Alcohol withdrawal

• Onset after last drink: 6-12h

• Onset after last drink: 6-48h
• Multiple seizures: 60% of patients
• Progression to DTs: 33% of patients
• Treat with benzos (not phenytoin)

• Onset after last drink: 12-24hr
• Visual hallucinations are most common
• Different from delirium tremens
  • Resolves within 24-48 from last drink (before onset of DTs)
  • No delirium
  • Normal vital signs

• Onset after last drink: 48+hrs
• Decreased attention and awareness
• Disturbance in attention, awareness, memory, orientation, language, perception, visouspatial ability that fluctuates in severity
• No evidence of coma or other evolving neurocognitive disorders

• Ethanol toxicity
• Alcohol use disorder
• Alcohol withdrawal
  • Alcohol withdrawal seizures
  • Delerium tremens
• Electrolyte/acid-base disorder
  • Alcoholic ketoacidosis
  • Beer potomania syndrome
  • Beriberi
  • Thiamine deficiency
  • Wernicke-Korsakoff syndrome

• Toxic alcohols
  • Ethanol
  • Ethylene glycol
  • Methanol
  • Isopropyl alcohol
• Benzodiazepines
  • Flunitrazepam (Rohypnol)
• Gamma hydroxybutyrate (GHB)
• Barbiturates
• Opioids
• Chloral hydrate

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
  • Non-compliance with anti-epileptic medications
• Non-epileptic seizure
  • Meningitis
  • Encephalitis
  • Brain abscess
  • Intracranial hemorrhage
  • Alcohol withdrawal
  • Benzodiazepine withdrawal
  • Barbiturate withdrawal
  • Baclofen withdrawal
  • Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
  • Eclampsia
  • Neurocysticercosis
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
  • Acute hydrocephalus
  • Arteriovenous malformation
  • Seizure with VP shunt
  • Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
  • Psychogenic nonepileptic seizure (pseudoseizure)
• Intracranial mass
• Syncope
• Hyperventilation syndrome
• Migraine headache
• Movement disorders
• Narcolepsy/cataplexy
• Post-hypoxic myoclonus (Status myoclonicus)

Clinical Institute Withdrawal Assessment – Alcohol – revised (CIWA-Ar)

• Headache 0-7
• Orientation 0-4
• Tremor 0-7
• Sweating 0-7
• Anxiety 0-7
• Nausea (and Vomiting) 0-7
• Tactile Hallucinations 0-7
• Auditory Hallucinations 0-7
• Visual Hallucinations 0-7
• Agitation 0-7

Maximum Score = 67

• <8: Typically do not require medication
• 8-19: Medication
• ≥20: Medication and admission

• Diazepam (Valium) 5-10 mg IV (depending on severity)
  • May repeat q5-10 min for severe withdrawal (may increase dose by 10 mg every 5-10 min until desired effect achieved, max dose of 200 mg)
  • Half-life 20-100 h (long acting)
• Lorazepam (Ativan) 1-4mg IV (depending on severity)
  • May repeat q15-20 min for severe withdrawal (titrated to effect)
  • Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis[1]
  • Half-life 10-20 h (medium acting)

• If patient does not respond to high doses of benzodiazepines
• 0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours

• Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
• Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min

• Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
• Phenobarbital 130-260 mg IV q 15-20 minutes
• Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions [2]

• May have some use in refractory cases
• Blocks the NMDA receptor which is excited an unregulated. [3]

• At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
• Give multivitamin PO; patient at risk for other vitamin deficiencies

The majority of chronic alcoholics do NOT require a banana bag[4][5]

• Thiamine 100mg IV
• Folate 1mg IV (cheaper PO)
• Multivitamin 1 tab IV (cheaper PO)
• Magnesium sulfate 2mg IV
• Normal saline as needed for hydration

• The propylene glycol diluent in lorazepam, phenobarbital, and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.[6] Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for delirium tremens.

Generally for outpatient treatment of mild cases and as a taper

• 25-50mg of chlordiazepoxide is equivalent to 10mg of diazepam
• 50mg of chlordiazepoxide every 8 hours for two days, then decrease to 25mg every 8 hours for another two days followed by 25mg PRN as needed.

• Have less abuse potential but may not prevent seizures[8]
• Gabapentin 400mg PO TID[9]
  • Some protocols call for higher dosing - 600 or 800mg x1
  • Similar efficacy to lorazepam in decreasing craving and anxiety[10]
  • Questionable efficacy in preventing alcohol withdrawal seizures
• Carbamazepine taper[11]
  • May start when BAL < 150 mg/dL
  • Varying evidence in support of whether agent truly reduces of alcohol withdrawal seizures and delirium tremens
  • 800 mg per day be fixed or tapered over 5-9 days

• 2 mg tid x3 days
• 2 mg BID on day 4
• 2 mg once on day 5

• 400 mg TID x3 days
• 300 mg BID on day 4
• 300 mg once on day 5

• 200 mg q6hr day 1
• 200 mg q8hr day 2
• 200 mg q12hr day 3
• 200 mg QD days 4 and 5

• Multiple seizures
• DTs
• Decreased LOC
• Inability to control withdrawal after administrating 3-4 doses of benzo's
• Consider ICU admission with CIWA score >20

• Two consecutive CIWA scores (two hours apart) <10 with resolution of tremor
• Consider discharge with 3 day course of benzodiazepines if patients are attempting to quit alcohol (controversial)
• Consider possible exclusions for outpatient treatment[12]:
  • Substance use disorders except alcohol, nicotine, or cannabis
  • Major Axis I psych disorder
  • Medication history of benzodiazepines, beta-blockers, calcium-channel blockers, antipsychotics
  • History of head injury, epilepsy, medical instability, ECG abnormality, grossly abnormal lab value