Acute and Chronic Ethanol Withdrawal Flashcards by Sally Lewis

True or false: Alcohol works as an anxiolytic.

True

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At this blood alcohol content level, you experience mild euphoria and are relaxed.
A. 0.05
B. 0.1
C. 0.2
D. 0.3
E. 0.4
F. 0.5

A. 0.05

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At this blood alcohol content level, you have decreased inhibitions and blunted feelings. It  requires about 2-4 drinks to get to this level for the average person.
A. 0.05
B. 0.1
C. 0.2
D. 0.3
E. 0.4
F. 0.5

B. 0.1

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The limit for blood alcohol content in Michigan is _____.

0.08

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BAC level of \_\_\_\_\_\_ is anywhere between 4-8 drinks for the average individual, this is where you get emotional swings and slurred speech, and this is due to the concentration that alcohol has in that frontal lobe now. 
A. 0.05
B. 0.1
C. 0.2
D. 0.3
E. 0.4
F. 0.5

C. 0.2

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At this BAC level, you have decreased motor function and CNS depression. The alcohol begins to concentrate now in the brain stem.
A. 0.05
B. 0.1
C. 0.2
D. 0.3
E. 0.4
F. 0.5

D. 0.3

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At this BAC level, you have decreased breathing, are at near loss of consciousness or can lose consciousness, can fall into coma. 
A. 0.05
B. 0.1
C. 0.2
D. 0.3
E. 0.4
F. 0.5

E. 0.4

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For most individuals, this BAC level results in death.
A. 0.05
B. 0.1
C. 0.2
D. 0.3
E. 0.4
F. 0.5

F. 0.5

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If you are an alcoholic, the BAC scale would be shifted to the ______ for you because your body has gotten accustomed to the alcohol and requires more drinks to exhibit the same effects.
A. Left
B. Right

B. Right

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True or False: Ethanol is a strong anesthetic.

False! It is a mild anesthetic.

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True or false: Alcohol is a CNS depressant.

True

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Ethanol acts as an ____ at GABA, which is the primary inhibitory neuro-receptor in the CNS.
A. Agonist
B. Antagonist

A. Agonist

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Ethanol acts as an ____ at NMDA, which is a part of glutamate, the primary excitatory neuro-receotor in the CNS.
A. Agonist
B. Antagonist

B. Antagonist

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What are the primary effects of ethanol at GABA?

It acts as an agonist there. It contributes to sedative, anxiolytic, loss of inhibition, and relaxation effects of alcohol.

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What are the primary effects of ethanol at NMDA receptors?

It acts as an antagonist there, and inhibition leads to increase in sedation effect.

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The addiction of ethanol comes as a result of the interaction of ethanol with:
A. GABA
B. NMDA
C. Mesolimbic pathway

C. Mesolimbic pathway

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How does ethanol work on the mesolimbic pathway? What are the effects?

It causes direct release of endogenous endorphins and increases dopamine release as well. The effects are that it causes euphoria and leads to addiction.

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Persistent stimulation or chronic ethanol consumption causes adaptive changes in the CNS. As a result, there is GABA receptor _____.
A. Up regulation
B. Down regulation

B. Down regulation

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Persistent stimulation or chronic ethanol consumption causes adaptive changes in the CNS. As a result, there is NMDA receptor _____.
A. Up regulation
B. Down regulation

A. Up regulation

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What is the DSM-V definition of chronic alcoholism?

5-10 drinks daily for 5-10 years.

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True or False: As a result of up regulation of the GABA receptors and down regulation of the NMDA receptor, a chronic alcoholic is then able to maintain a normal level of consciousness at a blood alcohol content level that most people can’t handle.

False! This is as a result of GABA receptor down regulation and NMDA receptor up regulation.

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_____________ is defined as a neurologic disorder that represents the culmination of progressively worsening symptoms caused by the effects of chronic ethanol use on the CNS

Alcohol Withdrawal Syndrome

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Why does alcohol withdrawal syndrome occur?

