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Alcohol withdrawal seizures are tonic- clonic seizures that can occur as early as six hours after the fall of blood ethanol levels. About 90% of withdrawal-related seizures occur within 48 hours after the fall of blood ethanol levels. Withdrawal seizures are usually singular or occur as a series of brief periods of seizure activity over a short time. If you witness recurrent seizures or prolonged seizure activity (status epilepticus), consider other etiologies for the seizure; the chronic alcohol abuser is at increased risk for trauma, hypoglycemia and sepsis. Table 2 lists the differential considerations for patients with suspected ethanol-related symptoms. Withdrawal Management The goals of prehospital management of the patient with ethanol withdrawal revolve around: • Ensuring an open and protected airway and protecting against aspiration; • Ensuring adequate ventilation; • Replacing volume depletion; • Preventing and/or stopping seizure activity; • Ruling out and/or treating hypoglycemia; and • Reducing patient agitation and discomfort. Create as much of a quiet, protective space as possible for the patient suffering mild withdrawal. This can be difficult in the prehospital environment, but little efforts (e.g., turning down the lights in the patient compartment, reducing speed and bumps during transport, not using lights and sirens unnecessarily) can contribute to a more optimal environment. Patients suffering nausea can be administered an antiemetic such as ondansetron (Zofran) or prochlorper- azine (Compazine) to control it and prevent vomiting. To protect both the patient and caregivers, restraints may be necessary for patients in withdrawal with profound agitation or DT. Physical restraints must be padded, prefer- ably applied to the extremities, and not restrict breathing. If physical restraints are utilized, consider the concomitant use of sedation. A patient resisting against physical restraints can cause themselves physical injury, raise their metabolism and body temperature, and possibly produce rhabdomyolysis. Benzodiazepines such as diazepam (Valium), lorazepam (Ativan) and midazolam (Versed) and IV antipsychotics such as haloperidol (Haldol) are sedatives commonly used in the prehospital environment for this purpose. All patients in DT require sedation with benzodiazepines, and the total amount of IV benzodiazepines that can be administered to control the symptoms of withdrawal is not insignificant. As was discussed earlier, chronic alcohol abuse desensitizes patients to GABA stimulation, which is the primary mechanism for benzodiazepines. Since the chronic alcoholic has a larger-than-normal number of GABA receptors, they will require a larger-than-normal amount of benzodiaz- epine to adequately stimulate the receptors to reach the goal of sedation. The Clinical Institute Withdrawal Assessment (CIWA) recommendations for administration of midazolam for severe alcohol withdrawal say a patient unable to take oral medications can receive 2–5 mg every five minutes x3, then 4–10 mg IV x3 until improvement, up to a total of 50 mg of midazolam. Most EMS systems do not have paramedic units stocking 50 mg of midazolam, nor do many prehospital proto- cols allow for the administration of that much. Consult online medical direction for guidance CE ARTICLE November 9 – 13, 2014 music city ceNter | Nashville, tN EMSWorldExpo.com | #EMSWorldExpo ExpEct morE. GEt morE… Sales Make the smart investment, and participate in the largest EMS show in North America. Year after year, EMS World Expo • Delivers more decision makers than any other EMS show • Attracts new attendees each year by varying locations so you can grow your customer base • Draws the largest international audience than any other EMS show • Averages a yearly attendance of 5,000 industry professionals over the past three years Exhibit at the show that delivers MORE. Reserve your exhibit space today at EMSWorldExpo.com. Wernicke's encephalopathy (WE) is a well-known central nervous system complication of vitamin B1 (thiamine) defciency. Thiamine defciency in the chronic alcoholic commonly occurs secondary to a combination of poor diet, reduced gastrointestinal absorption, decreased storage in the liver and impaired utilization of thiamine. WE is characterized by neurological symptoms and lesions on the brain. The "classic" triad of symptoms—gait ataxia, confusion and ophthalmoplegia, or any eye movement abnormalities—is not the rule but rather the exception, and presents in only 10%–33% of cases. 11,12 The symptoms can appear simultaneously, but ataxia often precedes others by a few days or weeks. 13 WE is often missed when the classic criteria are depended on for recognition. Untreated, most patients with WE will become increasingly confused, develop an altered mental status and level of consciousness, lapse into a coma and possibly die. The IV administration of thiamine is not only efective at preventing this outcome but is also cheap, safe and simple. Wernicke's Encephalopathy EMSWORLD.com | APRIL 2014 49 EMS_44-51_CEArticle,Index0414.indd 49 3/14/14 8:55 AM