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CE ARTICLE early as six hours after the fall of blood ethanol levels and usually peaks within 24–36 hours if the withdrawal is not going to progress. 9,10 The signs and symptoms of minor withdrawal include anxiety, gastrointestinal distress, anorexia, nausea, insomnia, vivid dreams, tremors, headache, diaphoresis, tachycardia and palpitations. These fndings are all consis- tent with increased autonomic activity and catecholamine release. Major ethanol withdrawal occurs after about 24 hours and usually peaks at about 50 hours but can take up to five days to resolve after the decline or termi- nation of drinking. 9 It is characterized by the greater and prolonged signs and symptoms of minor ethanol withdrawal as well as hypertension, fever, hallucina- tions, decreased seizure threshold and delirium. Delirium and Seizures Delirium tremens (DT) is a life- threatening manifestation of ethanol withdrawal characterized by tremors, hallucinations (most often visual), confu- sion and agitation, tachycardia, tachy- pnea, hypertension and diaphoresis. It is worth noting that a patient can have hallucinations without DT and its char- acteristic alterations of vital signs. The symptoms of DT typically appear 48–96 hours after the fall of blood ethanol levels and can persist for 1–7 days. Patients with DT have increased metabolism and oxygen requirements. In addition, hyperventilation can result in the development of a respiratory alkalosis and subsequent reduction in cerebral perfusion secondary to cerebral vasoconstriction. Patients in DT (and therefore severe ethanol withdrawal) can develop hypovolemia and electro- lyte abnormalities as a result of the fever, tachypnea, hyperthermia and vomiting characteristic of the state. This can lead to cardiac dysrhythmias, cardiac failure and seizures. The mortality associated with DT is about 5%, and advanced age, hyperthermia and preexisting liver or respiratory disease increase its risk. 10 *For terms and conditions please visit www.buyemp.com/customer-service.html buyemp.com You order. We ship (free). * It's that simple. Is Now Available From EMP Our Medstorm brand enables responders to deliver quality treatment and improve patient outcomes. With a portfolio of everyday products and solutions across multiple clinical categories, EMP continues to anticipate the needs of tomorrow's healthcare while responding to the needs of today. For More Information Circle 50 on Reader Service Card • Hypoglycemia • Hypoxia • Carbon monoxide poisoning • Acute schizophrenia • Metabolic derangements • Drug overdose • Isopropanol, ethylene glycol, methanol poisoning • Hepatic encephalopathy • Thyrotoxicosis • Gastrointestinal bleeding • Seizures • Postictal state • Trauma: intracranial hemorrhage • Anticholinergic poisoning • Liver failure • Infection/sepsis • Hypothermia • Hyperthermia • Stroke Table 2: Dierential Considerations for Patients With Suspected Ethanol Withdrawal 48 APRIL 2014 | EMSWORLD.com EMS_44-51_CEArticle,Index0414.indd 48 3/14/14 8:55 AM