NEUROLOGY
ALCOHOL WITHDRAWAL
Pathophysiology
• Alcohol is a CNS depressant
• Chronic use → insensitivity to inhibitory neurotransmitter g-aminobutyric acid (GABA)
• Abrupt alcohol cessation → CNS overactivity
Clinical manifestations
• Minor withdrawal sx (6–48 h after last drink): mild anxiety, tremulousness, HA
• Withdrawal seizures: typically w/in 48 h after last drink; if unRx’d, 1⁄3 → delirium tremens
• Alcoholic hallucinosis: isolated hallucinations (typically visual) 12–48 h after last drink
• Delirium tremens (DT): disorientation, agitation, hallucinations, ↑ HR & BP, fever, diaphoresis; begins 48–96 h after last drink, lasts 5–7 d
• Consider other dx: CNS infxn or bleed, sz, drug O/D, coingestions, acute liver failure, GIB
Clinical Institute Withdrawal Assessment scale for alcohol (CIWA-Ar)
• Assign points for each of the 10 criteria; each criteria is scored 0–7 except orientation which is scored 0–4; add points to calculate score
Treatment (NEJM 2003;348:1786)
• Benzodiazepines (BDZ)
Drug: diazepam (long-acting w/ active metab; ↓ risk of recurrent withdrawal), lorazepam (short half-life), chlordiazepoxide, oxazepam (no active metab; good if cirrhosis)
Route: start IV, transition to PO
Dosing: typically start w/ diazepam 10–15 mg IV q10–15min (or lorazepam 2–4 mg IV q15–20min) until appropriate sedation achieved, then titrate to CIWA-Ar scale, evaluating q1h until score <8 × 8 h, then q2h × 8 h, and if stable, then q4h (JAMA 1994;272:519)
• If refractory to BDZ prn, consider BDZ gtt, phenobarbital or propofol (& intubation)
• Avoid haloperidol (↓ seizure threshold) or βB/central ɑ2-agonists (mask sx)
• Mechanical restraints as needed until chemical sedation achieved
• Volume resuscitation as needed; thiamine then glc to prevent Wernicke’s encephalopathy (ataxia, ophthalmoplegia, short-term memory loss); replete K, Mg, PO4
• Prophylaxis: if min sx or asx (ie, CIWA score <8) but prolonged heavy EtOH con- sumption or h/o withdrawal seizures or DTs → chlordiazepoxide 25–100 mg (based on severity of EtOH use) q6h × 24 h, then 25–50 mg q6h × 2 d