ALCOHOL WITHDRAWAL by Nick Mark MD & Mark Ramzy DO ONE

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Ethanol is the most common drug of abuse in the world, by far the most Symptoms and clinical syndromes of EtOH W/D very by time after last drink
costly in lives lost and dollars spent. 5% of Americans are heavy drinkers
(≥8 drinks/wk for♀ or ≥15 drinks/wk for♂) and 50% of heavy drinkers
<6 - 12 Hours 12 - 24 Hours <24 - 48 Hours > 72 Hours
experience alcohol withdrawal. Despite the frequency, alcohol withdrawal MINOR WITHDRAWAL Symptoms: DELIRIUM TREMENS
(or AWS) is frequently misdiagnosed (and under-treated) in the ICU. · 6– 36 hours · 48-96 hrs (rarely up to 7 days)
Heavy drinking for as little as 15 days is sufficient to precipitate EtOH W/D. · tremulousness, anxiety, h/a, diaphoresis, palpitations, N/V, w/ normal mentation · Fluctuating cognition &
WITHDRAWAL SEIZURES attention, altered sensorium
PATHOPHYSIOLOGY:
· 6– 48 hours (hallucinations)
Consumption of large quantities of EtOH leads to constitutive GABAergic ALCOHOLIC HALLUCINOSIS · Autonomic instability (low
signaling and compensatory upregulation of NMDA and other excitatory · 1-3 usually generalized seizures
· 12– 48 hrs grade fever, tachycardia,
neurotransmitters. Removal of EtOH & its inhibitor effects leads to over- · Status epilepticus occurs in 3%
· High risk of progression to DTs · visual, auditory, & tactile hallucinations, hypertension, diaphoresis)
excitation of neurons. This causes a range of syndromes over hours to days. with intact orientation & normal sensorium,
Dose Onset Duration
SCORING ALCOHOL WITHDRAWAL SYNDROME (AWS): TREATMENT · with normal vital signs (mg)
Route
(min) (hrs)
Use of a structured tool for assessing severity of AWS can facilitate BZDs & Phenobarbital (PHB) are the commonly used treatments.
diagnosis, track severity, and directly trigger treatment. Several exist: Neither is superior. The goal is to treat symptoms & prevent life Midazolam 2–4 IM, IV 1–5 <2
PAWSS: CIWA-Ar AWS: threatening complications (seizures & autonomic instability.)
· Validated 10 item · Developed from CIWA-Ar to Diazepam 10 – 20 PO, PR,
1–3 <1
· Validated 10-item tool based on Remember scene safety: AWS/DTs can be dangerous to staff
questionnaire divided observations + participation cover entire spectrum of q5-10 min IM, IV
into 3 parts combines · Determines severity as sx are withdrawal BENZODIAZEPINES (BZDs)
interview, blood EtOH · Operationalized 6 objective
Lorazepam 2–4 5 – 10 6–8
level, Sx
actively being experienced · Common 1st Line therapy, ↑ frequency of GABA-receptor opening q15-30 min
PO, IM, IV
· Can’t differentiate b/w DTs & findings + 5 psych/behavioral
· Screening tool used to delirium from other causes symptoms · Symptom triggered therapy is preferable to scheduled (less sedation,
identify patients at risk · Requires participation, limited · Max score of 34 (17 for each shorter treatment duration; however patients with severe AWS 50 – 100
for severe withdrawal Chlordiazepoxide PO > 30 24 – 48
(Se = 93% & Sp = 99.5%)
by altered mental status of the two sections) may require frequent re-dosing. q60 min
· Variability in scoring can limit · Less reliant on patient’s
· Requires pt accuracy by several points responses · Lorazepam may accumulate less than diazepam in hepatic dysfunction.
Chlorodiazepoxide may be useful adjunct for patients at high risk for eloping
participation, limited · Scores 0 – 9 = Absent/minimal · · Score 0 – 5 = Absent to · THERE IS NO MAX DOSE ; Duration of Action & elimination variable
by AMS Scores 10 – 19 = Mild/moderate · minimal withdrawal
· Score 6 – 9 = Moderate BARBITUATES PHENOBARBITAL (PHB)
Scores ≥ 20 = Severe w/d (high risk
· Score ≥ 4 = HIGH RISK withdrawal · Dosing: 130 – 260 mg IV q 15-20 min until symptoms controlled
for impeding DTs) · ↑ duration of GABA-receptor channel opening; also decreases
for moderate to severe · Score ≥ 20 = Severe · Onset of action: 5 minutes, peaks at 15 – 30 minutes
glutamate signaling; can be used as a loading dose or boluses.
withdrawal · LIMITED BY EXCLUSION OF withdrawal · Infusion: 10-15 mg/kg IV
VITAL SIGNS · Used early as monotherapy; equivalence to benzos in some studies
· Duration: 10-12 hrs (elimination half life is days) longer in cirrhosis
· Also used in conjunction with benzos for refractory DTs
WORKUP · In patients w/o cirrhosis, consider a taper 1 mg/kg PO once
BZD APPROACH PHB APPROACH
SEVERE AWS MILD AWS

