Alcohol Withdrawal Flashcards
What is the defintion of alcohol withdrawl?
physical and psychological symptoms occurring when any patient who is alcohol dependent has stopped or reduced alcohol intake within hours or days of presentation
What two receptors are involved in alcohol?
- NMDA Receptors
2. GABA (Type A) receptors
What are NMDA receptors usually?
excitatory
What are GABA (type A) receptors usually?
inhibitory
What is the normal homestasis of these receptors?
homeostasis between the excitatory effects of NMDA receptors and inhibitory effects of GABA receptors
What happens to the receptors in acute alcohol drinking?
- ethanol predominantly targets the GABA (type A) receptor
2. inhibits the NMDA receptor though competitive binding
What happens to the receptors in chronic alcohol use?
- alcohol predominantly targets GABA type A receptors
- so body adapts by downregulating GABA type A receptors (this contributes to development of tolerance)
- alcohol inhibits NMDA receptors
- so the body adapts by upregulating NMDA receptors on the post-synaptic membrane
What happens when an alcohol-dependent person stops drinking alcohol?
- excess excitatory effect from the upregulation of NMDA receptors
- downregulation of inhibitory GABA (type A) receptors
- use to steady state of ethanol concentration
What are RF for alcohol withdrawal?
- Alcohol use of disorder
- History of alcohol withdrawal
- Acute illness e.g. pneumonia
- Poor Physical Health
How do you identify alcohol use disorder?
- AUDIT-C
- FAST
- PAT
What can poor nutrition lead to?
thiamine deficiency which leads to Wernicke’s encephalopathy
What are signs of chronic or decompensated liver disease?
- Hepatooemgalsy
- Jaundice
- Ascites
- Caput medusa
- Palmar erythema
- Hepatic encephalopathy
What does ammonia cause?
encephalopathy
What does the albumin cause?
ascites and peripheral oedema
What does the bilirubin cause?
jaundice
What does blood factors cause?
brusing
How do you remember the effects of liver disease?
AABB
What does thiamine B1 def cause?
Wernicke’s encephalopathy
What are signs of WE?
- CAN
1. Confusion
2. Ataxia
3. Nystagmus - Risk of irreversible brain damage
What are the symptoms of 6-12 hr withdrawal: minor withdrawal symptoms?
- Anxiety/agitation
- Palpitations
- GI upset
- Sweating/tremor
What are the symptoms of 12-24hr withdrawal: alcoholic hallucinosis?
hallucinations
What are symptoms of 24-48hr: withdrawal seizures?
generalised tonic-clonic seizures
What are the symptoms of 48-72hr: withdrawal delirium?
- Delirium Tremens
- Severe tremor
- Fever
- High BP + HR
How do you remeber a surgical sieve?
VITAMIN C DEF
What is the surgical sieve?
Vascular Infective/inflammatory Trauma Autoimmune Metabolic Iatrogenic Neoplastic Congenital Degenerative Endocrine/environment Functional
What are possible DDx for alcohol withdrawal?
- Hypoglycaemia
- Hepatic encephalopathy
- Meningitis
What are hypoglycaemia symptoms?
- Tremors
- anxiety
- palpitations
- seizures
- drowsiness
What are hepatic encephalopathy symptoms?
- Tremors
- Anxiety
- Palpitations
- Seizures
- Drowsiness
What are features of meningitis?
- Fever and altered mental status
2. Nuchal rigidity makes up the last part of the triad but not all patients present with this triad
What bedside tests are done for alcohol withdrawal?
- Screen for alcohol-use disorder
- ECG
- VBG
How do you screen for alcohol use disorder?
- CAGE/AUDIT-C
- CIWA-AR scale to assess severity
Why do you do an ECG for alcohol withdrawal?
- Electrolyte deficiencies are common and can cause arrhythmias
What do you look for on VBG?
- Respiratory alkalosis (due to hyperventilation in delirium tremens)
- Hypochloraemic metabolic acidosis (due to vomiting)
- Metabolic acidosis with high anion gap (alcoholic ketoacidosis)
What bloods are done?
- Glucose
- FBC
- U+E
- LFTs
- Coagulation studies
Why is glucose done for alcohol withdrawl?
- hypoglycaemia
- common due to poor nutrition or secondary to hepatic failure
What does FBC show on alcohol withdrawal?
- increased MCV due to chronic alcohol use
- thrombocytopenia due to splenomegaly
- folate deficiency and a direct toxic effect of alcohol on their production
What does U+Es show in alcohol withdrawal ?
- hypomagnesaemia (1/3 of people)
- hypokalaemia (50% of hospitalised patients)
- hypophosphataemia
What does LFTs show in alcohol withdrawal?
- elevated liver enzymes (AST, ALT, GGT)
- ALT higher than AST
What do coagulation studies show in alcohol withdrawal?
INR and PT are prolonged in chronic liver disease, correlated with severity
Why do you do a CT head?
- Suspected head injury (e.g. alcohol-related seizure)
- Altered cognition
Why is a CXR done?
- co-existing pneumonia is common
- Aspiration: reduced consciousness or seizures
What is the urgent management for alcohol withdrawal?
- Benzodiazepine
- CT head: suspected head injury, altered cognition or seizures
- Detect and treat co-existing illness
How would you treat sizures?
ensure patent airway and give IV benzo
How would you treat delirium tremens?
oral benzos and IV if symptoms persists
What is the suportive management for alcohol withdrawal?
- Rehydrate: IV fluid
- Pabrinex (Vit B)
- Glucose
- Electrolyte imbalances
When can glucose be given for alcohol withdrawal?
- if hypoglycaemia: After thiamine! But don’t delay glucose for life-threatening hypoglycaemia
- after thiamine to prevent WE
How could you manage alcohol dependent LT?
DALS, Community Services, Therapy
