›If no IV, then glucagon 1 mg IM
›Less effective in depleted glycogen states
›Bridge until IV access obtained
›Antiemetic options
›Ondansetron 4 mg IV
›Repeat 4 mg in 15 to 30 minutes if persistent
›QT prolongation caution
›Metoclopramide 10 mg IV
›Dystonia risk
›Avoid in suspected obstruction
›Aspiration prevention adjuncts
›NPO until awake and swallowing intact
›Consider NG suction only if airway protected and severe gastric distention
Agitation and behavioral control
›Nonpharmacologic de-escalation
›Low stimulation environment
›Dim lights
›Reduce crowding
›One to one observation
›Fall risk
›Elopement risk
›Chemical sedation for severe agitation
›Droperidol 2.5 mg to 5 mg IM or IV
›Repeat 2.5 mg to 5 mg every 15 minutes as needed
›Target calm cooperative state
›Avoid oversedation with rising ethanol level
›QT monitoring if high cumulative dose or risk factors
›Baseline QT prolongation
›Concurrent QT prolonging drugs
›Haloperidol 2 mg to 5 mg IM or IV
›Repeat 2 mg to 5 mg every 20 to 30 minutes as needed
›Extrapyramidal symptom risk
›Consider diphenhydramine rescue if dystonia
›Avoid as sole agent for withdrawal seizures risk
›Does not treat withdrawal physiology
›Lowers seizure threshold
›Midazolam 2 mg IM or IV
›Repeat 1 mg to 2 mg every 5 to 10 minutes as needed
›Respiratory depression risk with ethanol
›Continuous monitoring required
›Avoid large front loading in older adults
›Delirium risk
›Prolonged sedation
Respiratory depression and co-ingestion
›Naloxone pathway when indicated
›Naloxone 0.04 mg IV
›Escalate to 0.4 mg IV if no response
›Escalate to 2 mg IV if persistent apnea
›Titrate to adequate ventilation not full arousal
›Consider infusion if repeated boluses required
›Infusion rate two thirds of effective wake up dose per hour
›Monitor for renarcotization
Wernicke encephalopathy and severe deficiency
›High suspicion treatment
›Thiamine IV 500 mg
›Every 8 hours for 2 to 3 days if Wernicke concern
›Ophthalmoplegia or nystagmus
›Ataxia
›Then thiamine IV 250 mg daily for 3 to 5 days
›Transition to oral thiamine when eating
›Add magnesium repletion if low
Alcohol withdrawal overlap
›Withdrawal treatment if emerging
›Diazepam 10 mg PO or IV
›Repeat 10 mg every 10 to 20 minutes to symptom control
›Aim for CIWA guided control when awake
›Monitor respiratory status closely
›Avoid in severe liver disease if prolonged sedation risk
›Prefer lorazepam
›Dose reduction
›Lorazepam 2 mg IV
›Repeat 1 mg to 2 mg every 10 to 20 minutes as needed
›Better in hepatic impairment
›Less active metabolites
Evidence and guideline notes
›Evidence aligned practice points
›Airway protection and ventilation in poisoning is consistent with resuscitation consensus
›ACLS airway and breathing principles support early airway control in failure
›Class I recommendation for airway and ventilation when indicated
›Routine IV fluids do not reliably hasten ethanol clearance
›Use fluids for hypovolemia or hypotension not for sobriety speed
›ACEP Level C consensus aligned practice point