Ethanol withdrawal

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

Clinical Features

• 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

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

Differential Diagnosis

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)

Diagnosis

CIWA score

Clinical Institute Withdrawal Assessment – Alcohol – revised (CIWA-Ar)

• Headache 0-7
• Orientation 0-3
• 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

Inpatient Management

See Alcohol withdrawal: Inpatient management

Outpatient Management

See Alcohol withdrawal: Outpatient management

Disposition

Admit

• Multiple seizures
• DTs
• Decreased LOC
• Inability to control withdrawal after administrating 3-4 doses of benzo's
• Consider ICU admission with CIWA score >20

Discharge

• Consider discharge with 3 day course of benzodiazepines if patients are attempting to quit alcohol
• Consider possible exclusions for outpatient treatment:
  • Substance use disorders except alcohol, nicotine, or cannabis
  • Major Axis I psych disorder
  • Medication hx of benzodiazepines, BBs, CCBs, antipsychotics
  • Hx of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value

See Also

• Beer Potomania Syndrome
• Alcohol (ETOH) Intoxication
• Alcoholic ketoacidosis
• Alcohol withdrawal: Inpatient management
• Alcohol withdrawal: Outpatient management
• Alcohol withdrawal seizures
• Altered mental status
• Delerium tremens
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
• Sedative/Hypnotic

External Links

• MDCalc - CIWA-AR Calculator