Rosen & Barkin's 5-Minute Emergency Medicine Consult (786 page)

• 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

• 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
      

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

A thorough physical exam is necessary

Thorough history and physical exam with attention to the vital signs

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

• 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.
    

ECG when clinically warranted

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

TREATMENT

• Assess vital signs
  
• Assess capillary glucose
  

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

• 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.
  

• 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 μg/kg/min, then titrate as necessary
  

FOLLOW-UP

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

Mild symptoms and signs responsive to therapy

Referral to detox program or facility

• 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.
  

• 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

• 291.0 Alcohol withdrawal delirium
  
• 291.3 Alcohol-induced psychotic disorder with hallucinations
  
• 291.81 Alcohol withdrawal
  

BASICS

• Neuroexcitation is the hallmark of benzodiazepine, barbiturate, and opiate withdrawal
  
• Benzodiazepine and barbiturate withdrawal can be life threatening
  
• Opiate withdrawal can be extremely uncomfortable but is not typically life threatening
  
• Cocaine and amphetamine withdrawal are similarly not life threatening
  

• Chronic exposure to certain drugs cause adaptive changes in the CNS
  
• Withdrawal syndromes occur when the constant presence of drug is removed or reduced and the adaptive changes persist
  
• Tolerance occurs when increasing amounts of drug are required to achieve a given response
  
• Withdrawal and tolerance are distinct entities