September 22, 2023

Welcome back to UH EMS-I’s Pharmacy Phriday. In the September 2023 monthly continuing education topic, Dr. Forde reminds us that alcohol withdrawal and seizures can mimic a stroke. He also reminds us that in these hypoglycemic patients, it is important to give Thiamine prior to glucose. During this Pharmacy Phriday review, we will consider why the use of Thiamine, commonly known as vitamin B1, is so important within these situations.

Thiamine plays an important part in the metabolism of glucose within the body. In cases of a thiamine deficiency, a significant amount of energy available in glucose cannot be obtained, and lactic acids build-up due to the abnormal metabolism. As a result, cell damage can occur, especially in the brain. In a patient experiencing a diabetic emergency that has low levels of Thiamine, the administration of dextrose without giving additional Thiamine can increase the amount of lactic acids produced and precipitate or worsen signs and symptoms of the thiamine deficiency, often seen as Wernicke’s encephalopathy.

Wernicke’s encephalopathy is one of two major syndromes associated with a Thiamine deficiency. Some of the most common signs of Wernicke’s are confusion, ataxia (an unsteady gait), and nystagmus (constant involuntary eye movement). Wernicke’s can resolve quickly with the administration of Thiamine. If not treated, it can progress to a more severe long-term condition known as Korsakoff’s Psychosis or Syndrome, irreversible brain damage, and/or death. 

Our protocols call for the use of Thiamine before administering glucose in situations of “chronic alcoholism or malnourished” patients. These groups of patients are susceptible to a Thiamine deficiency. Thiamine is not produced by the body but taken in primarily through a normal diet. Chronic alcohol intake can interfere with the intake, absorption, and use of Thiamine. And in cases of the malnourished, whether from inadequate dietary intake, decreased absorption from the gastrointestinal tract, and/or reduced stores in the liver, a Thiamine deficiency can be present.

Examples of other patient conditions that can lead to a thiamine deficiency include:

• chronic drug abuse

• the elderly (often due to dietary intake, multiple medical conditions, and/or prescribed medications)

• those with chronic disease processes such as HIV/AIDS, cancer, and diabetes

• persistent nausea and vomiting

• patients who have had bariatric surgery

Standard adult dosing for Thiamine in the hypoglycemic patient suspected of having, or at risk of having a thiamine deficiency, is 100mg IV/IM prior to the administration of glucose. Pediatric dosing is not recommended in the pre-hospital setting.

Have a great week and stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals