Acute Alcohol Withdrawal (GMAWS)

Question 1

What is alcohol withdrawal?

Answer 1

When someone is alcohol dependent there is a risk of them developing withdrawal symptoms when they stop drinking. These can range from mild and uncomfortable to delirium tremens, which is life threatening. Symptoms occur at different times after alcohol consumption ceases:

Question 2

Timescale of alcohol withdrawal

Answer 2

6-12 hours: tremor, sweating, headache, craving and anxiety
•12-24 hours: hallucinations
•24-48 hours: seizures
•24-72 hours: “delerium tremens”

Question 3

What is delirium tremens

Answer 3

Delirium tremens is a medical emergency associated with alcohol withdrawal with a mortality of 35% if left untreated

Question 4

Pathophysiology of alcohol withdrawal

Answer 4

Alcohol stimulates GABA receptors in the brain. GABA receptors have a “relaxing” effect on the rest of the brain. Alcohol also inhibits glutamate receptors (also known as NMDA receptors) having a further inhibitory effect on the electrical activity of the brain.

Chronic alcohol use results in the GABA system becoming up-regulated and the glutamate system being down-regulated to balance the effects of alcohol. When alcohol is removed from the system, GABA under-functions and glutamate over-functions causing an extreme excitability of the brain with excess adrenergic activity

Question 5

How does delirium tremens present?

Answer 5

Acute confusion
•Severe agitation
•Delusions and hallucinations
•Tremor
•Tachycardia
•Hypertension
•Hyperthermia
•Ataxia (difficulties with coordinated movements)
•Arrhythmias

Question 6

Treatment

Answer 6

Diazepam is given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g. 10 – 40 mg every 1 – 4 hours). This is continued for 5-7 days.

Intravenous high-dose B vitamins (pabrinex). This should be followed by regular lower dose oral thiamine.