Yesterday
we discussed alcohol withdrawal.
Alcohol use
can have effects on the body from head to toe. Complications of alcohol use can
include:
-
Thiamine
deficiency
o
Causing
Wernicke encephalopathy characterized by the triad of encephalopathy,
oculomotor dysfunction, and ataxia, or Korsakoff syndrome, the chronic
consequence of Wernicke encephalopathy
-
Malnutrition
and refeeding syndrome
-
Alcoholic
ketoacidosis
-
Hypertension
and cardiovascular disease
-
Cardiomyopathy
-
Liver
disease including cirrhosis and hepatitis
-
Pancreatitis
-
Gastritis
and esophagitis
-
Peripheral
neuropathy
-
Bone
marrow suppression
-
Injury/trauma
-
Malignancies,
including GI, liver, and breast cancer
-
Psychiatric
disorders
Another complication
of alcohol use is alcohol withdrawal. There are several different phases of
alcohol withdrawal. As such, the timing of symptoms compared to the last drink
is helpful piece of information on history.
Manifestations
of alcohol withdrawal:
-
Early alcohol withdrawal (onset 1-48
hours after last drink) can include symptoms such as insomnia, tremulousness, anxiety, GI
upset, anorexia, headache, diaphoresis and palpitations.
-
Alcohol withdrawal seizures (onset
6-48 hours after last drink) are usually generalized, tonic-clonic seizures. Don’t forget basic
principles such as accuchecks to ensure it is not a hypoglycemic seizures and
reporting to the Ministry of Transportation for seizures. First line treatment
of alcohol withdrawal seizures is benzodiazepines
-
Alcoholic hallucinosis (onset 12-48
hours after last drink) usually involves visual, auditory or tactile hallucinations.
Importantly, orientation and vital signs are normal and that is what
distinguishes alcoholic hallucinosis from delirium tremens.
-
Delirium tremens (onset 24-96 hours
after last drink) is
a serious manifestation of alcohol withdrawal characterized by delirium,
agitation, tachycardia, hypertension, fever and diaphoresis. It is a medical
emergency.
Principles
of the management of alcohol withdrawal include:
1. Rule out other causes of symptoms.
Depending on the clinical presentation, for example confusion or change in
level of consciousness, don’t forget to investigate for other causes of the
presentation such as infection, co-ingestions, metabolic derangement, liver
failure, GI bleeds, pancreatitis, and injuries (such as subdural hematoma) to
name a few.
2. Supportive care.
a. Initial resuscitation including
ABCs. Treat volume depletion.
b. Treat any identified triggers or other
causes of symptoms. There can be something else going on, such as pancreatitis
or an infection, that led to reduced alcohol intake and then alcohol withdrawal.
c. GIVE THIAMINE (before giving
glucose) and a multivitamin
d. Nutritional support (may need to be
NPO depending on level of consciousness to prevent aspiration) à consider other methods of
nutritional support, get SLP and dietitian involved, and don’t forget to
monitor for refeeding syndrome.
e. Monitor severity of alcohol withdrawal
with CIWA-Ar and clinical assessments.
i.
Items
on the CIWA-Ar (Clinical Institute Withdrawal Assessment Scale for Alcohol,
revised) include: nausea and vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile auditory and visual disturbances, headache, and orientation.
f.
Treat
alcohol withdrawal with benzodiazepines.
i.
Often diazepam or lorazepam are the benzodiazepines of choice and they are used in a symptom-triggered approach (administration and dose triggered by CIWA-Ar score)
ii.
Diazepam has a longer half-life so is usually
the first choice to avoid recurrent withdrawal or seizures.
iii.
However,
with cirrhosis or acute hepatitis, a benzodiazepine with a shorter halt-life
such as lorazepam, may be preferred to avoid over-sedation.
iv.
Take
a look and become familiar with the CIWA-Ar protocols at your institution.
v.
For
refractory delirium tremens, barbiturates such as phenobarbital and/or propofol
may be necessary.
References:
1. Up-to-date “Management of moderate
and severe alcohol withdrawal syndromes”. Hoffman et al. Last updated Jan 17,
2017.
2. Schuckit M. Recognition and
Management of Withdrawal Delirium. NEJM. 2014;371:2109-13.
