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Alcohol Withdrawal
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Alcohol Withdrawal
, Alcohol Withdrawal Syndrome, Alcohol Detoxification, Delirium Tremens
See Also
Alcohol Dependence
Alcohol Toxicity
Alcohol Detoxification in Ambulatory Setting
Alcoholism Management
Chemical Dependency
Drug Withdrawal
Epidemiology
Onset: 6-24 hours after last
Alcohol
intake
Duration: 5-7 days after abstinence
Peak symptoms: 1-3 days after abstinence
Pathophysiology
Occurs after daily heavy
Alcohol
use for at least 2 weeks
Abrupt
Alcohol
cessation results in unmasked compensatory mechanisms for chronic
Alcohol Abuse
Disinhibition of alpha-2 receptors
Increases
Catecholamine
levels at presynaptic membranes
Risk Factors
Complicated Withdrawal
History of Delirium Tremens or Alcohol Withdrawal
Seizure
s
Multiple Prior Withdrawal Episodes
Comorbid Illness
Age >65 years old
Long duration of heavy
Alcohol
consumption
Seizure
s during current withdrawal episode
Significant autonomic hyperactivity on presentation (
Tachycardia
,
Hypertension
)
Physiologic dependence on GABAergic agents (
Benzodiazepine
s,
Barbiturate
s)
Risk Factors
Severe Withdrawal (Delirium Tremens)
Age >30-40 years
Heavy drinking >8 years
Alcohol
intake >100 grams, >1 pint liquor, >96 oz beer
Patient experiences withdrawal symptoms when abstinent
Hepatic
Cirrhosis
Lab abnormalities
Mean Corpuscular Volume
(MCV) increased
Blood Urea Nitrogen
(BUN) increased
Blood Alcohol Level
>0.20 g/dl on random draw
Reference
Ferguson (1996) J Gen Intern Med 11:410-4 [PubMed]
Symptoms
Stage 1 - Initial Withdrawal Symptoms (6-12 hours after last
Alcohol
)
Anxiety or
Panic Attack
s
Anorexia
Paresthesia
s
Shakes, Jitters or
Tremor
s
Chills, Sweats, or
Fever
s
Chest Pain
or
Palpitation
s
Insomnia
Headache
Nausea
or
Vomiting
Abdominal Pain
Still coherent
Alcohol
Hallucination
s or
Alcohol
ic hallucinosis (12-24 hours after last
Alcohol
)
Affects 8% of Alcohol Withdrawal patients
Paranoid
Delusion
s or
Illusion
s
Tactile Hallucination
s (common)
Auditory and
Visual Hallucination
s (less common)
Sensorium otherwise maintained
Stage 2 - Withdrawal
Seizure
s and autonomic hyperactivity (24-72 hours post-
Alcohol
)
Marked
Agitation
, restlessness and diaphoresis
Tremulous with constant eye movements
Nausea
,
Vomiting
,
Anorexia
, and
Diarrhea
Sinus Tachycardia
>120 bpm
Systolic
Hypertension
with SBP >160 mmHg
Confusion may be present
Withdrawal
Seizure
s (24-48 hours post-
Alcohol
)
Gene
ralized tonic-clonic
Seizure
s
Brief
Seizure
s (<5 minutes) and may recur
Isolated and self limited (
Status Epilepticus
is not due to withdrawal)
Stage 3 - Delirium Tremens (72-96 hours)
Of those with withdrawal
Seizure
s, 33% progress to DTs
Fluctuating disturance of attention, awareness, orientation, memory, language and visuospatial ability
Visual Hallucination
s
Disorientation
and
Delirium
