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Alcohol Withdrawal

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Alcohol Withdrawal, Alcohol Withdrawal Syndrome, Alcohol Detoxification, Delirium Tremens

  • See Also
  1. Alcohol Dependence
  2. Alcohol Toxicity
  3. Alcohol Detoxification in Ambulatory Setting
  4. Alcoholism Management
  5. Chemical Dependency
  6. Drug Withdrawal
  • 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
  • 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]
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Complications
  • Delirium Tremens
  1. Head Trauma
  2. Myocardial Infarction
  3. Aspiration Pneumonia and other infections
  4. Electrolyte disturbance (e.g. Hypomagnesemia)
  5. Death
  • 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
  • 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
      1. Avoid IV infusion >60 mg/min
      2. Phenobarbital 5-10 mg/kg IBW up to 130 to 260 mg every 20-30 minutes titrating to light sedation
      3. Nisavic (2019) Psychosomatics 60(5):458-67 [PubMed]
      4. Nelson (2019) Am J Emerg Med 37(4):733-6 [PubMed]
      5. Tidwell (2018) Am J Crit Care 27(6):454-60 [PubMed]
    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)
  • 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
  • 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
  • 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
  • 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]
  1. Information from your Family Doctor: Alcohol Withdrawal
    1. http://www.familydoctor.org/handouts/007.html
  • 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]