Ethanol withdrawal: Difference between revisions
m (Rossdonaldson1 moved page Alcohol Withdrawal to Alcohol withdrawal) |
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#Reduction in alcohol use that has been heavy and prolonged | #Reduction in alcohol use that has been heavy and prolonged | ||
#At least 2 of the following | #At least 2 of the following | ||
# | #*Autonomic hyperactivity (e.g., diaphoresis, HR>100) | ||
# | #*Increased hand tremor | ||
# | #*Insomnia | ||
# | #*[[Nausea/vomiting]] | ||
# | #*Transient visual, tactile, or auditory hallucinations | ||
# | #*Psychomotor agitation | ||
# | #*Anxiety | ||
# | #*Grand mal [[seizures]] | ||
#CIWA score | #CIWA score | ||
# | #*http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator | ||
# | #*Start [[Benzodiazepines|benzo]] therapy at score of 8. Consider ICU admission with score >20. | ||
==Treatment== | ==Treatment== | ||
Revision as of 18:54, 8 March 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
- Autonomic hyperactivity (e.g., diaphoresis, HR>100)
- Increased hand tremor
- Insomnia
- Nausea/vomiting
- Transient visual, tactile, or auditory hallucinations
- Psychomotor agitation
- Anxiety
- Grand mal seizures
- 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.
Treatment
General
- Benzodiazepines
- Beta blockers
- Improve VS, reduces craving
- 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.[1] 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
Source
- ↑ 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.