Alcohol Withdrawal

Aka: Alcohol Withdrawal, Alcohol Withdrawal Syndrome, Alcohol Detoxification, Delirium Tremens

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II. Epidemiology

  1. Onset: 6-24 hours after last Alcohol intake
  2. Duration: 5-7 days after abstinence
  3. Peak symptoms: 1-3 days after abstinence

III. Risk Factors: Severe withdrawal (Delirium Tremens)

  1. Age >30-40 years
  2. Heavy drinking >8 years
  3. Alcohol intake >100 grams, >1 pint liquor, >96 oz beer
  4. Patient experiences withdrawal symptoms when abstinent
  5. Hepatic Cirrhosis
  6. Lab abnormalities
    1. Mean Corpuscular Volume (MCV) increased
    2. Blood Urea Nitrogen (BUN) increased
    3. Blood Alcohol level >0.20 g/dl on random draw
  7. Reference
    1. Ferguson (1996) J Gen Intern Med 11:410-4 [PubMed]

IV. Symptoms

  1. Stage 1 - Initial Withdrawal Symptoms (6-12 hours after last Alcohol)
    1. Anxiety or Panic Attacks
    2. Paresthesias, Shakes or Jitters
    3. Chills, Sweats, or Fevers
    4. Chest Pain or Palpitations
    5. Insomnia
    6. Headache
    7. Nausea or Vomiting
    8. Abdominal Pain
    9. Still coherent
  2. Alcohol Hallucinations or Alcoholic hallucinosis (12-24 hours after last Alcohol)
    1. Affects 8% of Alcohol Withdrawal patients
    2. Paranoid Delusions or Illusions
    3. Tactile Hallucinations (common)
    4. Auditory and Visual Hallucinations (less common)
    5. Sensorium otherwise maintained
  3. Stage 2 - Withdrawal Seizures and autonomic hyperactivity (24-72 hours post-Alcohol)
    1. Marked Agitation, restlessness and diaphoresis
    2. Tremulous with constant eye movements
    3. Nausea, Vomiting, Anorexia, and Diarrhea
    4. Sinus Tachycardia >120 bpm
    5. Systolic Hypertension with SBP >160 mmHg
    6. Confusion may be present
    7. Withdrawal Seizures (24-48 hours post-Alcohol)
      1. Generalized tonic-clonic Seizures
      2. Brief Seizures (<5 minutes) and may recur
      3. Isolated and self limited (Status Epilepticus is not due to withdrawal)
  4. Stage 3 - Delirium Tremens (72-96 hours)
    1. Of those with withdrawal Seizures, 33% progress to DTs
    2. Fluctuating disturance of attention, awareness, orientation, memory, language and visuospatial ability
    3. Visual Hallucinations
    4. Disorientation and Delirium
    5. Autonomic instability
      1. Severe Tachycardia and Hypertension
      2. Severe Agitation and tremulousness
      3. Hyperthermia (Fever, severe diaphoresis)
  5. Resolution
    1. Resolves at 5-7 days

V. Signs

  1. Blood Pressure, pulse and Temperature elevated
  2. Hyperarousal, Agitation, or Restlessness
  3. Cutaneous Flushing or Diaphoresis
  4. Dilated pupils
  5. Ataxia
  6. Altered Level of Consciousness or Disorientation
  7. Delirium Tremens

VI. Labs

  1. Complete Blood Count
  2. Comprehensive metabolic panel
  3. Serum Magnesium
  4. ProTime (INR)
  5. Venous Blood Gas (VBG)
  6. Serum Osmolality
    1. Consider in suspected toxic Alcohol ingestion (Methanol, Polyethylene glycol)
  7. Drug screen
    1. Salicylate Level
    2. Acetaminophen Level
    3. Blood Alcohol Level
    4. Urine Drug Screen

VII. Diagnostics

  1. Electrocardiogram (EKG)
    1. Evaluate for QT Prolongation, QRS Widening (as in Unknown Ingestion)
    2. Evaluate for Acute Coronary Syndrome
  2. Consider other testing if suspicious of underlying infection
    1. Chest XRay
    2. Lumbar Puncture
    3. Urinalysis