Labs: DDx to Consider Symptom driven PHB IV load

Consider PHB Monotherapy if
CBC, BMP, Mg, Phos, LFTs, EtOH level, TSH - Hypoglycemia · Definite AWS; history of DTs or at high risk for delirium
BZD boluses 10 mg/kg IBW (e.g. PAWSS >4), prior ICU admission for AWS
Consider toxic alcohol panel - Serotonin Syndrome Skip PHB load if
· No other neurological problems (hepatic encephalopathy)
HEAD CT: - Hyponatremia pt has already
Check PHB level · Not on meds that interact with phenobarb (HIV meds)
received high
Helps differentiate alternative causes - Thyrotoxicosis goal 10-15 mcg/mL · Has not received high doses of BZDs already
Scheduled BZDs + doses of BZDs
· No history of AIP or on chronic PHB already
EEG: - Head Injury / ICH
Symptom driven boluses
For new onset seizure & status epilepticus - Other intoxications
ADJUNCTS
Reload PHB
DEXMETOMIDINE infusion: Possible BZD adjunct
May see ↓ amplitude of theta/delta waves - Hepatic Encephalopathy 3 mg/kg IBW (up to 2x)
reduces BZD dose, may reduce need for intubation,
& may ↑ or ↓ hospital LOS. Monitor for bradycardia.
mg diazepam or >10 mg lorazepam in 1 hour)
(No consistent definition; often requiring >50

Escalating BZD boluses

RESISTANT/REFRACTORY AWS

NUTRITION & FLUIDS PHB Boluses CLONIDINE 0.1 – 0.2 mg PO: Used to reduce
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130 mg IV autonomic symptoms of withdrawal. Max 1.2 mg/day.

Thiamine: cofactor in glucose metabolism
· Consider 100 mg IV or IM prophylaxis (avoid giving PO)
PHB Boluses* HALOPERIDOL 2.5 – 5 mg IV/IM q 4 hrs: Used for
· Concern for Wernicke’s Encephalopathy: 500mg IV/IM q8h BZD infusion
· earlier initiation, faster the recovery 260 mg IV persistent agitation. Does not replace BZD or PHB. Use
Folate: Deficiency causes megaloblastic anemia with caution as can lower seizure threshold & impair
· Consider 1 mg q24 hours heat dissipation. Check ECG prior and monitor QTc.
Electrolytes: Hypokalemia common & requires repletion Consider Intubation +
Propofol infusion BACLOFEN & KETAMINE - theoretic benefits;
- Hypomagnesemia & Hypophosphatemia may also be seen
- Fluids: Typically high insensible losses; consider replacement limited literature to support their use. Avoid.
*If using higher bolus doses; monitor total dose & check PHB levels