Updated: 10/17/2021

Alcohol Withdrawal

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Snapshot
  • A 38-year-old man is brought to the emergency department after being in a motor vehicle accident. The patient fractured his femur and required surgery. On postoperative day 2, the patient reports trouble falling asleep, palpitations, and feeling anxious. Medical history is significant for hypertension and alcohol use disorder. His blood pressure is 165/98 mmHg, pulse is 105/min, and respirations are 20/min. Physical exam is significant for tremulousness and diaphoresis. He is started on lorazepam.
Introduction
  • Definition
    • progression of signs and symptoms that occur after withdrawal from heavy and prolonged use of alcohol
  • Epidemiology
    • incidence
      • typically seen in hospitalized patients who have alcohol dependence
  • Pathogenesis
    • prolonged use of alcohol downregulates GABA receptors and upregulates glutamate receptors in order to maintain arousal
    • when alcohol is abruptly withdrawn, there is overexcitation of glutamate receptors
  • Associated conditions
    • Wernicke encephalopathy
      • triad
        • ophthalmoplegia
        • encephalopathy
        • ataxia
      • thiamine and magnesium depletion results in necrosis of the mammillary bodies, thalamus, and hippocampus
    • Korsakoff syndrome
      • memory impairment and confabulations
      • precipitated if giving dextrose prior to giving thiamine
  • Prognosis
    • alcohol withdrawal seizures and delirium tremens are life-threatening
Presentation
  • Symptoms/physical exam 
    • minor withdrawal
      • anxiety
      • agitation
      • restlessness
      • diaphoresis
      • palpitations
      • insomnia
    • moderate-to-severe withdrawal
      • hallucinations
      • seizures
      • delirium tremens
Studies
  • Labs
    • thiamine and magnesium deficiency
    • AST > ALT (2:1)
    • serum γ-glutamyltransferase (GGT)
      • a sensitive indicator of alcohol use
Withdrawal
 
Alcohol Withdrawal
Time (Hours)
Syndrome
Clinical Findings
6-36
  • Minor withdrawal
  • Anxiety
  • Tremulousness
  • Diaphoresis
  • Palpitations
6-48
  • Seizures
  • Tonic-clonic seizures
    • short post-ictal period
12-48
  • Alcoholic hallucinosis
  • Visual, auditory, and/or tactile hallucinations
    • intact orientation
    • normal vital signs
48-96
  • Delirium tremens
  • Delirium
  • Agitation
  • Tachycardia
  • Hypertension
  • Fever
  • Diaphoresis
 
Treatment
  • Medical
    • thiamine
      • indication
        • to prevent Wernicke encephalopathy
    • benzodiazepines
      • indications
        • the treatment of choice for alcohol withdrawal
      • comments
        • lorazepam and oxazepam are preferred in patients with liver disease
Complications
  • Cardiac arrhythmia
  • Delirium tremens
  • Tonic-clonic seizures

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Questions (4)
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(M1.PY.17.4725) A 59-year-old man presents to the emergency room with shortness of breath and swelling of his feet and legs. He denies any past medical problems, surgeries, medications, or illicit drug use. He reports drinking a few beers each night. He is diagnosed with a first episode of congestive heart failure and is admitted to the hospital. The next day, the nurse notices that his hands are shaky when he extends his arms. The patient says that he couldn’t sleep the night before and that he feels restless, anxious, and slightly nauseated. On the second night of admission the patient becomes agitated. He is disoriented, cannot remember where he is, and appears globally confused. His pulse is 125/min, blood pressure is 170/110 mmHg, and temperature is 101.7°F (38.7°C). He is diaphoretic and his hands are shaking at rest. He cries out in fear reporting voices whispering in his room and strange shadows passing over the walls. What medication should be administered to this patient?

QID: 108571
1

Flumazenil

7%

(15/226)

2

Naloxone

10%

(22/226)

3

Benzodiazepines

72%

(163/226)

4

Dantrolene

2%

(5/226)

5

Fomepizole

6%

(14/226)

M 3 C

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Evidence (2)
EXPERT COMMENTS (4)
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