Withdrawal, Alcohol, Emergency Medicine

Basics

Description

Alcohol withdrawal is the most common withdrawal syndrome encountered in the emergency department
Neuroexcitation is the hallmark of alcohol withdrawal
Alcohol withdrawal may be life threatening.
More severe symptoms and signs are seen in patients with prior episodes of withdrawal, a process called kindling
Alcoholism is not uncommon among older adults.
Age-related increase in alcohol sensitivity
Alcohol-related problems may be misdiagnosed as normal consequences of aging.

Etiology

Chronic alcohol use downregulates GABA (inhibitory) receptors, upregulates NMDA (excitatory) receptors.
Abstinence or reduction in use leads to increased adrenergic activity because of these receptor adaptations
4 components to alcohol withdrawal:
- Early withdrawal
- Withdrawal seizures
- Alcoholic hallucinosis
- Delirium tremens (DTs)
DTs occur in 5% of patients experiencing alcohol withdrawal
DTs have a 5 " 15% mortality rate

Diagnosis

Signs and Symptoms

Early withdrawal:
- Occurs: 6 " 8 hr after the last drink
- Duration: 1 " 2 days
  - Tremulousness
  - Anxiety
  - Palpitations
  - Nausea
  - Anorexia
Withdrawal seizures:
- Occurs: 6 " 48 hr after the last drink
- Duration: 2 " 3 days
  - Generalized seizures, generally brief
Alcoholic hallucinosis:
- Occurs: 12 " 48 hr after the last drink
- Duration: 1 " 2 days
  - Visual hallucinations (most common)
  - Tactile hallucinations
  - Auditory hallucinations
  - Sensorium typically otherwise clear
DTs:
- Occurs 48 " 96 hr after the last drink
- Can last up to 5 days
- Not necessarily preceded by hallucinosis or seizures:
  - Tachycardia
  - HTN
  - Diaphoresis
  - Delirium
  - Agitation
  - Sensorium typically not clear

History

Obtain substance abuse history:
- Time of last substance use
- History of previous withdrawal and how severe

Physical Exam
A thorough physical exam is necessary

Essential Workup

Thorough history and physical exam with attention to the vital signs

Diagnosis Tests & Interpretation

Lab

Electrolytes, BUN, creatinine, glucose, magnesium
CBC
Alcohol level
Urine drug screening rarely alters management
Urinalysis
Blood/urine culture:
- For suspected infection

Imaging

Not necessary if early withdrawal is clearly the presenting issue
CT head:
- For altered mental status or if the clinical situation is not straightforward
CXR:
- If secondary infection (e.g., aspiration pneumonia) is suspected.

Diagnostic Procedures/Surgery
ECG when clinically warranted

Differential Diagnosis

Benzodiazepine withdrawal
Barbiturate withdrawal
Intracerebral hemorrhage
CNS infection
Epilepsy
Hypoglycemia
Hyperthyroidism
Sepsis
Drug intoxication
Psychosis
Electrolyte disorder

Treatment

Pre-Hospital

Assess vital signs
Assess capillary glucose

Initial Stabilization/Therapy

Attention to the ABCs
Obtain IV access
IV fluid administration
Cardiopulmonary monitoring

Ed Treatment/Procedures

Aggressive supportive care
Benzodiazepines:
- The standard therapy
- No single benzodiazepine is more effective than another
- High doses are often required to control symptoms and signs
Barbiturates may be used as an alternate or adjunct to benzodiazepines.
Propofol may also be used in severe cases.

Medication

Diazepam: 5 " 20 mg PO for mild symptoms and signs; 5 " 10 mg IV; repeat for severe symptoms and signs
Lorazepam: 2 mg PO, repeat q2 " 4h as needed for mild symptoms and signs; 2 mg IV in repeated doses as necessary for severe symptoms and signs
Phenobarbital: 30 " 60 mg PO for mild symptoms and signs; 15 " 20 mg/kg slow intravenous administration for severe symptoms or status epilepticus
Propofol: Start with 25 " 75 ¼g/kg/min, then titrate as necessary

Follow-Up

Disposition

Admission Criteria

Moderate-to-severe symptoms
Persistent symptoms despite treatment
DTs or impending DTs
Comorbid medical illness

Discharge Criteria
Mild symptoms and signs responsive to therapy

Followup Recommendations

Referral to detox program or facility

Pearls and Pitfalls

Misdiagnosis of medical disease as withdrawal syndrome
Misunderstanding the relationship between withdrawal syndromes and comorbid medical illness
Administer sufficient quantities of benzodiazepines to control symptoms.

Additional Reading

Carlson RW, Kumar NN, Wong-Mckinstry E, et al. Alcohol withdrawal syndrome. Crit Care Clin. 2012;28(4):549 " 585.
DeBellis R, Smith BS, Choi S, et al. Management of delirium tremens. J Intensive Care Med. 2005;20:164 " 173.
McKeon A, Frye MA, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry. 2008;79:854 " 862.
Rathlev NK, Ulrich AS, Delanty N, et al. Alcohol-related seizures. J Emerg Med. 2006;31:157 " 163.
Tetrault JM, O 'Connor PG. Substance abuse and withdrawal in the critical care setting. Crit Care Clin. 2008;24:767 " 788.

Codes

ICD9

291.0 Alcohol withdrawal delirium
291.3 Alcohol-induced psychotic disorder with hallucinations
291.81 Alcohol withdrawal
291.1 Alcohol-induced persisting amnestic disorder
291.5 Alcohol-induced psychotic disorder with delusions
291.89 Other alcohol-induced mental disorders

ICD10

F10.231 Alcohol dependence with withdrawal delirium
F10.239 Alcohol dependence with withdrawal, unspecified
F10.951 Alcohol use, unsp w alcoh-induce psych disorder w hallucin
F10.96 Alcohol use, unsp w alcoh-induce persist amnestic disorder

SNOMED

191480000 Alcohol withdrawal syndrome (disorder)
8635005 alcohol withdrawal delirium (disorder)
191476005 alcohol withdrawal hallucinosis (disorder)
308742005 Alcohol withdrawal-induced convulsion (disorder)

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