ALCOHOL WITHDRAWL

Approach to scenario
Clinical Manifestations
1. Ensure pt stable / ABC’s
Historical features
 Withdrawl 2. History / Physical
o Abnormal sleep/insomnia, nausea/vomiting, anorexia - Seizure, DTs, hallucin
o Seizure (<48h from last drink withdrawl seizure; >48h DTs) - EtOH use, trauma
o Hallucinations - Visual-auditory (2-3d from last drink); Visual-tactile (DTs) - ABCs, CN, cerebellum
o Confusion (DTs, Wernicke’s), Delusions (DTs) 3. Investigations
 Ask about – Alcohol use history (past admissions, seizures, DTs), Last Drink - BW, CT head
o Trauma (SDH risk), PMHx, Meds, Smoking, Drug use (Co-ingestion), allergies 4. Management
Physical Examination - ABCs, Diazepam,
 ABC’s, vital signs, monitoring (IV, O2, BP, telemetry) - Thiamine
o Autonomic hyperreactivity – HTN, Tachycardia (assess rhythm), Fever
o Glucometer
 General
o Poor concentration, memory, judgment Classification
Problem drinking/Alcohol abusers:
o Confusion, Delirium, Agitation, Irritability, Restlessness, Tremor  > 12 drinks/week; drink moderately (<4
o Stigmata of chronic liver disease drinks/day); no withdrawal symptoms
 HEENT  Socially stable: no consequences
o CN – CN6 palsy, horizontal/vertical gaze nystagmus (Wernickes) Alcohol Dependence
 Neuro (Sensory, motor, reflexes, rectal)  > 40-60 drinks/week; no moderate
o Sensory – glove stocking (EtOH polyneuropathy) drinking; withdrawal symptoms
 Socially unstable: physical and social
o Motor – distal LE weakness consequences; neglects responsibilities
o Cerebellar – ataxia, incoordination (LE only – EtOH) Health risks associated with > 2 oz/d
o Reflexes – loss of ankle > knee jerks  GI: bleed, cancer, gastritis, pancreatitis,
 General Cardiovascular, Respiratory, Abdominal PUD, hepatitis, cirrhosis, peritonitis
 Cardiac: EtOH CMO, arrhythmia, HTN
Investigations  Neuro: Wernicke-Korsakoff, stroke,
 Bloodwork cerebellar degen, peripheral neuropathy
o CBC, Lytes (check AG for ketoacids), Cr, CK, LFTs, amylase, Ca, PO4, Mg  Hematologic: anaemia, coagulopathy
 ECG  GU: impotence, anovulation, abortion
o dysrhythmia Delerium Tremens (1-3 days)
 Severe Confusion
 CT Head  Visual-tactile hallucinations
o If suspicious re: subdural  Autonomic hyperreactivity
 Fluctuating agitation
Treatment
Wernicke
ABC’s: Oxygen, IV access, Monitors
 Ataxia, confusion, CN6 palsy/nystagmus
Management of Alcohol Emergencies
Korsakoff
 Mild withdrawl (6-8 h since last drink)  Marked STM loss, anterograde amnesia
o Diazepam 5-20mg PO q1-2h until no symptoms; observe for 1-2h post last dose  Confabulation, difficulty learning
o Multivitamin, Thiamine 100mg IM then 100 mg PO for 3 days, folate 5mg OD,
MgSO4
o Admit if: withdrawal after > 80mg diazepam, DT, arrhythmia, seizure, medically ill
 Withdrawal Seizures (“Rum Fits”)
o Diazepam 10mg PO q1h until calm
o If asthma, liver disease, or respiratory failure - Lorazepam SL/PO 1-2mg tid-qid or oxazepam PO 15-30mg tid-qid
 Hallucinations
o Haldol 2-5mg IM/PO q1-4h (max 5mg/day), Diazepam 20mg x 3 (seizure prophylaxis)
 Delerium Tremens
o Diazepam 10mg PO q1h until drowsy then ativan 1mg PO q1h prn + haldol
o Clonidine, atenolol for autonomic hyperactivity
o Supportive (hydration/nutrition): maintain fluid and electrolyte balance
Management of Stable Alcohol Use
 When Stable Assess Alcohol Use
o Screening: CAGE (Cut down, annoyed, guilt, eye opener) > AUDIT, MAST
 0 - Rules out (LR 0.14); 1 - equivocal (LR 1.5)
 >2 - Positive (2 - LR 4.5, 3 - LR 13.2, 4 - LR 101)
o Setting: time, place, occasion, drinking partners
o Consumption: quantity, frequency, weekly amount, maximum consumption on one occasion
o Pressures to drink: internal and external
o Impact on: family, work, social
 Conservative
o Compare consumption to Canadian norms; educate re: health effects of alcohol
o Avoid intoxication: alternate EtOH with non-EtOH, drink on a full stomach
o Supportive: Psychotherapy, behaviour modification, Alcoholics Anonymous, Detox Centres
 Pharmacologic
o Disulfuram (Antabuse) 125-250 mg/day: blocks OH acetaldehyde accumulates; ↑ HR, vomiting
o Naltrexone: opioid antagonist dulls the alcohol high
Alcohol Page 1 of 2
 o SSRI, buspirone, Lithium, trazodone, bromocriptine

Alcohol Page 2 of 2