EM Toxicology 16: Alcohol Withdrawal Syndrome

Question 1

Alcohol withdrawal symptoms may begin as early as _______ after reduction in alcohol consumption, and persist for up to _________

Answer 1

as early as 2 to 6 hours….
….for up to 2 weeks

Question 2

The first step in successful treatment of alcohol withdrawal is:

Answer 2

to identify alcohol withdrawal early and distuinguish withdrawal from mimics

Question 3

Alcohol withdrawal continuum

Answer 3

Minor Symptoms
Alcohol Withdrawal Hallucinations
Withdrawal Seizures
Delirium Tremens

Question 4

Remarks on Alcohol Withdrawal with only Minor Symptoms

Answer 4

anxiety, insomnia, palpitation, tremor
may not require medical care

Question 5

Remarks on Alcohol Withdrawal Hallucinations

Answer 5

tactile most common
occasionally auditory or visual
Patients generally recognize these hallucinations as not real and maintain a clear sensorium.

Question 6

Remarks on Alcohol Withdrawal Seizures

Answer 6

may occur as early as 6 h
90% occur within 48 hours

Question 7

Remarks on Delirium Tremens

Answer 7

Autonomic instability: AMS, fever, hypertension, tachycardia, diaphoresis
peaks at 5 days
may last up to 7 days

Question 8

Alcohol-induced psychotic disorder

Answer 8

auditory hallucinations predoinate
often of a persecutory nature

diagnostic criteria require that symptoms start within 2 weeks of alcohol consumption and persist for 48 horus or greater beyond the withdrawal state

Question 9

goals of therapy for alcohol withdrawal

Answer 9

1. alleviate autonomic hyperactivity and agitation
2. halt progression to delirium tremens
3. provide motivation for and access to detoxification to promote long-term abstinence

Question 10

initial therapy in alcohol withdrwal

Answer 10

benzodiazepines
no specific agent is superior to the others

Question 11

remarks on IM diazepam

Answer 11

absorption of iM diazepam is erratic, and therefore IM diazepam is not recommended

Question 12

scoring system used in alcohol withdrawal syndrome

Answer 12

CIWA-AR
Clinical Institute Withdrawal Assessment for Alcohol-Revised

Question 13

Frequency of giving benzodiazepines in alcohol withdrawal

Answer 13

If the CIWA score is ≥15, successive doses are given every hour until the score is <15.

If the score is 8-14, successive doses are given every 2 hours until the score is <8

Question 14

TRUE or FALSE
Phenytoin is not recommended for prevention of further alcohol-related seizures.

Answer 14

TRUE
In fact, loading of phenytoin may lower the seizure threhold.

Question 15

remarks on propofol infusion syndrome

Answer 15

may result from prolonged use (>48 hours) of propofol at a dose of >5 mg/kg/hour
dysrhythmia, hear failure, hyperkalemia, metablic acidosis, and rhabdomyolysis

Question 16

Vitamins that should be considered for patients with alcohol withdrawal delirium

Answer 16

Thiamine 100 mg daily
and folate 1 mg daily

Question 17

recommended treatment for alcohol-induced psychotic disorder

Answer 17

Antipsychotic therapy
Abstinence from alchol
Assesssment of mental health (because of increased risk of suicide)

Question 18

Indications for admission for alcohol withdrawal syndrome

Answer 18

advanced age
mild or moderate withdrawal that’s unresponsive to ED treatment
active medical comorbidities
prior history of delirium tremens
alcohol withdrawal seizures

ICU: moderate with comorbids or severe with sedative requirements