Alcohol withdrawal

Today we discussed alcohol withdrawal syndromes. Some important points:

This is a common problem, accounting for ~25% of ER visits by homeless patients. It is likely under-recognized in patients not presenting specifically for this problem. In Ontario, ~20% of the population has intake of over 14 drinks / week.

Clinical manifestations depend on timing since last drink.

Early (6-36h):
"Minor": anxiety, headache, tremor, diaphoresis, tachycardia, nausea/vomiting.
Seizures: May occur very early (i.e. with EtOH level still high)
Characteristics of withdrawal sz:
1) Generalized, tonic clonic (not focal; focal sz or Todd's paresis suggests alternative cause, which EtOH abusers are also at risk for)
2) May be multiple
3) Short (minutes)
4) Self-resolving, with minimal post-ictal phase

12-24h:
Hallucinosis
-most commonly visual or tactile. Not associated with decreased LOC.

48-96h:
Delirium tremens
All of above possible, with superimposed autonimic instability (fever, severe HTN, tachycardia). Mortality of DT is ~5%. Major causes for mortality are arrhythmias, ACS, pneumonia.

Treatment principles:
1) Benzodiazepines
2) Vitamin / nutrient supplementation (thiamine, B6)
3) Supportive care

Some points about treatment:
-Medications studied include benzos (long-acting, e.g. diazepam), barbiturates, and propofol. Outside the rare ICU setting, mainstay is long acting benzos.
-Common error is to underdose; it is difficult to cause benzodiazepine toxicity in the typical patient who has EtOH withdrawal
-No role for antipsychotics; they may be harmful by lowering the seizure threshold
-Options for benzo dosing are 1) clinically-driven (e.g. CIWA) or 2) standing/tapering regardless of symptoms

There is RCT evidence (see below) supporting a symptom/sign-driven approach over infusion and taper regardless of clinical status; there was less total benzodiazepine needed, less overall withdrawal severity, and shorter ICU stays in this group.

Links:
Click here for the Spies et al RCT of symptom-driven treatment protocol
Click here for a NEJM RCT supporing IV ativan vs. placebo for recurrent EtOH withdrawal seizure prevention