VIII. Diagnosis: DSM-5 Criteria Alcohol Withdrawal

  1. Heavy Alcohol usage for a prolonged period followed by Alcohol cessation or reduction
  2. Two or more of the following, developing several hours to a few days after Alcohol cessation or reduction
    1. Autonomic hyperactivity
    2. Increased hand Tremor
    3. Insomnia
    4. Nausea or Vomiting
    5. Transient auditory, visual or Tactile Hallucinations or Illusions
    6. Psychomotor Agitation or anxiety
    7. Generalized Tonic Clonic Seizures

IX. Differential Diagnosis

  1. See Altered Level of Consciousness
  2. See Sympathomimetic Toxicity
  3. See Unknown Ingestion or Overdose
  4. Wernicke's Encephalopathy
  5. Agitated Delirium
  6. Acute Psychosis
  7. Serotonin Syndrome
  8. Thyrotoxicosis
  9. Infection or Sepsis
  10. Electrolyte abnormalities (e.g. Hyponatremia, Hypokalemia)
  11. Thyrotoxicosis
  12. Acute blood loss (e.g. Trauma, Gastrointestinal Bleeding)
  13. Closed Head Injury
  14. Intracranial Hemorrhage (e.g. Subdural Hematoma, Subarachnoid Hemorrhage)
  15. Meningitis or Encephalitis

X. Complications: Delirium Tremens

  1. Head Trauma
  2. Myocardial Infarction
  3. Aspiration Pneumonia and other infections
  4. Electrolyte disturbance (e.g. Hypomagnesemia)
  5. Death

XI. Management: General Measures

  1. Seizure precautions
  2. Supplementation
    1. Vitamin Deficiency is common (Vitamins A, C, B1, B3, B6, B9, B12)
      1. See Alcohol Dependence
    2. Thiamine (Vitamin B1) 100 mg orally daily
    3. Folate (Vitamin B9) 1 mg orally daily
    4. Multivitamin daily
    5. Treat Hypomagnesemia if present
  3. Intravenous Fluids (Normal Saline or banana bag)
    1. Frequently administered to intoxicated patients admitted to the Emergency Department
    2. IV Fluids do not shorten the length of ED stay for intoxicated patients (typical ED stay averages 4.5 hours)
      1. Perez (2013) Emerg Med Australas 25(6): 527-34 [PubMed]
  4. Disposition
    1. See Clinical Sobriety

XII. Management: Agents used in Alcohol Withdrawal

  1. Also see Alcohol Detoxification in Ambulatory Setting
  2. Benzodiazepine choice
    1. See dosing potocols below
    2. Early aggressive Benzodiazepine loading offers best Alcohol Withdrawal control
    3. Valium and Librium offer lower risk of rebound
      1. Preferred in most cases for long half-life
      2. Librium has less stimulation of reward system (lower abuse potential)
    4. Seizure history: Valium
    5. Liver disease or elderly patient: Ativan or Serax
  3. Benzodiazepine Alternatives (in patients in whom Benzodiazepines are considered too risky, commonly used in Europe)
    1. Precautions
      1. Carbamazepine, Gabapentin and Valproic Acid have not been shown to prevent Alcohol Withdrawal Seizure
      2. Carbamazepine, Gabapentin and Valproic Acid increase GABA (via Sodium channel blockade)
      3. Adverse risks include Thrombocytopenia and other Bone Marrow suppression, Pancreatitis
    2. Carbamazepine
      1. Effective in moderate withdrawal
      2. Dosing: 200 mg four times daily tapered over 5 days
        1. Start at Carbamazepine (Tegretol) 800 mg on day 1
        2. Finish at 200 mg once on day 5
      3. References
        1. Malcolm (2002) J Gen Intern Med 17:349-55 [PubMed]
    3. Gabapentin
      1. Potentiates CNS GABA activity and decreases glutamate activity
        1. Decreases Alcohol craving and depression
      2. Dosing (minimum effective daily dose 900 mg/day)
        1. Start 600 mg three times daily for 3 days
        2. Then 300 mg three times daily for 3 days
      3. References
        1. Stock (2013) Ann Pharmacother 47: 961-9 [PubMed]
        2. Myrick (2009) Alcohol Clin Exp Res 33(9): 1582-8 +PMID:19485969 [PubMed]
    4. Valproic Acid
      1. Has also been used in Alcohol Withdrawal
  4. Adjunctive agents that require airway and ventilation management (see severe Alcohol Withdrawal protocol below)
    1. Phenobarbital
    2. Propofol infusion
    3. Dexmedetomidine (Precedex)
  5. Other symptomatic agents
    1. Beta Blockers (Propranolol or Atenolol)
      1. Avoid in general as these mask withdrawal signs
      2. Symptomatic relief of chills, shakes
      3. Improves Vital Signs
      4. Use selective Beta Blocker in Coronary Artery Disease
    2. Haloperidol
      1. Decreases Agitation and Hallucinations
      2. May lower Seizure threshold (but typically does not cause recurrent Seizures)

