Background
- Withdrawal symptoms due to reduced GABA and increased glutamate
- Benzos useful due to cross tolerance at ethanol GABA receptor
- Sx triggered Tx
- As effective as fixed dose tx with 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
Treatment
- Benzos
- PO route
- Diazepam 10-20mg PO q1-2hr
- Chlordiazepoxide 50-100mg PO q1-2hr
- IV route
- Diazepam 5-10mg IV q5-10min
- Lorazepam 2-4mg IV Q10min
- Banana Bag
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- MVI 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- NS 1L IV
- Other
- Beta blockers
- Improve VS, reduces craving
- Alpha agonists (clonidine)
Seizures
- Onset after last drink - 6-48hr
- Multiple sz - 60% of pts
- Progression to DTs - 33%
- Tx with benzos (not phenytoin!)
Alcoholic Hallucinosis
- Onset after last drink - 12-24hr
- Visual hallucinations are most common
- Different from delirium tremens
- Resolves w/in 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
- Hyerdynamic 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 gtt if benzo-nonresponsive
- Thiamine 100mg
Disposition
- Admit:
- Status
- DTs
- Focal/first sz
- 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
