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Alcohol Withdrawal and Delirium Tremens: Diagnosis and Management

Alcohol withdrawal is everywhere. We see over half a million patients in U.S. EDs for alcohol withdrawal every year. Despite these huge volumes of patients and the diagnosis of alcohol withdrawal seeming relatively straightforward, it’s actually missed more often than we’d like to admit, being confused with things like drug intoxication or sepsis. Or it’s not even on our radar when an older patient presents with delirium.

The differential diagno­sis is enormous – and no blood test on the planet will help us diagnose alcohol withdrawal. In fact, the diagnosis is entirely a clinical one. What’s even more surprising is that even if we do nail the diagnosis, observational studies show…

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 Managing alcohol emergencies

There are four stages of alcohol withdrawal. Stages 1, 2 and 3 are early alcohol withdrawal and symptoms will be present within 24 to 72 hours of decrease or cessation of alcohol consumption. Stage 4, which is delirium tremens, is a late syndrome that does not manifest until three-to-five days after cessation. “That timing differentiation is very important for clinicians to determine what’s wrong with a patient,” Birnbaumer said.

 Managing alcohol withdrawal

Before considering treatment look for the withdrawal tremor – if it isn’t present they are likely intoxicated.

Articles of Interest

#SimBlog: Alcohol Withdrawal

Locally we use the Glasgow Modified Alcohol Withdrawal Scale (GMAWS), which allows us to monitor the patient’s symptoms. The scale advises a dose of diazepam based on which symptoms are present, and their severity. If a patient does have a withdrawal seizure (which is not self-terminating) it is treated with benzodiazepines.

Alcohol prescribing for severe withdrawal – what the research shows

In rare and severe cases of alcohol withdrawal, one NHS trust is prescribing alcohol to treat patients. A specialised team at Sandwell and West Birmingham Hospitals NHS Trust prescribes carefully controlled doses of alcohol in a medical setting to a select group of patients. The goal? To prevent life-threatening complications. This unconventional approach has sparked discussions surrounding its safety and effectiveness. But a review by my colleagues and I found that alcohol prescribing was as effective as standard treatments in most cases.

Alcohol Withdrawal By Dr. Sandhya Ashokkumar

ETOH withdrawal begins 6-8 hours after last intake and peaks in 72 hours Symptom based treatment via the CIWA score can help stratify patients, scores >15 indicate severe withdrawal. Start with IV diazepam at 10mg or lorazepam at 4mg and repeat them in doubling doses.

Alcohol Withdrawal: Blame it on the...

If a patient has an elevated serum ethanol level, never assume the pt cant be in alcohol withdrawal. Those who heavily drink and those who drink nearly every day can start withdrawing at non-zero ethanol levels.

Alcohol Withdrawal: One order to sedate them all

Patients without other ICU issues can be loaded incrementally with phenobarbital over a couple days and then discharged to the ward. There is no need to keep patients in the ICU for week-long benzodiazepine infusions.

Alcohol Withdrawal: Pearls and Pitfalls

While benzodiazepines are the optimal treatment for AWS, there is debate regarding which benzodiazepine is best. No single benzodiazepine has been shown to be superior.

Benzodiazepine-Refractory Alcohol Withdrawal

Phenobarbital, propofol, and dexmedetomidine have been shown to reduce benzodiazepine requirements in AWS.

Dexmedetomidine as Adjunctive Therapy for the Treatment of Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis

Alcohol withdrawal syndrome (AWS) is defined as the cessation or reduction in heavy and prolonged alcohol use within several hours to a few days of cessation. The recommended first-line therapy for AWS ranging from mild to severe or complicated remains benzodiazepines; in cases where benzodiazepines are not adequate in controlling persistent autonomic hyperactivity or anxiety, dexmedetomidine could be utilized. The possible advantage of dexmedetomidine compared to benzodiazepines is that it does not cause respiratory depression, thus reducing the risk of intubation and hospitalization in the ICUs, with the potential reduction in healthcare costs. Dexmedetomidine, as adjunctive therapy, is not more effective than standard sedative therapy in reducing the risk of tracheal intubation in AWS patients. It also appears to be less safe than sedative therapy as it significantly increases the risk of bradycardia.

Distilling it Down Part I: Alcohol Withdrawal in the ED

The DSM5 criteria are currently the gold standard for withdrawal. The CIWA-Ar score should not be used for diagnosis – the syndrome it describes is non-specific. Inappropriate application of the CIWA-Ar score to a patient not in withdrawal may lead to adverse events including over sedation and misdiagnosis.

Managing Alcohol Withdrawal In The ED

Benzodiazepines are used to treat the symptoms of alcohol withdrawal. Diazepam is often preferred since it is long-acting. Chlordiazepoxide is also a popular agent given it is long-acting and is thought to be less addictive. However, lorazepam may be preferable in those who metabolize the drug more slowly including the elderly and those with advanced liver disease. Lorazepam has a shorter half-life and therefore, its active metabolites are less likely to reach toxic levels

Treatment of severe alcohol withdrawal

The goal of treatment is to reduce the severity of symptoms and prevent progression to delirium tremens. It is widely accepted that the best way to treat alcohol withdrawal in hospitalized patients is with symptom triggered benzodiazepine therapy. Such treatment results in equivalent outcomes and less benzodiazepine use compared with scheduled benzodiazepine therapy.

“Don’t Set the Precedent”: Precedex for Alcohol Withdrawal

Precedex is a cool drug. It’s a continuous IV medication that causes anesthetic and sedative effects through agonizing alpha-2 adrenergic receptors in the brainstem, inhibiting norepinephrine release. The bummer is that it can cause bradycardia through its effects on presynaptic alpha-2-adrenergic receptors and hypotension through peripheral vasodilation. The nice thing about Precedex is that it can reduce autonomic symptoms while still allowing the patient to be arousable and cooperative without causing respiratory depression. But a very important thing to remember here is that Precedex should never be used alone in alcohol withdrawal. It’s mechanism of action doesn’t affect GABA or NMDA receptors at all- so it doesn’t treat the underlying pathophysiology of the disorder.

Resources

4-Step Approach to Treating Alcohol Withdrawal

Even though more than half a million patients are seen in U.S. emergency departments for alcohol withdrawal each year, this seemingly straightforward diagnosis is missed more often than we may believe.1 Even when it is picked up, it is often mismanaged. Why?

EMcrit Project

There are numerous (perhaps innumerable) reasonable ways to treat alcohol withdrawal. Prior to the ~1970s, barbiturates were front-line agents. Following a push by pharma to market newly developed benzodiazepines, this shifted to benzodiazepines. This transition wasn't based upon any evidence that benzodiazepines deserved to be front-line agents, but rather perhaps the perception that benzodiazepines were newer and therefore must be better. Currently, the pendulum is swinging back to barbiturates. Those lacking a historical perspective will view benzodiazepines as conventional front-line therapy, but in the larger context of medical history the use of benzodiazepines for alcohol withdrawal may wind up having been a mistake.

Life in the Fastlane

common and can be fatal. manifests within 48 hours of stopping drinking.

CIWA-Ar for Alcohol Withdrawal

The CIWA-Ar objectifies severity of alcohol withdrawal.