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CE ARTICLE when presented with a patient in severe ethanol withdrawal. Many clinicians use the CIWA protocol to help assess the degree of withdrawal and amount of medica- tion therefore needed. While prehos- pital care providers will most likely not use this tool to direct total doses, it is useful to consider your clinical exam findings against the CIWA criteria to determine the degree of withdrawal in your patient. (See Table 3 in the online version of this article at www.emsworld. com/11324257.) Chronic alcoholics, because of the derangements of liver function charac- teristic of the disease, are at increased risk of developing hypoglycemia. Any patient with an altered mental status, especially the chronic alcoholic suffering from withdrawal, should have their blood glucose level determined and dextrose administered if they are found to be hypoglycemic. Patients with AMS or a decreased level of consciousness should have IV access established and dextrose administered via that route. Patients in withdrawal who are alert and oriented, have an intact gag reflex and can follow directions may be administered oral glucose. However, the risk of aspiration should be evaluated, and IV dextrose administered if any risk of aspiration or vomiting exists. Chronic alcoholics are at high risk for aspiration and the develop- ment of pneumonia due to their inability to adequately protect their airway when they are heavily intoxicated and also because of the immunosuppression characteristic of alcoholism. Patients with clinical evidence of volume depletion and dehydration should be administered an isotonic electrolyte solution such as normal saline, and IV thiamine can be given to the chronic alcoholic to prevent or treat Wernicke's encephalopathy. In the emer- gency department, these patients are commonly administered a multivitamin, glucose and folate-containing solution to correct the deficiencies in glucose, potassium, magnesium and phosphate typical in the chronic alcoholic. This solution, because of the multivitamins, has a bright yellow appearance and is commonly referred to as a "banana bag." However, this treatment has not been well studied, and it is unknown if it actually meets the vitamin, glucose and electro- lyte demands of the patient with ethanol withdrawal. 10 Case Wrap-up The patient is placed on oxygen via nasal cannula at 4 lpm, which brings his SpO 2 up to 100%. He is placed on the cardiac monitor, which shows a sinus tachycardia. IV access is obtained with an 18-gauge angiocath in the right ante- For More Information Circle 51 on Reader Service Card 1601 W. Deer Valley Road, Phoenix, AZ 85027 • www.knoxbox.com • info@knoxbox.com Knox ® MedVault ® Drug Locker P r o t e c t y o u r D e Pa r t M e n t, S ta f f a n D I n V e n t o r y • neW – Two Sizes Available • Know Who Accessed Narcotics & When • neW – WiFi Remote Administration • Narcotic Access Control & Accountability 800-552-5669 • knoxbox.com r e D u c e e x P o S u r e t o n a r c o t I c S t h e f t For More Information Circle 52 on Reader Service Card 50 APRIL 2014 | EMSWORLD.com EMS_44-51_CEArticle,Index0414.indd 50 3/14/14 8:55 AM