= Solution
\b[Neither the smell of <alcohol> nor a drunken appearance excludes <concussion> or a more serious <head injury>.] The useful distinction comes from the history, a complete examination and repeated assessment; <alcohol intoxication> and <head injury> may occur together.
First establish the order of events. Witnesses may describe drinking followed by progressive slurring, unsteadiness and drowsiness, or a blow or fall followed immediately by altered <consciousness>, confusion or a gap in <human memory>. Ask about the amount and timing of the drink, the mechanism of injury and any interval of apparent recovery. A person may have fallen because of <alcohol intoxication>, and subsequently have suffered a <head injury>. Conversely, an injured person may be mistakenly described as drunk because of slurred speech and an unsteady gait.
Examine the level of <consciousness>, orientation, speech, <human memory> and ability to follow commands. In <alcohol intoxication>, disinhibition, slurred speech, incoordination, <vomiting> and increasing drowsiness can occur; severe poisoning can progress to <coma> and impaired <breathing>. After <concussion>, confusion, <amnesia>, <headache>, dizziness, <nausea> and <vomiting> may occur, with or without an observed loss of <consciousness>. Thus <vomiting> or drowsiness alone does not decide the diagnosis.<Alcohol poisoning by the National Health Service>[Symptoms of alcohol poisoning]{ref}<Head injury and concussion by the National Health Service>[Symptoms and warning signs after a head injury]{ref}
Look for a scalp wound, swelling or other evidence of impact, and examine the <pupils>, their reaction to light, limb movements and any focal <neurological deficit>. Unequal <pupils>, one-sided weakness, a worsening level of <consciousness> or a <seizure> should prompt concern for significant <traumatic brain injury>, rather than be dismissed as ordinary drunkenness or uncomplicated <concussion>. The absence of an external wound does not exclude an internal injury. Nor are a flushed face, a particular <pulse> or the smell of drink sufficiently specific to settle the question.
The defensible diagnostic conclusion may initially be uncertainty requiring observation and investigation. Current guidance specifically requires important <traumatic brain injury> to be excluded before depressed <consciousness> is attributed to intoxication. Modern <computed tomography> and measurement of <blood glucose> can resolve problems that an 1864 bedside examination could not; these are later diagnostic aids, not equipment to attribute to the examination's period.<Head injury: assessment and early management by NICE>[Recommendations 1.4.1–1.4.2: initial assessment and intoxication]{ref}
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