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 related disease processes

Seizure

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]
  • α-2 agonists (Dexmedetomidine)
    • Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
    • Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min
  • Ketamine
    • May have some use in refractory cases
    • Blocks the NMDA receptor which is excited an unregulated. [5]

Special Situations

Disposition

  • Admission

See Also

External Links

References

  1. Manasco A, Chang S, Larriviere J, et al. Alcohol withdrawal. Southern Medical Journal. 2012; 105(11):607–612.
  2. 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/
  3. National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm
  4. 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.
  5. 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
  6. 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.