Autonomic instability
Severe
Tachycardia
and
Hypertension
Severe
Agitation
and tremulousness
Hyperthermia (
Fever
, severe diaphoresis)
Resolution
Resolves at 5-7 days
Signs
Blood Pressure
, pulse and
Temperature
elevated
Hyperarousal,
Agitation
, or Restlessness
Cutaneous
Flushing
or Diaphoresis
Dilated pupils
Ataxia
Altered Level of Consciousness
or
Disorientation
Delirium Tremens
Labs
Complete Blood Count
Comprehensive metabolic panel
Serum
Electrolyte
s
Renal Function
tests
Liver Function Test
s
Serum Magnesium
ProTime
(INR)
Increased INR is a marker of advanced liver dysfunction
Drug screen
Blood Alcohol Level
Urine Drug Screen
Other testing to consider in risk for multiple ingestion or toxic
Alcohol
ingestion
Salicylate
Level
Acetaminophen
Level
Serum Osmolality
Consider in suspected toxic
Alcohol
ingestion (
Methanol
,
Polyethylene glycol
)
Venous Blood Gas
(VBG)
Diagnostics
Electrocardiogram
(EKG)
Evaluate for
QT Prolongation
,
QRS Widening
(as in
Unknown Ingestion
)
Evaluate for
Acute Coronary Syndrome
Consider other testing if suspicious of underlying infection
Chest XRay
Lumbar Puncture
Urinalysis
Diagnosis
DSM-5 Criteria Alcohol Withdrawal
Heavy
Alcohol
usage for a prolonged period (>2 weeks) followed by
Alcohol
cessation or reduction
Signs or symptoms cause significant distress or
Impairment
of functioning and not explained by other condition
Two or more of the following, developing several hours to a few days after
Alcohol
cessation or reduction
Autonomic hyperactivity (e.g. diaphoresis,
Tachycardia
>100 bpm)
Increased hand
Tremor
Insomnia
Nausea
or
Vomiting
Transient auditory, visual or
Tactile Hallucination
s or
Illusion
s
Psychomotor
Agitation
Anxiety
Generalized Tonic Clonic Seizure
s
Modifiers
With perceptual disturbance
Visual or
Tactile Hallucination
s occur with intact reality testing OR
Auditory, visual or
Tactile Hallucination
s when
Delirium
is absent
Grading
See
Clinical Institute Withdrawal Assessment for Alcohol
(CIWA)
See
Short Alcohol Withdrawal Scale
(
SAWS
)
Mild Alcohol Withdrawal
Mild to moderate anxiety
Sweating
Insomnia
Moderate Alcohol Withdrawal
Moderate Anxiety
Mild
Tremor
Severe Alcohol Withdrawal
Severe Anxiety
Moderate to severe
Tremor
Complicated Alcohol Withdrawal
Alcohol Withdrawal
Seizure
s
Confusion
Delirium
Differential Diagnosis
See
Altered Level of Consciousness
See
Sympathomimetic Toxicity
See
Unknown Ingestion
or
Overdose
Wernicke's Encephalopathy
Agitated Delirium
Acute
Psychosis
Serotonin Syndrome
Thyrotoxicosis
Infection or
Sepsis
Electrolyte
abnormalities (e.g.
Hyponatremia
,
Hypokalemia
)
Thyrotoxicosis
Acute blood loss (e.g.
Trauma
,
Gastrointestinal Bleeding
)
Closed Head Injury
Intracranial Hemorrhage
(e.g.
Subdural Hematoma
,
Subarachnoid Hemorrhage
)
Meningitis
or
Encephalitis
Complications
Delirium Tremens
Head Trauma
Myocardial Infarction
Aspiration Pneumonia
and other infections
Electrolyte
disturbance (e.g.
