Alcohol withdrawal
Genetic predisposition
Withdrawal usually does not occur in the general population because most people drink in an episodic fashion that does not lead to the sustained high blood concentrations of alcohol necessary to develop tolerance and withdrawal.
Symptoms of alcohol withdrawal occur because alcohol is a central nervous system depressant.
Alcohol simultaneously enhances inhibitory tone (via modulation of gamma-aminobutyric acid activity) and inhibits excitatory tone (via modulation of excitatory amino acid activity). Only the constant presence of ethanol preserves homeostasis. Abrupt cessation unmasks the adaptive responses to chronic ethanol use resulting in overactivity of the central nervous system.
Gamma-aminobutyric acid — Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the brain. Highly specific binding sites for ethanol are found on the GABA receptor complex. Chronic ethanol use induces an insensitivity to GABA such that more inhibitor is required to maintain a constant inhibitory tone. As alcohol tolerance develops, the individual retains arousal at concentrations which would normally produce lethargy or even coma.
Excitatory amino acids — Glutamate is one of the major excitatory amino acids. When glutamate binds to the N-methyl-D-aspartate (NMDA) receptor, calcium influx leads to neuronal excitation. Ethanol inhibits glutamate induced excitation. Adaption occurs by increasing sensitivity to glutamate in an attempt to maintain a normal state of arousal.
Minor withdrawal symptoms are due to central nervous system hyperactivity, and can include:
Insomnia
Tremulousness
Mild anxiety
Gastrointestinal upset; anorexia
Headache
Diaphoresis
Palpitations
Symptoms are usually present within six hours of the cessation of drinking and may develop while patients still have a significant blood alcohol concentration. If withdrawal does not progress, these findings resolve within 24 to 48 hours. The specific minor withdrawal symptoms in a given patient typically are consistent from one episode to the next.
Alcohol withdrawal can be a problem both medically and behaviorally.
DTs is the biggest danger, which has up to 15% mortality rate and requires close monitoring.
Watch for sx of DT: confusion, tachycardia, dilated pupils, and diaphoresis, usually 2 - 7 days after the last drink, although sx occur before then in most cases. DTs should be managed with benzodiazepines promptly. IV fluids and electrolyte repletion are also helpful. If Pt. is not easily controlled and shows deterioration in mental status; admit in ICU.
DTs: tremulousness, hallucinations, agitation, confusion, disorientation, and autonomic hyperactivity (fever, tachycardia, diaphoresis), typically after 72 - 96 hours after cessation of drinking. Sx generally resolve within 3 - 5 days. DT complicates 5% - 10% of cases of alcohol withdrawal, with mortality up to 15%.
Well lit room, reorientation, reassurance, and the presence of family and friends.
Seizure and Fall Precautions
Thiamine 100 mg IV/IM, followed by 100 mg PO daily.
Folic acid 1 mg PO daily
Multivitamin 1 Tab PO q Day
Librium (Chlordiazepoxide), 100 mg IV or PO q6h (max: 500 mg/day), till patient is calm.
Give 1/2 initial 24-h dose next day, then reduce dose by 25 - 50 mg/day each day thereafter.
Whiskey, 30-60 mL, q1 hr till calm and sedated.
For older patients and those with reduced drug clearance:
Ativan (lorzepam) 2-4 mg IVP q4 hours, or 2 mg PO q6h x 4 doses, then 1 mg q6h x 8 doses
or
Serax (oxazepam) 15 - 30 mg PO q6h - q8h in Pts with liver dz. Drug is excreted by kidneys.
IV fluids (Use D5-0.45NS if not Diabetic). Give thiamine first!
HTN: give Clonidine
Hallucinations, combativeness: Haldol (haloperidol 0.5 - 1 mg IV x 1)
Check electrolytes: hypomagnesemia, hypokalemia, hypoglycemia, and fluid losses which may be considerable due to fever, diaphoresis, and vomiting in alcoholic patients.
Minor withdrawal symptoms like tremulousness, irritability, anorexia, and nausea characterize minor alcohol withdrawal. Pts. threaten to leave AMA (to go out for a drink). These sx occurs within few hours of cessation or reduction of alcohol consumption. and resolve within 48 hours.
Benzo sparing protocol to treat alcohol withdrawal, that includes valproic acid 750 mg intravenously every 8 hours (for 7 days), in addition to clonidine patch 0.2 mg/h patch, the patient needs 2 patches to be started today, the first patch should stay on for the full 7 days, second patch should be taken off after 4 days. This protocol should continue regardless of the patient's disposition, (valproic acid can be switched to the same dose but given orally for the rest of the duration).
Olanzapine 5 mg p.o./IM every 6 hours as needed for severe psychomotor agitation, if the patient still agitated after olanzapine may use a second as needed chlorpromazine 200 mg p.o. or 100 mg IM every 2 hours for psychomotor agitation.
