Alcohol withdrawal seizures

Background

• Onset after last drink: 6-48h
• Multiple seizures: 60% of patients
• Progression to Delerium tremenss: 33% of patients
• May occur in spectrum or independent of Alcohol withdrawal syndrome

Clinical Features

• Single or multiple brief tonic-clonic seizures in the appropriate time setting for alcohol withdrawal

Differential Diagnosis

Ethanol related disease processes

• Ethanol toxicity
• Alcohol use disorder
• Alcohol withdrawal
  • Alcohol withdrawal seizures
  • Delerium tremens
• Electrolyte/acid-base disorder
  • Alcoholic ketoacidosis
  • Beer potomania syndrome
  • Beriberi
  • Thiamine deficiency
  • Wernicke-Korsakoff syndrome

Seizure

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
  • Non-compliance with anti-epileptic medications
  • Hyponatremia
  • INH toxicity
• Non-epileptic seizure
  • Meningitis
  • Encephalitis
  • Brain abscess
  • Intracranial hemorrhage
  • Alcohol withdrawal
  • Benzodiazepine withdrawal
  • Barbiturate withdrawal
  • Baclofen withdrawal
  • Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
  • Eclampsia
  • Neurocysticercosis
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
  • Acute hydrocephalus
  • Arteriovenous malformation
  • Seizure with VP shunt
  • Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
  • Psychogenic nonepileptic seizure (pseudoseizure)
• Intracranial mass
• Syncope
• Hyperventilation syndrome
• Migraine headache
• Movement disorders
• Narcolepsy/cataplexy
• Post-hypoxic myoclonus (Status myoclonicus)

Diagnosis

• Clinical features
• Elevated CIWA
• Other diagnoses excluded (ICH from head injury, hyponatremia, etc.)

Management

• Treat with benzos (not phenytoin)
• See Alcohol withdrawal: Inpatient management

Disposition

• Admission

See Also

• Alcohol withdrawal
• Delerium tremens
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal

External Links

• MDCalc - CIWA-AR Calculator