Hypomagnesemia
)
Death
Delirium Tremens has a 5-10% mortality rate
Management
Gene
ral Measures
Seizure
precautions
Supplementation
Vitamin Deficiency
is common (
Vitamin
s A, C, B1, B3, B6, B9, B12)
See
Alcohol Dependence
Thiamine
(
Vitamin B1
) 100 mg orally daily
Folate
(
Vitamin B9
) 1 mg orally daily
Multivitamin
daily
Treat
Hypomagnesemia
if present
Intravenous Fluid
s (
Normal Saline
or banana bag)
Frequently administered to intoxicated patients admitted to the Emergency Department
IV Fluids do not shorten the length of ED stay for intoxicated patients (typical ED stay averages 4.5 hours)
Perez (2013) Emerg Med Australas 25(6): 527-34 [PubMed]
Management
Disposition
See
Clinical Sobriety
Facility Level Indications
Level 1 Withdrawal Management: Outpatient Clinic
Mild Alcohol Withdrawal (CIWA <=10)
Level 2 Withdrawal Management: Onsite Monitoring (e.g. Detox and CD treatment Centers)
Mild or Moderate Alcohol Withdrawal (CIWA <=18)
Complicated withdrawal risk factors (see above)
Opioid Use Disorder
(or physiologic
Opioid Dependence
)
Severe Alcohol Withdrawal within the last year
Seizure Disorder
Inpatient Withdrawal Management
Severe Alcohol Withdrawal (CIWA >18)
Complicated withdrawal symptoms
Active psychiatric conditions
Unstable chronic condition
Inability to tolerate oral intake
Clinical significant abnormal lab testing
Serious
Electrolyte
abnormalities
Significant
Acute Kidney Injury
Management
Agents used in Alcohol Withdrawal
Also see
Alcohol Detoxification in Ambulatory Setting
Benzodiazepine
s
See dosing potocols below
Early aggressive
Benzodiazepine
loading offers best Alcohol Withdrawal control
Benzodiazepine
s are the primary agent in moderate to severe Alcohol Withdrawal
Reduces Alcohol Withdrawal
Seizure
risk
Reduces Delirium Tremens risk
Precautions
Monitor for over-sedation and respiratory depression (esp. concomitant liver disease)
Agent Selection
Agents with long half-life are preferred for most patients (lower rebound risk)
Valium
Librium
Librium
has less stimulation of reward system (lower abuse potential)
Seizure
history
Valium
Liver
disease or elderly patient (use agents with less hepatic metabolism)
Ativan
Serax
Benzodiazepine
Alternatives (in patients in whom
Benzodiazepine
s are considered too risky, commonly used in Europe)
Precautions
Carbamazepine
,
Gabapentin
and
Valproic Acid
have not been shown to prevent Alcohol Withdrawal
Seizure
Carbamazepine
,
Gabapentin
and
Valproic Acid
increase GABA (via
Sodium
channel blockade)
Adverse risks include
Thrombocytopenia
and other
Bone Marrow
suppression,
Pancreatitis
Carbamazepine
Effective in mild to moderate withdrawal
Protocol 1: Tapered
Tapered 200 mg four times daily tapered over 5 days
Start at
Carbamazepine
(
Tegretol
) 800 mg on day 1
Finish at 200 mg once on day 5
Protocol 2: Constant
Carbamazepine
200 mg every 8 hours or 400 mg every 12 hours
References
Malcolm (2002) J Gen Intern Med 17:349-55 [PubMed]
Gabapentin
Potentiates CNS GABA activity and decreases glutamate activity
Decreases
Alcohol
craving and depression
Dosing (minimum effective daily dose 900 mg/day)
Start 600 mg three times daily for 3 days
Then 300 mg three times daily for 3 days
References
Stock (2013) Ann Pharmacother 47: 961-9 [PubMed]
Myrick (2009) Alcohol Clin Exp Res 33(9): 1582-8 +PMID:19485969 [PubMed]
Valproic Acid
Has also been used in Alcohol Withdrawal
Not recommended for monotherapy (may be used as adjunct with
Benzodiazepine
s)
Avoid in severe liver disease or pregnancy
Dosing 300 mg to 500 mg every 6 hours
Adjunctive agents that require airway and ventilation management (see severe Alcohol Withdrawal protocol below)
Phenobarbital
Avoid IV infusion >60 mg/min
Phenobarbital
5-10 mg/kg IBW up to 130 to 260 mg every 20-30 minutes titrating to light sedation
Nisavic (2019) Psychosomatics 60(5):458-67 [PubMed]
Nelson (2019) Am J Emerg Med 37(4):733-6 [PubMed]
Tidwell (2018) Am J Crit Care 27(6):454-60 [PubMed]
Propofol
infusion
Dexmedetomidine
(
Precedex
)
Other symptomatic agents
Beta Blocker
s (e.g.