XIII. Management: Symptom-Triggered Regimen (preferred)

  1. Preferred over protocol below
  2. Clinical Institute Withdrawal Assessment (CIWA-Ar)
    1. http://addiction-medicine.org/files/15doc.html
    2. Assess hourly to determine medication need
  3. Give one of following hourly until CIWA-Ar <8-10 points
    1. Librium 50 to 100 mg
    2. Valium 10 to 20 mg
    3. Ativan 2 to 4 mg

XIV. Management: Mild Alcohol Withdrawal Protocol (CIWA-Ar 15 or less)

  1. General Protocol
    1. Diazepam (Valium) 5-10 mg orally every 6-8 hours prn for 1-3 days or
    2. Lorazepam (Ativan) 1-2 mg orally every 4-6 hours prn for 1-3 days or
    3. Chlordiazepoxide (Librium) 25-50 mg orally every 6-8 hours for 1-3 days
  2. Defining Criteria and Additional Medication Indications
    1. Systolic Blood Pressure > 150 mmHg
    2. Diastolic Blood Pressure > 90 mmHg
    3. Heart Rate > 100
    4. Temperature > 37.7 C (100 F)
    5. Tremulousness, Insomnia, or Agitation

XV. Management: Moderate Alcohol Withdrawal Protocol (CIWA-Ar 16-20)

  1. General Protocol
    1. Diazepam (Valium)
      1. Day 1: 15 to 20 mg PO qid
      2. Day 2: 10 to 20 mg PO qid
      3. Day 3: 5 to 15 mg PO qid
      4. Day 4: 10 mg PO qid
      5. Day 5: 5 mg PO qid
    2. Lorazepam (Ativan)
      1. Days 1-2: 2-4 mg PO qid
      2. Days 3-4: 1-2 mg PO qid
      3. Day 5: 1 mg PO bid
    3. Chlordiazepoxide (Librium) 25-50 mg PO qid
      1. Decrease by 20% per day
  2. Defining Criteria and Additional Medication Indications
    1. Systolic Blood Pressure: 150-200 mmHg
    2. Diastolic Blood Pressure: 100-140 mmHg
    3. Heart Rate: 110-140
    4. Temperature: 37.7 to 38.3 C (100 to 101 F)
    5. Tremulousness, Insomnia, or Agitation

