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Updated: Dec 29 2021

Acute Alcohol Withdrawal

  • Snapshot
    • A 46-year-old male underwent an emergency operation for a lung laceration from an altercation. Twenty-four hours later, he developed anxiety, tremors, and insomnia. The patient is started on a benzodiazepine taper, thiamine, multivitamin, IV fluids, and dextrose.
  • Introduction
    • Occurs when a chronic alcohol drinker is suddenly restricted from drinking
      • can be initiated by an acute hospital stay
      • assessed with Clinical Institute Withdrawal Assessment for Alcohol (CIWA)
  • Presentation
    • Symptoms
      • early (12-24 hours)
        • autonomic hyperactivity symptoms
          • tremor, tachycardia, hypertension, anxiety, and insomnia
      • mid (24-48 hours)
        • seizures
      • late (48-72 hours)
        • delirium tremens
          • psychotic symptoms and confusion
  • Treatment
    • Pharmacologic
      • thiamine (administer prior to glucose to prevent worsening of or precipitation of Wernicke encephalopathy)
      • glucose
      • folate
      • sedative-hypnotics with taper
        • e.g., clonidine or propranolol
      • lorazepam
        • if seizures present
      • phenobarbital
        • long half life
        • highly effective
        • interacts with medications that induce or inhibit CYP system
      • haloperidol
        • if psychosis present
  • Complications
    • Minor Withdrawal
    • Alcoholic Hallucinosis
    • Withdrawal Seizure
    • Delirium Tremens
    • Time Since Last Drink
    • 6 hours
    • 12 - 24 hours
    • 48 hours
    • 48 - 96 hours
    • Symptoms
    • Trembling
    • Irritability
    • Anxiety
    • Headache
    • Tachycardia
    • Insomnia
    • Visual, auditory, and in some cases tactile hallucinations
    • Tonic-clonic seizures
    •  Autonomic instability
    • Disorientation
    • Hallucinations
    • Agitation
    • Management
    • Thiamine
    • Folate
    • Multivitamin
    • Dextrose
    • IV Flulids
    • Begin benzodiazepine taper to avoid seizures
    •  Benzodiazepine taper
    • Head CT
    •  Suspect in patient with unknown history followed by DT symptoms 2 days later
    • Benzodiazepine taper
  • prognosis
    • Delirium tremens is associated with a high mortality
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