Ethanol withdrawal: Difference between revisions

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(Reverted edits by JCMiller (talk) to last revision by Silas Chiu)
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==Background==
==Background==
*Withdrawal symptoms due to reduced GABA and increased glutamate
*Withdrawal symptoms due to reduced GABA and increased glutamate
*[[Benzodiazepines|Benzos]] useful due to cross tolerance at [[Ethanol toxicity|ethanol]] GABA receptor
*Benzos useful due to cross tolerance at ethanol GABA receptor
*Symptom triggered therapy
*Symptom triggered therapy
**As effective as fixed dose therapy, but w/ more rapid detox
**As effective as fixed dose therapy, but w/ more rapid detox
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##Psychomotor agitation
##Psychomotor agitation
##Anxiety
##Anxiety
##[[Seizure|Grand mal seizures]]
##Grand mal seizures
#CIWA score
#CIWA score
##http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
##http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
##Start [[Benzodiazepines|benzo]] therapy at score of 8. Consider ICU admission with score >20.
##Start benzo therapy at score of 8. Consider ICU admission with score >20.


==Treatment==
==Treatment==
===General===
===General===
*Benzos
*Benzos
**[[Diazepam]] (Valium) 5-10mg IV (depending on severity)
**Diazepam 5-10mg IV (depending on severity)
***May repeat q5-10min for severe withdrawal (titrated to effect)
***May repeat q5-10min for severe withdrawal (titrated to effect)
**[[Lorazepam]] (Ativan) 1-4mg IV (depending on severity)
**Lorazepam 1-4mg IV (depending on severity)
***May repeat q15-20min for severe withdrawal (titrated to effect)
***May repeat q15-20min for severe withdrawal (titrated to effect)
*Beta blockers
*Beta blockers
**Improve VS, reduces craving
**Improve VS, reduces craving
*Alpha agonists ([[clonidine]])
*Alpha agonists (clonidine)
**Decrease severity of sxs
*Barbituates (Phenobarbital)
**Used when refractory to benzos
** Phenobarbital 130-260 mg IV q 15-20 minutes
*Banana Bag
**Thiamine 100mg IV
**Folate 1mg IV (cheaper PO)
**MVI 1 tab IV (cheaper PO)
**Magnesium sulfate 2mg IV
**NS 1L IV
 
===Seizures===
*Onset after last drink: 6-48h
*Multiple seizures: 60% of pts
*Progression to DTs: 33% of pts
*Treat with benzos (not phenytoin)
 
===Alcoholic Hallucinosis===
*Onset after last drink: 12-24hr
*Visual hallucinations are most common
*Different from delirium tremens
**Resolves within 24-48 from last drink (before onset of DTs)
**No delirium
**Normal vital signs
 
===Delirium Tremens===
====Diagnosis====
*Onset after last drink - 48 to 96hrs
*Delirium
**Disconnected from the environment
*Hyperdynamic vital signs
*Febrile
====Treatment====
*Goal = sleepy, but arousable w/ HR <110
*Diazepam
**Long duration of action, max effect within 5min
**Start 10mg IV
***Redose q5min after observing effect
***Can double subsequent doses until achieve goal
*Propfol
**Consider intubation + propofol drip if benzo-nonresponsive
*Thiamine 100mg
 
==Special Situations==
*The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref>  Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens
 
==Disposition==
*Admit:
**Multiple seizures
**DTs
**Decr LOC
**Inability to control withdrawal
*Consider D/C with 3 day course if want to quit
 
==See Also==
*[[Beer Potomania Syndrome]]
*[[Alcohol (ETOH) Intoxication]]
 
==Source==
<references/>
 
[[Category:Tox]]

Revision as of 16:40, 6 February 2015

Background

  • Withdrawal symptoms due to reduced GABA and increased glutamate
  • Benzos useful due to cross tolerance at ethanol GABA receptor
  • Symptom triggered therapy
    • As effective as fixed dose therapy, but w/ more rapid detox

Diagnosis

  1. Reduction in alcohol use that has been heavy and prolonged
  2. At least 2 of the following
    1. Autonomic hyperactivity (e.g., diaphoresis, HR>100)
    2. Increased hand tremor
    3. Insomnia
    4. Nausea/vomiting
    5. Transient visual, tactile, or auditory hallucinations
    6. Psychomotor agitation
    7. Anxiety
    8. Grand mal seizures
  3. CIWA score
    1. http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
    2. Start benzo therapy at score of 8. Consider ICU admission with score >20.

Treatment

General

  • Benzos
    • Diazepam 5-10mg IV (depending on severity)
      • May repeat q5-10min for severe withdrawal (titrated to effect)
    • Lorazepam 1-4mg IV (depending on severity)
      • May repeat q15-20min for severe withdrawal (titrated to effect)
  • Beta blockers
    • Improve VS, reduces craving
  • Alpha agonists (clonidine)
    • Decrease severity of sxs
  • Barbituates (Phenobarbital)
    • Used when refractory to benzos
    • Phenobarbital 130-260 mg IV q 15-20 minutes
  • Banana Bag
    • Thiamine 100mg IV
    • Folate 1mg IV (cheaper PO)
    • MVI 1 tab IV (cheaper PO)
    • Magnesium sulfate 2mg IV
    • NS 1L IV

Seizures

  • Onset after last drink: 6-48h
  • Multiple seizures: 60% of pts
  • Progression to DTs: 33% of pts
  • Treat with benzos (not phenytoin)

Alcoholic Hallucinosis

  • Onset after last drink: 12-24hr
  • Visual hallucinations are most common
  • Different from delirium tremens
    • Resolves within 24-48 from last drink (before onset of DTs)
    • No delirium
    • Normal vital signs

Delirium Tremens

Diagnosis

  • Onset after last drink - 48 to 96hrs
  • Delirium
    • Disconnected from the environment
  • Hyperdynamic vital signs
  • Febrile

Treatment

  • Goal = sleepy, but arousable w/ HR <110
  • Diazepam
    • Long duration of action, max effect within 5min
    • Start 10mg IV
      • Redose q5min after observing effect
      • Can double subsequent doses until achieve goal
  • Propfol
    • Consider intubation + propofol drip if benzo-nonresponsive
  • Thiamine 100mg

Special Situations

  • The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.[1] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens

Disposition

  • Admit:
    • Multiple seizures
    • DTs
    • Decr LOC
    • Inability to control withdrawal
  • Consider D/C with 3 day course if want to quit

See Also

Source

  1. ↑ Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.
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