Because if you take away alcohol, you have a lot of NMDA receptors and few GABA receptors, so you’re in an excitatory state, and this is where you start to see alcohol withdrawal symptoms.

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Acute ethanol withdrawal symptoms can present as early as __ hours after drinking cessation.

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True or False: As serum ethanol levels decline, the severity of ethanol withdrawal symptoms increase.

True

True or False: A patient Can have high levels of alcohol in their body and still be going through ethanol withdrawal.

True (this can happen if say their baseline is 0.5 because they're always drinking and their alcohol content is 0.3 now and they're experiencing withdrawal because this isn't the norm for their body).

Early ethanol withdrawal occurs 6-12 hours after a person's last drink. It is characterized by __________.

Autonomic hyperactivity (tachycardia, tremors, hypertension, psychomotor agitation)

Alcoholic hallucinosis, which occurs in about 25% of patient with Alcohol Withdrawal Syndrome and is characterized by tactile, visual, and auditory hallucinations, usually occurs how long after a person has had their last drink?

12-24 hours later

In AWS, if a person is experiencing alcoholic hallucinosis, what is a major difference in their auditory hallucinations vs. someone with psychosis/schizophrenia?

Auditory = Usually someone very close to them, like a family member that they hear in their head that has always been close in their lives.

Alcohol withdrawal seizures are usually experienced 24-48 after alcohol cessation. It occurs in about 10% of patients and often called "rum fits". How is it treated?

IV benzodiazepines

Why do we want to use IV benzodiazepines instead of something like phenytoin?

Because benzos work on GABA receptors, while phenytoin works on sodium channels, which aren't affected by alcohol.

Delirium tremens (DT) occurs ____ hours after drinking cessation.

48-96 hours

Delirium tremens (DT) can last up to __ weeks

This is a phase in Alcohol Withdrawal Syndrome where the patient experiences agitation, disturbance in consciousness, changes in cognition and memory deficits.

Delirium Tremens (DT)

True or False: Time elapsed since drinking cessation is critical in treatment of AWS.

True

Drug of choice for prevention of AWS and alcohol withdrawal seizures is/are _______.

Benzodiazepines

True or False: Benzodiazepines have a narrow therapeutic index.

False! Large therapeutic index!!

Benzodiazepines are very lipophilic, meaning that they can cross BBB quickly and have a quick onset in IV formulation. Which benzodiazepines are often used for prevention of AWS and treatment of alcohol withdrawal seizures?

Lorazepam Diazepam Chlordiazepoxide

Which of the following is/are considered long acting benzodiazepine(s)? A. Lorazepam B. Diazepam C. Chlordiazepoxide

B. Diazepam | C. Chlordiazepoxide

Which of the following have active metabolites? A. Lorazepam B. Diazepam C. Chlordiazepoxide

B. Diazepam | C. Chlordiazepoxide

Which of the following is/are intermediate acting benzodiazepine(s)? A. Lorazepam B. Diazepam C. Chlordiazepoxide

A. Lorazepam

Which of the following benzodiazepines would be a great option for someone with a liver/renal impairment our to the fact that it doesn't have any active metabolites and therefore, doesn't accumulate? A. Lorazepam B. Diazepam C. Chlordiazepoxide

A. Lorazepam

Chlordiazepoxide is metabolized to _________, which is then metabolized to oxazepam.

Desmethyldiazepam

Diazepam and clorazepate are metabolited to ___________ then _______ then _____ and finally are eliminated.

Diazepam and clorazepate (and chlordiazepoxide) --> Desmethyldiazepam --> Oxazepam --> inactive metabolites --> elimination

Lorazepam is metabolized to _____.

Inactive metabolites which are then eliminated.

Why do we use chlordiazepoxide for Alcohol Withdrawal Syndrome (AWS)?

Chlordiazepoxide is very long acting so it is ideal for someone going through alcohol withdrawal because it helps them to ride it out.