Metoprolol
)
Avoid in general as these mask withdrawal signs
Symptomatic relief of chills, shakes
Improves
Vital Sign
s
Use selective
Beta Blocker
in
Coronary Artery Disease
Metoprolol Tartrate
(
Lopressor
) 25 to 50 mg orally every 12 hours
Haloperidol
Decreases
Agitation
and
Hallucination
s
May lower
Seizure
threshold (but typically does not cause recurrent
Seizure
s)
Management
Mild Alcohol Withdrawal Protocol (
CIWA-Ar
10 or less,
SAWS
<12)
See
Outpatient Alcohol Withdrawal Protocol
Indications
Mild Alcohol Withdrawal (
CIWA-Ar
<=10,
SAWS
<12)
No Complicated Withdrawal Risk Factors (see above)
If criteria not met, proceed to Mild Alcohol Withdrawal protocol as below
Contraindications
Lack of reliable social support
Lack of safe home environment
Able to sustain daily reevaluation
Disposition
Outpatient Clinic
Education
Review Alcohol Withdrawal expected course
Review signs of severe Alcohol Withdrawal
Maintain home low-stimulation environment
Maintain hydration with non-caffeinated fluid
Other measures
Thiamine
100 mg daily for 5 days
Multivitamin
orally daily
Gabapentin
(
Neurontin
) may be considered (may reduce craving)
Start 600 mg three times daily for 3 days
Then 300 mg three times daily for 3 days
Does NOT prevent withdrawal
Seizure
s or Delirium Tremens
Monitoring
Evaluations may be performed by any health care professional (e.g. RN, medical provider)
Daily reevaluation for up to 5 days
Modify based on symptom severity (increased or decreased)
Face to face evaluations with
Vital Sign
s are preferred
Telemedicine
may be used as needed
Evaluate withdrawal severity
Record
Blood Pressure
,
Heart Rate
Obtain
Alcohol
breath analysis
Calculate
CIWA-Ar
or
SAWS
Symptom and sign review
Hydration
Sleep
Mental status
Mood
Suicidality
Substance use
Indications for Emergent referral to higher level of care (detox center, emergency department)
Continued symptoms refractory to multiple doses of withdrawal medications
Worsening or severe symptoms
Persistent
Vomiting
Hallucination
s
Confusion
Seizure
s
Management
Mild to Moderate Alcohol Withdrawal Protocol (
CIWA-Ar
10 to 15, or Complicated withdrawal risk factors)
Indications
Mild or Moderate Alcohol Withdrawal (CIWA 10 to 15) OR
Complicated withdrawal risk factors (see above)
Disposition
Level 2 Withdrawal Management: Onsite Monitoring (e.g. Detox and CD treatment Centers)
Level 1 Outpatient Clinic if no complicated withdrawal risk factors
See
Outpatient Alcohol Withdrawal Protocol
Gene
ral Symptom Triggered Protocol (based on
CIWA-Ar
or
SAWS
)
Diazepam
(
Valium
) 5-10 mg orally every 6-8 hours prn for 1-3 days OR
Lorazepam
(
Ativan
) 1-2 mg orally every 4-6 hours prn for 1-3 days OR
Chlordiazepoxide
(
Librium
) 25-50 mg orally every 6-8 hours for 1-3 days
Defining Criteria and Additional Medication Indications
Systolic
Blood Pressure
> 150 mmHg
Diastolic
Blood Pressure
> 90 mmHg
Heart Rate
> 100
Temperature
> 37.7 C (100 F)
Tremulousness,
Insomnia
, or
Agitation
Management
Moderate to Severe Alcohol Withdrawal Protocol (
CIWA-Ar
16-20)
Indications: Defining Criteria and Additional Medication Indications
Systolic
Blood Pressure
: 150-200 mmHg
Diastolic
Blood Pressure
: 100-140 mmHg
Heart Rate
: 110-140
Temperature
: 37.7 to 38.3 C (100 to 101 F)
Tremulousness,
Insomnia
, or
Agitation
Disposition
Level 2 Withdrawal Management: Onsite Monitoring (e.g. Detox and CD treatment Centers) OR
