Alcohol withdrawal seizures
Background
- Onset after last drink: 6-48h
- Multiple seizures: 60% of patients
- Progression to Delerium tremens: 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[1]
Differential Diagnosis
- Ethanol toxicity
- Alcohol use disorder
- Alcohol withdrawal
- Electrolyte/acid-base disorder
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)
Evaluation
- Clinical features
- Elevated CIWA
CIWA score
Clinical Institute Withdrawal Assessment – Alcohol – revised (CIWA-Ar)
- Headache 0-7
- Orientation 0-4
- Tremor 0-7
- Sweating 0-7
- Anxiety 0-7
- Nausea (and Vomiting) 0-7
- Tactile Hallucinations 0-7
- Auditory Hallucinations 0-7
- Visual Hallucinations 0-7
- Agitation 0-7
Maximum Score = 67
- <8: Typically do not require medication
- 8-19: Medication
- ≥20: Medication and admission
Management
Don’t use phenytoin or fosphenytoin to treat seizures caused by drug toxicity or drug withdrawal.[2]
Vitamin Prophylaxis for Chronic alcoholics
- At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
- Give multivitamin PO; patient at risk for other vitamin deficiencies
Banana bag
The majority of chronic alcoholics do NOT require a banana bag[3][4]
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- Multivitamin 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- Normal saline as needed for hydration
Disposition
- Admission
See Also
- Alcohol withdrawal
- Delerium tremens
- EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
- Seizure
External Links
References
- ↑ Manasco A, Chang S, Larriviere J, et al. Alcohol withdrawal. Southern Medical Journal. 2012; 105(11):607–612.
- ↑ Choosing Wisely. American College of Medical Toxicology and The American Academy of Clinical Toxicology. http://www.choosingwisely.org/clinician-lists/acmt-and-aact-phenytoin-or-fosphenytoin-to-treat-seizures/
- ↑ Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
- ↑ Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.