Alcohol withdrawal
Background
- Withdrawal symptoms due to reduced GABA pathway and increased glutamate transmission
- Benzos useful due to cross tolerance at ethanol GABA receptor (same place carbemazipine and valproate also work
- Symptom Triggered Tx- quantify sx and give meds upon reaching threshold- as effective as fixed dose tx and needs less drug and get more rapid detox
Diagnosis
- Sweating, anxiety, tremor, hallucinations, N/V, HA, visual disturbance, disorientation
- Alcohol withdrawal symptoms peak in 72 hrs
Treatment
- Do not need meds for more than 7 days unless have DT's
- Banana Bag
- Thiamine 100mg IV
- Folate 1mg IV (cheaper PO)
- MVI 1 tab IV (cheaper PO)
- Magnesium sulfate 2mg IV
- NS 1L IV
- Benzodiazapines PRN
- Valium 5-10mg IV or Ativan 2-4mg IV Q10min until no tremor, then Q1hr
- Valium quicker to theraputic CNS levels
- Dilantin
- Consider in non-classic cases
Medications
- benzos- decrease severity of sx, sz, dt
- anticonvulsants- same
- beta blockers- improve vital signs and reduce craving
- alpha agonists- decrease severity of sxs
Adjuvant Txs- not sole txs but for combination
- phenothiazines- reduce signs and sxs but less effective than benzos for sz and dt
- beta blockers/ clonidine- no sz protection, not for benzo wd
Anticonvulsants - dilantin no role
- carb- less emotional distress and has anti sz prop too, does not inhibit mem like benzos, less abuse potential
o can have dizzy, n/v
o not for dts
o has fewer protracted sxs than benzos, less relapse, less side effect
- carb may be used for benzo wd
- valproate- also useful
Disposition
- Admit:
- Status
- DTs
- Focal/first sz
- Decr loc
- Inability to control withdrawal
- Consider D/C with 3 day course if want to quit