Inpatient medical facility
Symptom-Triggered Regimen (preferred)
Preferred in moderate to severe Alcohol Withdrawal
Based on Clinical Institute Withdrawal Assessment (
CIWA-Ar
)
http://addiction-medicine.org/files/15doc.html
Assess hourly to determine medication need
Give one of following hourly until
CIWA-Ar
<8-10 points
Chlordiazepoxide
(
Librium
) 50 to 100 mg
Diazepam
(
Valium
) 10 to 20 mg
Lorazepam
(
Ativan
) 2 to 4 mg
Oxazepam
(
Serax
) 15 to 30 mg
Fixed-Dose Protocol
Diazepam
(
Valium
)
Day 1: 15 to 20 mg orally four times daily
Day 2: 10 to 20 mg orally four times daily
Day 3: 5 to 15 mg orally four times daily
Day 4: 10 mg orally four times daily
Day 5: 5 mg orally four times daily
Lorazepam
(
Ativan
)
Days 1-2: 2-4 mg orally four times daily
Days 3-4: 1-2 mg orally four times daily
Day 5: 1 mg orally twice daily
Chlordiazepoxide
(
Librium
)
Day 1: 50-100 mg orally four times daily
Days 2-4: 25-50 mg orally four times daily
Decrease by 20% per day
Management
Severe Alcohol Withdrawal Protocol (
CIWA-Ar
>20, with maximum score 67)
Indicated in Delirium Tremens
Disposition
Inpatient Facility
Intensive Care
Unit
Gene
ral Protocol (Requires ICU observation)
Endpoint: until adequate sedation (
RASS
Score 0 to -2) and improved
CIWA-Ar
score
Diazepam
(
Valium
)
Start: 10-20 mg IV every 5-15 min prn
Titrate dose for refractory symptoms to 20 mg, then 40 mg, then 80 mg
Lorazepam
(
Ativan
)
Start: 2-4 mg IV every 15-20 min prn
Titrate dose for refractory symptoms to 4 mg, then 8 mg, then 16 mg, then 32 mg
Chlordiazepoxide
(
Librium
)
Start: 25 to 100 mg IM/IV every 1-4 hours (max: 300 mg/day)
Defining Criteria and Additional Medication Indications
Systolic
Blood Pressure
> 200 mmHg
Diastolic
Blood Pressure
> 140 mmHg
Heart Rate
> 140
Temperature
> 38.3 C (101 F)
Tremulousness,
Insomnia
, or
Agitation
Adjunctive measures (may require
Advanced Airway
and
Ventilator
y support)
Phenobarbital
10 mg/kg up to 130-260 mg IV prn
Propofol
induction (RSI), followed by intubation and
Propofol
infusion
Dexmedetomidine
(
Precedex
) 0.2 to 0.6 mcg/kg/hour up to 1.2 mg/kg/hour
Do not reduce
Benzodiazepine
dose when used with
Dexmedetomidine
Ketamine
(
NMDA
antagonist)
May reduce
Benzodiazepine
requirement in severe
Alcohol
withdawal (ICU patients)
Ketamine
0.2 g/kg/hour infusion (avoid doses 0.3 to 1 g/kg/hour)
Wong (2015) Ann Pharmacother 49(1):14-9 +PMID:25325907 [PubMed]
Pizon (2018) Crit Care Med 46(8):e768-71 +PMID:29742583 [PubMed]
Shah (2018) J Med Toxicol 14(3): 229-36 +PMID:29748926 [PubMed]
Prevention
See
Alcohol Abuse Management
Following
Alcohol
treatment program and aftercare are critical following Alcohol Withdrawal protocol
Resources
Patient Education
Information from your Family Doctor: Alcohol Withdrawal
http://www.familydoctor.org/handouts/007.html
References
Cardy, Swadron, Nordt in Herbert (2018) EM:Rap 18(8): 9-11
Ferri (2001) Care of Medical Patient, p. 802-5
Leaf and Musgrave (2017) Crit Dec Emerg Med 31(7): 15-20
McMicken in Marx (2002) Rosen Emergency Med, p. 2513-16
Orman and Hayes (2015) EM:Rap 15(11): 7-8
Orman and Starr (2015) EM:Rap 15(12): 10-11
Bayard (2004) Am Fam Physician 69(6):1443-50 [PubMed]
Chang (2001) Med Clin North Am 85(5):1191-212 [PubMed]
Muncie (2013) Am Fam Physician 88(9): 589-95 [PubMed]
Tiglao (2021) Am Fam Physician 104(3): 253-62 [PubMed]
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