Alcohol withdrawal

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Background

  • Withdrawal symptoms due to reduced GABA pathway and increased glutamate transmission
  • Benzos useful due to cross tolerance at ethanol GABA receptor (same place carbemazipine and valproate also work
  • Symptom Triggered Tx- quantify sx and give meds upon reaching threshold- as effective as fixed dose tx and needs less drug and get more rapid detox


Diagnosis

  • Sweating, anxiety, tremor, hallucinations, N/V, HA, visual disturbance, disorientation
  • Alcohol withdrawal symptoms peak in 72 hrs


Treatment

  • Do not need meds for more than 7 days unless have DT's


BANANA BAG

100mg thiamine IV

1mg folate IV (cheaper PO)

1 tab MVI IV (cheaper PO)

2mg magnesium sulfate IV

1 L NS IV


Benzodiazapines PRN

  • Valium 5-10mg IV or Ativan 2-4mg IV Q10min until no tremor, then Q1hr)
  • Valium quicker to theraputic CNS levels


Consider Dilantin in non-classic cases


Medicationss

- benzos- decrease severity of sx, sz, dt

- anticonvulsants- same

- beta blockers- improve vital signs and reduce craving

- alpha agonists- decrease severity of sxs


Treatment

- benzos best of alcohol wd- decrease severity, szs and dt

- more abuse if have rapid onset of effect- valium, xanax, ativan,

- phenobarb- less abused but poorer safety profile- resp depression

- carbemazipine similar to benzos for adverse effects


Adjuvant Txs- not sole txs but for combination

- phenothiazines- reduce signs and sxs but less effective than benzos for sz and dt

- beta blockers/ clonidine- no sz protection, not for benzo wd


Anticonvulsants

- dilantin no role

- carb- less emotional distress and has anti sz prop too, does not inhibit mem like benzos, less abuse potential

o can have dizzy, n/v

o not for dts

o has fewer protracted sxs than benzos, less relapse, less side effect

- carb may be used for benzo wd

- valproate- also useful


Disposition

Admission Criteria

-status

-DTs

-focal/first sz

-dec loc

-inability to control wthdl


  • Consider D/C with 3 day course if want to quit


See Also

FEN: Beer Potomania Syndrome

Tox: ETOH Intoxication