Past Case 5: Alcohol withdrawal + delirium

Question 1

You are the orthopaedic intern. A 52 year old man was admitted after falling at home whilst intoxicated and sustained a hip fracture which was repaired 2 days ago. Last night, nursing staff noticed he was becoming more perplexed and agitated. He was awake for most of the night and was noted to be gesturing and talking to himself. On examination today, he appears dishevelled and malnourished, perplexed, pre-occupied and agitated and stares suspiciously around the room. He struggles to hold his focus and says: “they want to hurt me – can’t you see them?” He is disoriented to time and place, tachycardic with fluctuating blood pressure, tremors and increased sweating and is afebrile. He denies wanting to harm himself or others but fears for safety. Bloods on admission indicate elevated LFTs but no other abnormality.

Answer 1

Impression
Impression
Given the history of significant alcohol intake and intoxication coupled with the physiological features of withdrawal (HTN, tremors, diaphoresis, hallucination, confusion, and elevated LFTS) this is strongly indicative of acute alcohol withdrawal, and I am concerned about this potentially becoming a delirium tremens

There are other differentials I would need to consider in this case.
- Withdrawal from other substances
- Delirium (given recent surgery, may have other triggers i.e post-op infection)
- Organic causes (seizures, post-ictal confusion, medication interaction, thyroid dysfunction, ICH, electrolyte derangement, hypoglycaemia, sepsis), as well as any underlying cognitive impairment, rule out sub-arachnoid haemorrhage from fall
- Psychiatric:
o Psychosis, brief psychotic disorder, schizophreniform
o Mood disorder: Depression/bipolar with psychotic features

Priorities

• Treat alcohol withdrawal imminently and limit risk of severe life-threatening complications including Wernickes-Korsakoffs syndrome
• rule out other life-threatening complications (sub-dural hb)
• Conduct psychiatric assessment to rule out underlying psychiatric pathology (H/E/I)

Question 2

Alcohol withdrawal - History

Answer 2

History

• Sx: further characterise symptoms of alcohol withdrawal, and stratify as to whether it is mild-mod or severe (severe: hallucinations, tremors, N/V/D, diaphoresis, palpitations, tachycardia, seizures). Would want to screen for evidence of Wernickes encephalopathy (ataxia, ophthalmoplegia, confusion) and korsakoffs (memory loss/cognitive decline, personality change, confabulation)
• HPI: characterise extent of alcohol use disorder, volume, duration, timing, previous withdrawal sx.
• Corroborative history if possible from partner/family members, particularly if too confused to answer questions
• Screen for psychotic features, mood disturbances, mania, and violence history as a part of risk assessment and for ruling out psychiatric differential diagnosis
• Complete substances history (any other substances)
• Risk assessment: violence, suicide and self harm tendencies, ask about personality and get impression of impulsivity
• Past psych history
• Fam history
• Developmental history
• Current background
• Social history

Question 3

Alcohol withdrawal - Examination

Answer 3

Examination
- General obs + vital signs
- Would utilise and AWS to objectively assess and inform management
- Gastrointestinal examination: stigmata of chronic liver disease (clubbing, palmar erythema, telangiectasia, gynaecomastia)
MSE
- A/B: agitation, non-cooperation, adiposity, muscle wasting, poor self-care
- S: slurred, incoherent
- M/A: hostile/agitated, reactive
- TC: delusions, hallucinations, delirium
- P: hallucinations
- I/J: impaired

Question 4

Alcohol withdrawal - Investigations

Answer 4

Investigations
Would conduct a number of investigations to rule out organic causes of the presentation and to guide initial medical management of the patient;
- Bedside: urine drug screen, BSL, ECG, urinalysis
- Bloods: FBC, CRP/ESR, LFTs, UEC, TFT, vitamins panel, BAC
- Imaging: abdominal ultrasound + elastography, consider head CT/MRI given fall while intoxicated to rule out ICH
- Other: CAMS, A4W assessment for delirium, conduct cognitive assessment (MMSE) to assess for any underlying impairment

Question 5

Alcohol withdrawal - Management

Answer 5

Management
Goals are to reduce the acute risks of Acohol withdrawal and limit any complications. Keep patient comfortable, and initiate ongoing management plans to reduce future risk.

Risk assessment

• Patient: complications of withdrawal; DT, wernickes/korsakoffs. Other medical prolems
• Staff: if patient becomes aggressive, or hard to control, may require de-escalation measures, sedation (sedated as per Alcohol withdrawal management anyway)

Setting/location

• Given the severity of the patients symptoms, and surgical issues he will need to be managed on an inpatient basis, and discharged once long-term management plan is adequately in place
• Voluntary vs involuntary
• If DT, would likely need ICU admission, high mortality rate associated with this complication

Biological

• Benzodiazepines: diazepam 20mg PO every 2 hours until sx subside, cumulative dose of 60mg per day is usually sufficient. If there is chronic liver disease/impairment, can use lorazepam, oxazepam or temazepam as they have less conversion by CYP450 enzyme system
• Thiamine: start thiamine replacement therapy at 300mg TDS, ensure starting prior to dextrose if hypoglycaemic (as this can precipitate wernicke’s encephalopathy)
• Further supportive measures: supplemental O2, fluids, electrolytes
• If worsening of psychotic features, consider administration of antipsychotic, namely haloperidol 0.5mg PO every 2 hrs and titrated to clinical effect

Long-term pharmacological management

• Disulfiram (Antabuse): lactate dehydrogenase inhibitor
• AcamprosateL enhances GABA transmission, reduces cravings and increases period of abstinence
• Naltrexone: opioid receptor antagonist, reduces pleasurable effects of

Psychological

• CBT
• Counselling
• AA group therapy

Social

• Regular GP review/follow-up
• D&A referral