alcohol_withdrawal_flashcards
What is the mechanism of alcohol withdrawal?
Chronic alcohol consumption enhances GABA mediated inhibition in the CNS and inhibits NMDA-type glutamate receptors. Alcohol withdrawal leads to the opposite: decreased inhibitory GABA and increased NMDA glutamate transmission.
What are the symptoms that start at 6-12 hours after alcohol withdrawal?
Tremor, sweating, tachycardia, anxiety.
When is the peak incidence of seizures during alcohol withdrawal?
36 hours.
When is the peak incidence of delirium tremens during alcohol withdrawal?
48-72 hours.
What are the features of delirium tremens?
Coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia.
How should patients with a history of complex withdrawals from alcohol be managed?
They should be admitted to hospital for monitoring until withdrawals are stabilized.
What is the first-line treatment for alcohol withdrawal?
Long-acting benzodiazepines e.g. chlordiazepoxide or diazepam.
Which benzodiazepine may be preferable in patients with hepatic failure during alcohol withdrawal?
Lorazepam.
What is another effective medication for the treatment of alcohol withdrawal?
Carbamazepine.
Is phenytoin effective in the treatment of alcohol withdrawal seizures?
No, phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.
summarise alcohol withdrawal
Alcohol withdrawal
Mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Features
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Management
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
A 62-year-old known alcoholic was admitted to hospital 3 days ago following a fall. Nurses say that in the last 3 hours he has become aggressive, confused, has been complaining of ‘pixies dancing around the bed’. On assessment you also note a coarse tremor and pyrexia. What is your best initial management?
Ethanol
Haloperidol
Chlordiazepoxide
Psychiatric team review
Thiamine
Chlordiazepoxide
Decreasing doses of long-acting benzodiazepines are used in the management of alcohol withdrawal
Ethanol use in delirium tremens (DTs) is not supported.
Haloperidol use is reserved for those who do not respond to oral lorazepam.
Oral chlordiazepoxide should be used first line to treat DTs, as per nice guidance.
Psychiatric team review may be appropriate, but it is not the best initial treatment, as this is clearly the DTs.
Thiamine should be started, but it is not the most important initial treatment for the DTs.
A 45-year-old man is admitted due to haematemesis. He reports drinking 120 units of alcohol a week. When is the peak incidence of seizures following alcohol withdrawal?
2 hours
6 hours
12 hours
24 hours
36 hours
36 hours
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Important for meLess important
A man is admitted from the angiography suite after the cardiologist discovered severe triple vessel disease. He awaits transfer to a tertiary hospital for a coronary artery bypass graft. Around 48 hours into his admission you are called to see him as he has become confused, sweaty, tremulous, and agitated.
His observations show a pyrexia at 37.9ºC, heart rate of 105 bpm, and blood pressure 175/98mmHg.
You review his record and note a history of asthma, variceal bleed, and cirrhosis secondary to alcohol excess.
Given the likely diagnosis, what would be the most appropriate immediate intervention?
CT head
Chlordiazepoxide
IV antibiotics
Intravenous hydration
Pabrinex
Chlordiazepoxide
Chlordiazepoxide or diazepam are used in the treatment of delirium tremens/alcohol withdrawal
Alcohol withdrawal usually presents within hours to days of alcohol cessation. Symptoms include agitation, confusion, autonomic dysfunction (e.g. high blood pressure, sweating and pyrexia, raised heart rate), hallucinations, and tremors.
Chlordiazepoxide is the correct answer. Chlordiazepoxide, diazepam, and lorazepam are used to treat alcohol withdrawal.
IV antibiotics are not the best answer here. Although confusion, sweating, and agitation can be signs of potential infection when we take into account the alcohol history for this patient the most likely diagnosis is delirium tremens as a result of alcohol withdrawal. If there were any concerns regarding infection it would not be unreasonable to give antibiotics, but this would not treat alcohol withdrawal. The blood pressure is high, rather than low as is often the case in infection, which is a hint.
Intravenous hydration is important if patients are diaphoretic with high insensible fluid losses. In this case, it is not the best answer as it would not treat the main problem which is alcohol withdrawal.
Pabrinex does have a role in the treatment of alcohol withdrawal in that it can help prevent the development of Wernicke’s encephalopathy (manifested by confusion, ataxia, and ophthalmoplegia). It does not, however, have any effect on the symptoms of delirium tremens and does not reduce the risk of alcohol withdrawal-related seizures. Chlordiazepoxide is therefore the most correct answer.
