Alcohol Withdrawal Flashcards
1
Q
Epidemiology
A
- Effects 5.4% of US population
- Plays a role in 32.5% of trauma center visits
- 50% experience severity with withdrawal
2
Q
Pathophysiology
A
- GABA receptors get downregulated in chronic use and NMDA is upregulated
- When alcohol is removed from system, excess excitatory input from NDMA and inadequate inhibitory tone from GABA receptor
3
Q
Presentation
A
- Minor: anxiety, agitation, nausea, insomnia, HA
- Seizures (6-48 hours): tonic-clonic, short, multiple
- Alcohol hallucinosis (12-48 hours)- hallucinations, altered cognition, normal vitals
- Delirium/tremens (48-96 hours) - disturbance of cognition, hallucinations, hyperthermia, increased cardiac indices, 20% mortality with no treatment
4
Q
Diagnosis
A
- Cessation or reduction of alcohol use after being heavy/prolonged
- Two or more conditions: develop within hours to days of decreased alcohol use, distress/impairment in social, occupational, or other areas, can’t be attributed to other disorder
5
Q
Diagnosis Difficulties
A
- Patient is obtunded can make it hard to get history
- Can present similar to other withdrawals, infections, drug overdose, or pancreatitis
- Always keep in the back of your mind
6
Q
Labs
A
- CBC
- BMP
- LFTs
- Amylase
- Lipase
- EtOH level
- Urine drug screen
- HCG for women
- CT of head
- Lumbar puncture
- Toxic alcohol panel
7
Q
CIWA
A
- Reliable, uncomplicated
- Used to assess severity of presentation and response to treatment
- NOT for diagnosis
- Can be used every 15 minutes in severe presentation until symptoms are controlled
- Give medications at scores of >= 9
- Increase doses as score increases
8
Q
Treatment Options
A
- Benzos
- Phenobarbital
- Propofol
- Dexmedetomidine
9
Q
Benzos
A
- Drug of choice
- Prevents alcohol withdrawal seizures and delirium tremens
- Caution for liver dysfxn in certain agents (chlordiazepoxide and diazepam)
- No agent shown to be more effective than the others
- Some IV and PO and others only oral
10
Q
Phenobarbital
A
- Long half life
- Acts on GABA-alpha receptors
- Can be IV, IM, or PO
- Prevents alcohol withdrawal seizures and delirium tremens
- No tapering necessary at discharge
11
Q
Propofol
A
- Good option for intubated patients
- Increases inhibitory tone at GABA receptor and decreases excitatory of NMDA
- Continuous IV infusion
12
Q
Dexmedetomidine
A
- Alpha-receptor agonist
- Useful for symptom control in patients with delirium tremens and increased cardiac indices
- DOESN’T effect GABA/NMDA imbalance, give with GABA agent
- Continuous IV infusion
13
Q
Symptom Triggered Therapy
A
- Standard of care in hospital setting
- Fixed dose tapers are appropriate therapy for selected patients with mild withdrawal who be treated outpatient
14
Q
Additional Treatments
A
- Fluids: hypovolemia and hyperthermia can lead to rhabdomyolysis, consider NS or LR for resuscitation and D5/1/2NS/K for maintenance
- Thiamine: chronic nutritional deficiency can alter mental status, neuropathy, or ocular abnormalities
- Electrolytes/multivitamin: chronic nutritional deficiency, replete K/Phos/Mg as needed, add multivitamin with folate to medication regimen
- Glucose: Usually given as D5, nutritional deficiency due to not tolerating PO intake, give after thiamine
15
Q
Wernicke Korsokoff Encephalopathy
A
- Cell damage secondary to chronic thiamine deficiency
- Confusion, ataxia, ophthalmoplegia
- Give thiamine 500 mg TID for 3-5 days and then PO supplementation for 2 weeks if improvement seen on IV
- 20% mortality risk
- Permanent amnestic syndrome in up to 75% of patients