XVI. Management: Severe Alcohol Withdrawal Protocol (CIWA-Ar >20, with maximum score 67)

  1. Indicated in Delirium Tremens
  2. General Protocol (Requires ICU observation)
    1. Endpoint: until adequate sedation (RASS Score 0 to -2) and improved CIWA-Ar score
    2. Diazepam (Valium)
      1. Start: 10-20 mg IV every 5-15 min prn
      2. Titrate dose for refractory symptoms to 20 mg, then 40 mg, then 80 mg
    3. Lorazepam (Ativan)
      1. Start: 2-4 mg IV every 15-20 min prn
      2. Titrate dose for refractory symptoms to 4 mg, then 8 mg, then 16 mg, then 32 mg
    4. Chlordiazepoxide (Librium)
      1. Start: 25 to 100 mg IM/IV every 1-4 hours (max: 300 mg/day)
  3. Defining Criteria and Additional Medication Indications
    1. Systolic Blood Pressure > 200 mmHg
    2. Diastolic Blood Pressure > 140 mmHg
    3. Heart Rate > 140
    4. Temperature > 38.3 C (101 F)
    5. Tremulousness, Insomnia, or Agitation
  4. Adjunctive measures (may require Advanced Airway and Ventilatory support)
    1. Phenobarbital 10 mg/kg up to 130-260 mg IV prn
    2. Propofol induction (RSI), followed by intubation and Propofol infusion
    3. Dexmedetomidine (Precedex) 0.2 to 0.6 mcg/kg/hour up to 1.2 mg/kg/hour
      1. Do not reduce Benzodiazepine dose when used with Dexmedetomidine
    4. Ketamine (NMDA antagonist)
      1. May reduce Benzodiazepine requirement in severe Alcohol withdawal (ICU patients)
      2. Ketamine 0.2 g/kg/hour infusion (avoid doses 0.3 to 1 g/kg/hour)
      3. Wong (2015) Ann Pharmacother 49(1):14-9 +PMID:25325907 [PubMed]
      4. Pizon (2018) Crit Care Med 46(8):e768-71 +PMID:29742583 [PubMed]
      5. Shah (2018) J Med Toxicol 14(3): 229-36 +PMID:29748926 [PubMed]

XVII. Resources: Patient Education

  1. Information from your Family Doctor: Alcohol Withdrawal
    1. http://www.familydoctor.org/handouts/007.html

XVIII. References

  1. Cardy, Swadron, Nordt in Herbert (2018) EM:Rap 18(8): 9-11
  2. Ferri (2001) Care of Medical Patient, p. 802-5
  3. Leaf and Musgrave (2017) Crit Dec Emerg Med 31(7): 15-20
  4. McMicken in Marx (2002) Rosen Emergency Med, p. 2513-16
  5. Orman and Hayes (2015) EM:Rap 15(11): 7-8
  6. Orman and Starr (2015) EM:Rap 15(12): 10-11
  7. Bayard (2004) Am Fam Physician 69(6):1443-50 [PubMed]
  8. Chang (2001) Med Clin North Am 85(5):1191-212 [PubMed]
  9. Muncie (2013) Am Fam Physician 88(9): 589-95 [PubMed]

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Ontology: Alcohol Withdrawal Delirium (C0001957)