Which of the following is used orally for AWS prevention and/or treatment? A. Lorazepam B. Diazepam C. Chlordiazepoxide

C. Chlordiazepoxide

For mild to moderate AWS, use ___ benzodiazepines. A. Oral B. IV

A. Oral

For moderate to severe AWS (moderate to severe automatically includes seizures, DT, and severe agitation), use ___ benzodiazepines. A. Oral B. IV

B. IV

The starting dose of Ativan (Lorazepam) for the prevention/treatment of AWS is _____.

2 mg IV

The starting dose of Diazepam for the prevention/treatment of AWS is _____.

5 mg IV

The starting dose of Chlordiazepoxide for the prevention/treatment of AWS is _____.

25 mg oral

Which has a higher propylene glycol concentration: Lorazepam or Diazepam?

Lorazepam

Why do we worry about propylene glycol from (diazepam and lorazepam)?

Because it is metabolized into acetic acid and lactic acid and lactic acid can cause lactic acidosis (toxicity).

How do we monitor for propylene glycol toxicity?

Monitor anion gap

True or False: The dose titration for benzodiazepines should correlate with cessation of drinking.

True

Since barbiturates open the GABA channel wide open, there is an increase risk of this adverse event.

Sedation

When would you use barbiturates (like phenobarbital) for AWS?

In treatment of benzodiazepine-resistance patients.

_________ is a hypothesis that states that the GABA receptor is saturated, so as a result, benzodiazepines are no longer effective and you now need something to cause full open of the channel, like a barbiturate.

GABA saturation hypothesis

Which is the starting dose of phenobarbital in treating AWS?

65 mg

What is the starting dose of IV ethanol?

2.5-5 mg/hour IV

The proposed benefit of _____ is that it provides effective management of withdrawal symptoms without the excessive sedation and respiratory depression associated with benzodiazepines

IV ethanol

True or False: Studies have shown that oral ethanol is just as effective as IV ethanol for treatment of AWS.

False! There hasn’t been proven benefit to using oral ethanol.

True or False: IV ethanol is dosed on a gram to gram basis per consumption.

False! No longer dosed that way because patient stays drunk all the time!

IV EtOH infusion of 2.5-5 mg/hour is equivalent to how many drinks?

5-10 alcoholic drinks/day

Why must blood glucose be monitored with IV ethanol?

Because ethanol infusion is made in D5W.

This class of medications is not recommended as the sole pharmacologic agent in treating AWS due to its adverse events of QTc prolongation, torsades, hypotension, neuroleptic malignant syndrome, and seizures.

Antipsychotics

This antipsychotic can be Beneficial as adjunctive treatment in combination with sedative agent, mainly in patients with severe agitation.

Haloperidol

True or False: Once a patient is stabilized after AWS, symptom triggered therapy with benzodiazepines is proven more effective than scheduled/"around-the-clock" administration.

True

This scale is a validated assessment that can be used by nursing to assess various symptoms associated with AWS.

CIWA-Ar

The CIWA-Ar is a 67 point scale. If the CIWA-Ar is > __, medication should be administered

The CIWA-Ar is a 67 point scale. If the CIWA-Ar is > __, ICU admission should be considered.

You worry about the development of Wenicke-Korsakoff Syndrome in AWS, which is due to _____ deficiency.

Thiamine

What is the dose and duration of thiamine that should be provided as supportive therapy to AWS patients to prevent Wenicke-Korsakoff Syndrome.

Thiamine 100 mg IV daily for 2-5 days or until regular diet is resumed.

_____ shuttles glucose into your neurons, so without it, you're not feeding your neurons and can develop CNS altered mental status changes.

Thiamine

What are the 4 FDA approved agents for treatment of alcohol dependence?

Disulfiram (Antabuse) Acamprosate Oral naltrexone IM ER naltrexone

___ blocks the enzyme ALDH, so you accumulate acetaldehyde and have hangover feeling. Patients stop drinking or they stop taking this drug because of the feeling, so it doesn’t work that well.

Disulfiram

For alcohol dependence, naltrexone has shown the best efficacy to prevent relapse. However, it can't be used for _____, and is is common in a lot of alcohol addicts, so it excludes a large population from treatment with it.

Acute hepatic/liver failure

What is the normal anion gap?

4-10 mEq/L