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Withdrawal, Alcohol, Emergency Medicine

Basics

Description

- 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

- 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

  • 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 withdrawalWithdrawal seizuresAlcoholic hallucinosisDelirium 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 drinkDuration: 1 " 2 daysTremulousnessAnxietyPalpitationsNauseaAnorexia
  • Withdrawal seizures:Occurs: 6 " 48 hr after the last drinkDuration: 2 " 3 daysGeneralized seizures, generally brief
  • Alcoholic hallucinosis:Occurs: 12 " 48 hr after the last drinkDuration: 1 " 2 daysVisual hallucinations (most common)Tactile hallucinationsAuditory hallucinationsSensorium typically otherwise clear
  • DTs:Occurs 48 " 96 hr after the last drinkCan last up to 5 daysNot necessarily preceded by hallucinosis or seizures:TachycardiaHTNDiaphoresisDeliriumAgitationSensorium typically not clear

History

  • Obtain substance abuse history:Time of last substance useHistory 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:

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 therapyNo single benzodiazepine is more effective than anotherHigh 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.

See Also (Topic, Algorithm, Electronic Media Element)

Withdrawal, Drug

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)