Definition (MSH) An acute organic mental disorder induced by cessation or reduction in chronic alcohol consumption. Clinical characteristics include CONFUSION; DELUSIONS; vivid HALLUCINATIONS; TREMOR; agitation; insomnia; and signs of autonomic hyperactivity (e.g., elevated blood pressure and heart rate, dilated pupils, and diaphoresis). This condition may occasionally be fatal. It was formerly called delirium tremens. (From Adams et al., Principles of Neurology, 6th ed, p1175)
Definition (PSY) Acute alcoholic, psychotic condition characterized by intense tremors, anxiety, hallucinations, and delusions.
Concepts Disease or Syndrome (T047)
MSH D000430
ICD9 291.0
ICD10 F10.4
SnomedCT 192211007, 154853008, 8635005
DSM4 291.0
English Delirium Tremens, Delirium, Alcohol Withdrawal, Men & behav dis due alcohl: withdrawl state with delirium, Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium, Mental and behavioural disorders due to use of alcohol: withdrawal state with delirium, [X]Alcohol withdrawal delirium, [X]Men & behav dis due alcohl: withdrawl state with delirium, [X]Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium, [X]Mental and behavioural disorders due to use of alcohol: withdrawal state with delirium, Mental and behavioral disorders due to use of alcohol, withdrawal state with delirium, Mental and behavioural disorders due to use of alcohol, withdrawal state with delirium, ALCOHOL WITHDRAWAL IND DELIRIUM TREMENS, DELIRIUM TREMENS ALCOHOL WITHDRAWAL IND, alcohol withdrawal delirium, alcohol withdrawal with delirium, DTs, alcohol withdrawal delirium (diagnosis), alcohol withdrawal delirium ('D. tremens'), Delirium tremens, alcoh-ind, [X]Delirium tremens, alcoh-ind, Delirium tremens, alcohol-induced, [X]Delirium tremens, alcohol-induced, Alcohol Withdrawal-Induced Delirium Tremens, Delirium Tremens, Alcohol Withdrawal Induced, Alcohol Withdrawal Delirium [Disease/Finding], delerium tremens, delirium tremens, dts, Delirium tremens;alcoholic, deliriums tremens, Alcohol Withdrawal Induced Delirium Tremens, Delirium tremens (disorder), [X]Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium (disorder), Alcohol withdrawal delirium, Delirium tremens, DTs - delirium tremens, Alcohol withdrawal delirium (disorder), delirium; alcohol, due to withdrawal, delirium; alcohol, delirium; tremens, intoxication; alcohol, withdrawal state, with delirium, alcohol; delirium, withdrawal, alcohol; delirium, alcohol; intoxication, withdrawal state, with delirium, alcohol; withdrawal state with delirium, alcohol; withdrawal syndrome, with delirium, alcohol; withdrawal, with delirium, syndrome; alcohol withdrawal, with delirium, tremens; delirium, withdrawal state; alcohol, with delirium, withdrawal; alcohol, with delirium, Alcohol Withdrawal Delirium, Alcoholic delirium
French Délirium trémens, Délire induit par le sevrage à l'alcool, Délirium trémens provoqué par le sevrage alcoolique, Délirium trémens dû au sevrage alcoolique, Délirium trémens dû au sevrage à l'alcool, Delirium tremens, Délire alcoolique
Swedish Delirium tremens
Japanese ｼﾝｾﾝｾﾝﾓｳ, アルコール離脱譫妄, 振戦せん妄, せん妄-アルコール離脱性, アルコール離脱せん妄, 振戦譫妄, ｱﾙｺｰﾙﾘﾀﾞﾂｾﾝﾓｳ, アルコール離脱性せん妄, アルコール離脱症候群
Czech delirium tremens, alkoholismus - delirium abstinenční, Delirium tremens, Alkoholový odvykací stav s deliriem
Finnish Juoppohulluus
Russian BELAIA GORIACHKA, TROMOMANIIA, DELIRII ALKOGOL'NYI, ALKOGOL'NYI DELIRII PRI VOZDERZHANII, ALKOGOL'NYI DELIRII ABSTINENTNYI, DELIRIUM TREMENS, АЛКОГОЛЬНЫЙ ДЕЛИРИЙ АБСТИНЕНТНЫЙ, АЛКОГОЛЬНЫЙ ДЕЛИРИЙ ПРИ ВОЗДЕРЖАНИИ, БЕЛАЯ ГОРЯЧКА, ДЕЛИРИЙ АЛКОГОЛЬНЫЙ, ТРОМОМАНИЯ
German Psychische und Verhaltensstoerungen durch Alkohol: Entzugssyndrom mit Delir, Alkoholentzugsdelirium, Alkoholentzugsdelir, Delirium tremens, Entzugsdelir, Alkohol-
Italian Delirium tremens, Delirio indotto da astinenza da alcol, Delirium tremens indotto da astinenza da alcol, Delirio da astinenza da alcool, Delirio da astinenza da alcol
Spanish Delirio por abstinencia de alcohol, [X]trastornos mentales y de conducta debidos al uso de alcohol: estado de abstinencia con delirio, [X]trastornos mentales y de conducta debidos al uso de alcohol: estado de abstinencia con delirio (trastorno), delirio por abstinencia de alcohol, delirium por abstinencia de alcohol (trastorno), delirium por abstinencia de alcohol, delirium tremens, Delirium tremens, Delirium por Abstinencia Alcohólica, Delirium Tremens
Portuguese Delírio por abstinência de álcool, Delirium tremens, Delirium por Abstinência de Álcool, Delirium Tremens
Dutch alcoholonthouding delirium, alcohol; delirium bij onthouding, alcohol; delirium, alcohol; intoxicatie, onthoudingstoestand, met delirium, alcohol; onthouding met delirium, alcohol; onthoudingstoestand met delirium, alcoholonthouding; syndroom, met delirium, delirium; alcohol, bij onthouding, delirium; alcohol, delirium; tremens, intoxicatie; alcohol, onthoudingstoestand, met delirium, onthouding; alcohol, met delirium, onthoudingstoestand; alcohol, met delirium, syndroom; alcoholonthouding, met delirium, tremens; delirium, Psychische stoornissen en gedragsstoornissen door gebruik van alcohol; Onthoudingstoestand met delirium, delirium tremens, Delirium tremens
Polish Majaczenie drżenne, Delirium tremens, Majaczenie alkoholowe
Hungarian Delirium tremens, Alkohol megvonási delirium
Norwegian Delirium tremens
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Detoxication psychiatric therapy for alcoholism (C0204597)

