Ethanol withdrawal: Difference between revisions

Revision as of 16:36, 6 February 2015

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

Reduction in alcohol use that has been heavy and prolonged
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
CIWA score
1. http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
2. Start benzo therapy at score of 8. Consider ICU admission with score >20.

Treatment

General

Benzos
- Diazepam (Valium) 5-10mg IV (depending on severity)
  - May repeat q5-10min for severe withdrawal (titrated to effect)
- Lorazepam (Ativan) 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)

@@ Line 18: / Line 18: @@
 #CIWA score
 ##http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
-##Start benzo therapy at score of 8. Consider ICU admission with score >20.
+##Start [[Benzodiazepines|benzo]] therapy at score of 8. Consider ICU admission with score >20.
 ==Treatment==
 ===General===
 *Benzos
-**Diazepam 5-10mg IV (depending on severity)
+**[[Diazepam]] (Valium) 5-10mg IV (depending on severity)
 ***May repeat q5-10min for severe withdrawal (titrated to effect)
-**Lorazepam 1-4mg IV (depending on severity)
+**[[Lorazepam]] (Ativan) 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)
+*Alpha agonists ([[clonidine]])
-**Decrease severity of sxs
-*Barbituates (Phenobarbital)
-**Used when refractory to benzos
-** Phenobarbital 130-260 mg IV q 15-20 minutes
-*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
-*Hyperdynamic 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
-==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.<ref>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.</ref>  Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for Delirum Tremens
-==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==
-<references/>
-[[Category:Tox]]