Ethanol withdrawal

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

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
• 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
• Hyerdynamic 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

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

• UpToDate