EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/285693
CE ARTICLE to catecholamine release in the body. The chronic alcoholic has been suppressing these NMDA receptors, leading to the seda- tive effects of alcohol. Over time the body upregulates the NMDA receptors, which leads to the person needing a larger amount of alcohol to suppress the now-larger number of receptors and achieve the sedative intox- icated state. If that heavy drinker abruptly stops drinking, they have a larger-than-normal number of NMDA receptors that are all unin- hibited. The result is diffuse stimulation of catecholamines throughout the body, leading to CNS hyperactivity, agitation, tachycardia and diaphoresis. Chronic alcoholism results in a myriad of physiologic changes and comorbidities that complicate its clinical picture. Ethanol Withdrawal It is well known but not completely under- stood why some persons suffer more severe withdrawal symptoms than others. Genetic predisposition to withdrawal and the amount and duration of ethanol ingestion are thought to play roles. 7,8 A classic 1955 study demon- strated that individuals who drink alcohol continuously for longer periods of time and who develop high, sustained levels of blood ethanol are more likely to suffer severe with- drawal after abrupt reduction or cessation than are those who drink for shorter periods of time. Ethanol withdrawal does not usually occur in persons who drink in an intermittent manner that does not lead to the sustained high blood levels of ethanol needed to develop tolerance and withdrawal. 8 It is worth noting that total cessation of ethanol ingestion is not required for with- drawal symptoms to occur. Rather, withdrawal can occur any time after blood ethanol levels start to fall, not just when blood ethanol is absent. Consequently, the chronic alcoholic can start to have symptoms of withdrawal at blood alcohol levels that would render other individuals profoundly intoxicated. For example, an occasional drinker might drink heavily, develop a blood alcohol content (BAC) of 0.15 g/dL, and not only be above the legal limit to drive in most states (typi- cally around 0.08 g/dL) but also experience lethargy and difficulty sitting upright without assistance. A BAC of 0.25–0.3 g/dL will render this occasional drinker comatose. Most important, the occasional drinker of alcohol will not experience withdrawal symptoms when they stop drinking alcohol and their BAC returns to the normal baseline of 0.0 g/ dL. A chronic alcoholic may live at a BAC of 0.35 g/dL, a level that would render unhab- ituated persons comatose, and his stopping drinking for even a short time may result in withdrawal symptoms at a BAC of 0.15 g/dL. Minor ethanol withdrawal can occur as November 9 – 13, 2014 music city ceNter | Nashville, tN EMSWorldExpo.com | #EMSWorldExpo ExpEct morE. GEt morE… Exhibits Attend the show that delivers MORE. Register today at EMSWorldExpo.com. The best value in the industry, EMS World Expo features the largest exhibit hall in North America and offers attendees • Over 300 exhibitors showcasing the latest products and services that will change the way you do your job • The industry's best SimLab – test your skills on state-of-the-art medical devices • 30-minute classes offering FREE CE An alcohol use disorder (AUD) is present with two or more of these symptoms. The severity of AUD is defned as mild (presence of 2–3 symptoms), moderate (presence of 4–5 symptoms) or severe (presence of 6 or more symptoms). • Alcohol is often taken in larger amounts or over a longer period than was intended. • There is a persistent desire or unsuccessful eforts to cut down or control alcohol use. • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its efects. • Craving or strong desire or urge to use alcohol. • Recurrent alcohol use resulting in a failure to fulfll obligations at work, school or home. • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the efects of alcohol. • Important social, occupational or recreational activities are given up or reduced because of alcohol use. • Recurrent alcohol use in situations in which it is physically hazardous. • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. • Tolerance, as defned by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired efect; b) Markedly diminished efect with continued use of the same amount of alcohol • Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol; b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. Table 1: DSM-5 Criteria for Alcohol Use Disorder EMSWORLD.com | APRIL 2014 47 EMS_44-51_CEArticle,Index0414.indd 47 3/14/14 8:55 AM