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]
Benzodiazepine overview
| Agents | Equivalent PO dose (mg) | Route | Onset of Action (min) | Half Life (hr) | Metabolism |
| Chlordiazepoxide | 25 | PO, IV | 30 - 120 | 7-28 | CYP; active metabolites |
| Diazepam | 5 | PO, IV, IM | 2 - 5 | 20-120 | CYP; active metabolites |
| Lorazepam | 1 | PO, IM, IV | 15-20 | 8-19 | Glucuronidation |
Benzodiazepines
- Diazepam (Valium) 5-10 mg IV (depending on severity)
- May repeat q5-10 min for severe withdrawal (may increase dose by 10 mg every 5-10 min until desired effect achieved, max dose of 200 mg)
- Half-life 20-100 h (long acting)
- Lorazepam (Ativan) 1-4mg IV (depending on severity)
- May repeat q15-20 min for severe withdrawal (titrated to effect)
- Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[3]
- Half-life 10-20 h (medium acting)
Other Agents
For use in cases refractory to benzodiazepine treatment
- Propofol
- If patient does not respond to high doses of benzodiazepines
- 0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours
- Barbiturates (Phenobarbital)
- Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
- Phenobarbital 130-260 mg IV q 15-20 minutes
- Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions [4]
- Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
- α-2 agonists (Dexmedetomidine)
- Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
- Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr[5]
- Ketamine
- May have some use in refractory cases
- Blocks the NMDA receptor which is excited an unregulated. [6]
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.[7] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for delirium tremens.
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/
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
- ↑ Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.
- ↑ Rayner SG, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care. 2012; 2: 12. Published online 2012 May 23. doi: 10.1186/2110-5820-2-12.
- ↑ Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907
- ↑ 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.