Updated: 3/5/2021

Acute Alcohol Withdrawal

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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
Prognosis, Prevention, Complications
  • Delirium tremens is associated with a high mortality

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 Fluids
  • Begin benzodiazepine taper to avoid seizures
  • Benzodiazepine taper
  • Head CT
  • Suspect in patient with unknown history follwed by DT symptoms 2 days later
  • Benzodiazepine taper

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Questions (1)

(M2.PY.16.4682) A 45-year-old man has a history of smoking 1 pack per day and drinking a six-pack of beer daily over the last ten years. He is admitted to the medical floor after undergoing a cholecystectomy. One day after the surgery, the patient states that he feels anxious and that his hands are shaking. While being checked for a clean surgical site, the patient starts shaking vigorously and loses consciousness. The patient groans and falls to the floor. His arms and legs begin to jerk rapidly and rhythmically. This episode lasts for almost five minutes, and the patient's airway, breathing, and circulation are stabilized per seizure protocol. What is the best next step for this patient?

QID: 107303
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Urinalysis

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Lorazepam

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Morphine

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Antibiotics

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Chest radiograph

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