Ethanol withdrawal: Difference between revisions
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==Background== | ==Background== | ||
*Withdrawal symptoms due to reduced GABA and increased glutamate | *Withdrawal symptoms due to reduced GABA and increased glutamate | ||
*Benzos useful due to cross tolerance at ethanol GABA receptor | *[[Benzodiazepines|Benzos]] useful due to cross tolerance at [[Ethanol toxicity|ethanol]] GABA receptor | ||
*Symptom triggered therapy | *Symptom triggered therapy | ||
**As effective as fixed dose therapy, but w/ more rapid detox | **As effective as fixed dose therapy, but w/ more rapid detox | ||
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##Psychomotor agitation | ##Psychomotor agitation | ||
##Anxiety | ##Anxiety | ||
##Grand mal seizures | ##Grand mal [[seizures]] | ||
#CIWA score | #CIWA score | ||
##http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator | ##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== | ==Treatment== | ||
===General=== | ===General=== | ||
* | *[[Benzodiazepines]] | ||
**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) | ***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) | ***May repeat q15-20min for severe withdrawal (titrated to effect) | ||
*Beta blockers | *Beta blockers | ||
**Improve VS, reduces craving | **Improve VS, reduces craving | ||
*Alpha agonists (clonidine) | *Alpha agonists ([[clonidine]]) | ||
**Decrease severity of sxs | **Decrease severity of sxs | ||
*Barbituates (Phenobarbital) | *Barbituates (Phenobarbital) | ||
**Used when refractory to benzos | **Used when refractory to [[Benzodiazepines|benzos]] | ||
** Phenobarbital 130-260 mg IV q 15-20 minutes | ** Phenobarbital 130-260 mg IV q 15-20 minutes | ||
*Banana Bag | *Banana Bag | ||
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*Multiple seizures: 60% of pts | *Multiple seizures: 60% of pts | ||
*Progression to DTs: 33% of pts | *Progression to DTs: 33% of pts | ||
*Treat with benzos (not phenytoin) | *Treat with [[Benzodiazepines|benzos]] (not phenytoin) | ||
===Alcoholic Hallucinosis=== | ===Alcoholic Hallucinosis=== | ||
Revision as of 16:48, 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
- 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.