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Updated: Oct 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      • when alcohol is abruptly withdrawn, there is overexcitation of glutamate receptors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 hallucinationsnormal vital signs
        • intact orientation
        • normal vital signs
      • 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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