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Background
Ethanol or ethyl alcohol is improperly used substance in the globe. It can be used in to create different substances with different concentrations like wine, beer, and hard liquors like rum, vodka, and whisky. Methanol and ethylene glycol which are found in windshield wiper fluid, antifreeze is used as a proxy with fatal consequences in person who is desperate for alcohol or has no access.
Ethanol is a water-soluble compound with 2 2-carbon chain (CH2CH3OH). Small intestine and stomach absorb the ethanol. Liver metabolizes it and eliminate it. It is excreted by the sweat, urine, or exhaled breath. The volume of the distribution is about the total body water. About 90 % of the alcohol is oxidized in the liver by ALDH aldehyde dehydrogenase and ADH alcohol dehydrogenase. It follows the 0-order kinetics rule if the concentration is high. The zero-order rule is not dependent on the time and concentration of the substance.
ADH converts the alcohol in the toxic substance acetaldehyde in the 1st metabolic pathway. Small amount of ADH is found in other organs like stomach. It converts into acetate by ALDH. Acetate is absorbed in the Krebs cycle and converts into H2O and CO2.
As per the estimation, every ounce of whisky, 5 ounces of wine, or 12 ounces of beer increases the blood alcohol level is about 15 to 25 mg/dL. Maximum level occurs in 30 minutes if the consumption is taken on a fasting state to 3 hour after last drink. Metabolism takes place in 10 to 30 mg/dL/hour. It is on the basis of many factors like liver size. The levels of intoxication is affected by gender, age, weight and presence of food, no. of drink/hour, % of alcohol in drink, and presence of other drugs which interact with alcohol. Women are at the peak level than men because female has an increased fat content than male. The small amount of ADH is seen in stomach. Metabolism can be the factor of sex-related variation in concentration of ethanol.
Indications/Applications
Ethanol level can be measured for medical or legal reasons. Blood test is common method for medical reasons. Serum ethanol level can be done in the suspected alcohol consumption, coma, changes mental status of unknown cause, psychiatric or traumatic emergency, and any history of ingestions like salicylates, toxic alcohol. It is necessary to regularly reassess the patient and use blood ethanol level to know the overall health of patient because of the associated disease. Patient who are intoxicated and have negative level of alcohol, other diagnose should be considered like toxic alcohol use like methanol, isopropyl alcohol, or ethylene glycol.
Other laboratory tests like basic metabolic panel for the anion gap acidosis, urinalysis for the crystal evaluation, arterial blood gas test, osmolarity level to know osmolar gap and serum toxic alcohol level. Fomepizole is used to treat the toxic alcohol consumption. Ethanol is a treatment option and need monitoring of serum ethanol level.
Blood glucose level must be checked due to ethanol can lead to hypoglycemia for children. This is because of the small glycogen is stored in the liver of children and inhibition of the gluconeogenesis by ethanol.
Reference Range
Ethanol level is measured by saliva, urine, blood, or breath test. Toxic concentrations is on the basis of patient tolerance and usage. More than 300 or 400 mg/dL is fata because of the respiratory depression.
Ethanol unit conversion formula: 1 mmol/L of blood = 4.61 mg/100 ml of blood
Move decimal point to left for 3 points to convert the serum level of ethanol to BAC.
Level of ethanol in serum 100 mg/dL = 0.10 BAC (gm/dL) or 0.10 %.
If the level of ethanol in blood is below 50 mg/dL or 0.05 %, it is considered as intoxicated. If it is > 300 mg/dL, it is fatal.
Urine level ethanol can vary and cannot correlate with blood ethanol level. As per the Wallach, it is not used to know the level of intoxication.
Interpretation
The common effect of different BAC level with a more variation in individual and overlap symptoms among the different BAC level are given below:
| BAC | Effect |
| 0.01 to 0.05 | Lack of shyness, mild joy, no loss of cohesion |
| 0.04 to 0.06 | Feelings of well-being, calmness, reduced inhibition, slight impairment in memory and reasoning, and euphoria |
| 0.07 to 0.09 | Mild impairment of speech, hearing, vision, balance, and response speed, exhilaration. Self-control and judgment were reduced. Memory, thinking, and caution are reduced. |
| 0.10 to 0.125 | Loss of good judgment and motor coordination, speech become slur, vision, balance, reaction time and hearing will be reduced, and euphoria. |
| 0.13 to 0.15 | Absence of physical control, dysfunction in gross motor, loss of balance, blurred vision, euphoria, dysphoria. |
| 0.16 to 0.20 | Anxiety, restlessness, dysphoria, nausea, and predominates |
| 0.25 | Need guidance in the activity like walking, mental confusion. Dysphoria like nausea and vomiting. |
| 0.30 | Loss of consciousness. |
| 0.40 and above | Coma, possible death because of respiratory depression or arrest. |
Blood alcohol level is used to diagnose alcoholism because individual who is using this drug regularly become tolerant. This individual has the normal capacity with a blood alcohol level > 150 mg/dL. Urine ethanol sample is inaccurate to determine BAC and degree of intoxication. It is enough if the main goal is know if the alcohol is consumed. Urine ethanol level will reach to peak in 45 to 60 minutes after the consumption.
Collection And Panels
Serum ethanol level sample
Sample type: Blood
Sample collection tube: It is dependent on hospital. Serum separator tube (SST)is used which has serum separator gel and the clot activation, grey, green, or red tube is also used. Please mark that plasma or serum level is about 1 or 2 times higher than the whole blood level.
Sample collection method: Routine venipuncture. Puncture site must be cleaned with non-alcoholic solution like aqueous povidone-iodine or benzalkonium chloride.
Centrifugation: Serum must be separated from the RBCs and analyzed in 4 hours when the samples are used without preservation.
Sample storage: Samples are sealed because alcohol is volatile. Plasma or serum samples are stored in the frozen condition.
Urine ethanol sample
Sample type: Use randomly collected freshly discharged urine samples
Sample volume: 25 ml
This method gives more accurate and proper if the 2 samples are collected in the 30 minutes. 1st sample is discarded because of the unknown timeframe in bladder and 2nd is used to determine BAC. Estimation ratio differs from 1.3:1 to 1.5:1.
Saliva ethanol
The enzymatic color strip interacts and changes on the basis of concentration of ethanol in the saliva. The results are compared to color scale.
Breathalyzer
Indirect detection of BAC is taken from alveoli. The ratio of breath ethanol to blood ethanol is 2100:1. 2100 ml of air contains same level of ethanol as the 1 ml of blood contains.
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