Concepts Therapeutic or Preventive Procedure (T061)
ICD9 94.62
ICD10 92003-00
SnomedCT 151253000, 64297001
Italian Disintossicazione da alcool
Japanese アルコールの解毒, ｱﾙｺｰﾙﾉｹﾞﾄﾞｸ
Czech Detoxikace při léčbě alkoholové závislosti
English alcohol detoxification, alcohol detoxification (treatment), detoxification alcohol, Alcohol detoxification (procedure), Alcohol detoxification, Detoxication psychiatric therapy for alcoholism (regime/therapy), Detoxication therapy for alcoholism, Detoxication psychiatric therapy for alcoholism, Detoxication psychiatric therapy for alcoholism (regime/therapy)(procedure)
Hungarian Alkohol detoxikáció
Spanish desintoxicación alcohólica, terapia de desintoxicación para el alcoholismo (régimen/tratamiento), terapia de desintoxicación para el alcoholismo, terapia psicológica de desintoxicación para el alcoholismo (procedimiento), Desintoxicación alcohólica
Portuguese Desintoxicação alcoólica
Dutch alcoholdetoxificatie
French Détoxication de l'alcool
German Alkoholentgiftungsmassnahme
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Alcohol withdrawal syndrome (C0236663)

Definition (PSY) Processes and symptomatic effects resulting from abstinence from alcohol. Used for both human and animal populations.
Concepts Disease or Syndrome (T047)
ICD9 291.81
SnomedCT 268745002, 154854002, 191480000
DSM4 291.8
Italian Sindrome di astinenza dall'alcool
Japanese アルコール離脱症候群, ｱﾙｺｰﾙﾘﾀﾞﾂｼｮｳｺｳｸﾞﾝ
English alcohol withdrawal, alcohol withdrawal (diagnosis), withdrawal alcohol, alcohol syndrome withdrawal, alcohol withdrawal syndrome, alcohol syndromes withdrawal, alcohol withdrawals, Withdrawal syndrome - alcohol, Alcohol withdrawal syndrome (disorder), intoxication; alcohol, withdrawal state, alcohol; abstinence symptoms or syndrome, alcohol; intoxication, withdrawal state, alcohol; withdrawal state, alcohol; withdrawal syndrome, alcohol; withdrawal, syndrome; alcohol withdrawal, withdrawal state; alcohol, withdrawal; alcohol, Alcohol Withdrawal, Alcohol withdrawal syndrome, Alcohol withdrawal, Alcohol abstinence syndrome or symptoms, Alcohol withdrawal syndrome or symptoms
Czech Alkoholový odvykací syndrom
Hungarian Alkohol megvonásos szindróma
Dutch alcohol; abstinentieverschijnselen of -syndroom, alcohol; intoxicatie, onthoudingstoestand, alcohol; onthoudingssyndroom, alcohol; onthoudingstoestand, alcohol; onthouding, intoxicatie; alcohol, onthoudingstoestand, onthouding; alcohol, onthoudingstoestand; alcohol, syndroom; alcoholonthouding, alcoholonthoudingssyndroom
Portuguese Síndrome de privação de álcool
Spanish Síndrome de abstinencia alcohólica, síndrome de abstinencia del alcohol (trastorno), síndrome de abstinencia del alcohol
French Syndrome du sevrage de l'alcool
German Alkoholentzugssyndrom
Derived from the NIH UMLS (Unified Medical Language System)

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