CT head is not the best answer here. In this case, we have an agitated patient and this can be an indication for a CT head to exclude an intracranial cause. There is no history of trauma, no mention of any focal neurological finding, and there is a good alternative explanation for the presentation. CT head would therefore not be the best immediate intervention.
A 42-year-old homeless woman is brought to ED during the day by a friend after being found slumped by a bus stop and with an acutely swollen, red, and hot right leg. She looked drowsy, emaciated, and was unable to give a coherent history. She was treated for a right leg cellulitis with intravenous flucloxacillin and fluids.
Her admission bloods showed:
Hb 105 g/L Male: (135-180)
Female: (115 - 160)
Platelets 175 * 109/L (150 - 400)
WBC 17.0 * 109/L (4.0 - 11.0)
Na+ 133 mmol/L (135 - 145)
K+ 3.6 mmol/L (3.5 - 5.0)
Urea 12.0 mmol/L (2.0 - 7.0)
Creatinine 145 µmol/L (55 - 120)
CRP 265 mg/L (< 5)
Glucose 4.6 mmol/L (4.0 - 11.1)
Albumin 30 g/L (35 - 50)
Alanine aminotransferase (ALT) 45 IU/L (10 - 50)
Aspartate aminotransferase (AST) 52 IU/L (10-40)
Alkaline phosphatase (ALP) 100 IU/L (25 - 115)
Bilirubin 22 µmol/L (<17)
Gamma glutamyl transferase (γGT) 110 U/L (9 - 40)
During the night, the ward nurse bleeped the doctor on-call as the patient had become sweaty, had a new tachycardia, and was trying to shake off ‘bugs’ that were crawling under her skin. Physical examination was normal, except for a tachycardia, sweating, and a red, hot, and swollen right leg. She was clearly agitated and constantly distracted by ‘crawling’ under her skin.
Her observations were:
Heart rate 110/min
Blood pressure 121/65 mmHg
Respiratory rate 26/min
Oxygen saturation 96% on room air
Temperature 37.4ºC
Glasgow Coma Score 15/15
Which one of the following measures would best treat her symptoms?
Intramuscular haloperidol
Intravenous naloxone
One-to-one nursing
Oral chlordiazepoxide
Escalate antibiotics to piperacillin-tazobactam (Tazocin)
Oral chlordiazepoxide
Chlordiazepoxide or diazepam are used in the treatment of delirium tremens/alcohol withdrawal
This woman has presented to hospital with cellulitis and little other history. Apart from raised markers for infection, her blood tests here would not explain her acute delirium. Mildly raised liver function tests (LFTs) may indicate a liver pathology - but be aware that cirrhotic patients may have normal LFTs as their liver starts to lose function. A low albumin can point towards reduced liver synthetic function, and an element of malnutrition. A raised gamma-GT is commonly seen in alcoholic patients, which is a clue in the question stem. The raised urea and creatinine are likely secondary to dehydration and sepsis.
She has developed a new tachycardia, sweating, and tactile hallucinations some hours after admission. Given her demographic, the timeframe before onset, and the nature of symptoms, you should consider acute alcohol withdrawal. This can be precipitated by admission to hospital, where the patient has lost access to alcohol. The fact she could not give enough information on admission to include a social history means this should be considered early on. This is best treated with a reducing regimen (and appropriate ‘as required’ cover) of chlordiazepoxide or another benzodiazepine, namely diazepam. You would choose oral over intravenous medication as an initial measure, as you should choose the least invasive or restrictive option.
Haloperidol can be used in acute delirium, but the question here points towards alcohol withdrawal, for which chlordiazepoxide is a better treatment. A delirium secondary to infection is a differential, but tactile hallucinations are uncommon, and you should consider alcohol withdrawal in patients with her risk factors and blood test results.
Naloxone is a treatment for opioid toxicity. In this, you’d expect a reduced GCS, low respiratory rate, and/or pinpoint pupils. You’d also expect a history of opioid use.
One-to-one nursing is important in patients with delirium and is often first-line in its management along with other de-escalation techniques. However, it is unlikely to treat the underlying withdrawal, and the patient is likely to get worse and is at risk of delirium tremens.
Escalating antibiotics to piperacillin-tazobactam would be premature, given she hasn’t had enough time to respond to the flucloxacillin. Moreover, her presentation fits more with alcohol withdrawal - one wouldn’t expect her to have tactile hallucinations, and you’d expect evidence of worsening infection; that is, drowsiness rather than agitation, hypotension, and/or a fever.
