptom of alcohol intoxication need assessment

Risk assessment

History

• Amount and type of alcohol ingested
• Clarify if the alcohol ingested is a toxic alcohol (eg methanol, ethylene glycol)
• Other drug ingestion (eg recreational drugs, medications, other deliberate overdose)
• Trauma / injury, especially trauma to head
• Level of neurological depression, and progression of symptoms which could suggest evolving intracranial pathology
• Exposure to cold environment
• Ethanol drinks can be spiked with other drugs such as gamma hydroxybutyrate (GHB)
• Possibility of unplanned sexual activity / assault requiring emergency contraception or forensic evaluation

Examination

• CNS effects (See Dose Related Toxicity table below)
• Hypotension and tachycardia may occur as a result of ethanol-induced peripheral vasodilation, or secondary to volume loss, eg from vomiting
• Hypothermia may occur due to vasodilatation and / or prolonged exposure to cold environment
• Hypoglycaemia can cause decreased conscious state

Adapted from Baum, C.A “ Ethanol intoxication in children: Epidemiology, estimation of toxicity, and toxic effects”

Always check for Medical alert bracelet in any unconscious patient, or any other signs of underlying medical condition (fingerprick marks etc)

Investigations

Consider a lower threshold for investigation in infants and young children as neurological and behavioural signs of intoxication may be harder to interpret

If only mild symptoms (decreased inhibition, slight incoordination) consider blood alcohol concentration (BAC) and blood glucose

If more than mild symptoms or symptoms not improving or worsening after two hours, the following investigations should be arranged:

• Blood glucose
• U&E
• Acid base (metabolic acidosis)
• ECG if any consideration of poly drug overdose
• Consider CT brain if decreased conscious state / conscious state deteriorating
• Blood alcohol concentration can be considered (especially if easily available in ED).  BAC should ideally be done in all patients who require admission.

If involved in an MVA, either as driver or passenger, you may be obliged by state law to take a Police Sample BAC

Acute Management

Key interventions are mainly supportive and include management of:

• hypoglycaemia
• hypovolemia
• hypothermia
• decreased conscious state (keeping in mind that this may not be due to alcohol ingestion: consider trauma, polydrug ingestion, DKA etc)
• respiratory depression
• co-morbidities

Resuscitation
Standard procedures and supportive care
Enhance elimination – ineffective as ethanol is rapidly absorbed after ingestion
Antidote – Nil

Consider consultation with local paediatric team when

• Need for ongoing medical management and monitoring
• Child protection and safety concerns

Consult the Poisons Information Centre 13 11 26 for advice

Consider transfer when 

• Children require care beyond the comfort level of the current hospital
• Significantly decreased conscious stage or conscious state not improving as expected
• Need for respiratory support

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Consider discharge when

• Blood glucose / temperature normal / investigations normal
• Normal level of consciousness

Assessing risk and connecting to community services

• Prior to discharge, adolescents who present with deliberate ingestions need risk assessment regarding the likelihood of further ingestions or other attempts to self-harm
• Assessment of other drug and alcohol use should also be undertaken
• If, after risk assessment, it is deemed safe to discharge a child or adolescent from hospital, but ongoing mental health or drug and alcohol needs are identified, they should be linked with appropriate services

Discharge information and follow-up

Parent Information: Poisoning prevention for children

Poisons Information Centre : phone 13 11 26

Victorian Mental Health, Drug and Alcohol Services

Child & Adolescent Mental Health Services (CAMHS): Victorian government mental health services are region-based
Infoxchange Service Seeker: Search for local community support services eg local doctor, dentist, counselling services, drug and alcohol services
Victorian Poisons Information Centre: Austin Health
YSAS (Youth Support and Advocacy Service): Outreach teams across Melbourne and regional Victoria for young people experiencing significant problems with alcohol and/or drug use
YoDAA: Victoria’s Youth Drug and Alcohol Advice service - provides information and support for youth AOD needs or anyone concerned about a young person

Last Updated April 2021