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Alcohol Withdrawal

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Alcohol Withdrawal Timeline and treatment Stats 8 Million alcoholics in the US 500,000 episodes of withdrawal requiring medication per year Daily drinking for 7-34 ... – PowerPoint PPT presentation

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Title: Alcohol Withdrawal


1
Alcohol Withdrawal
  • Timeline and treatment

2
Stats
  • 8 Million alcoholics in the US
  • 500,000 episodes of withdrawal requiring
    medication per year
  • Daily drinking for 7-34 days will cause minor
    withdrawal in most people
  • Daily drinking for 36-84 days will cause major
    withdrawal symptoms

3
Why?
  • EtOH is a CNS depressant
  • Abrupt withdrawal causes compensatory over
    stimulation
  • GABA major CNS inhibitor, and receptor is
    downregulated with EtOH consumption
  • NE elevates with EtOH withdrawal due to a
    decrease in the alpha-2 receptor-mediated
    inhibition of presynaptic norepinephrine release
  • Serotonin implicated in tolerance and craving
    for alcohol

4
Minor withdrawal symptoms
  • Insomnia
  • Tremulousness
  • Mild anxiety
  • Gastrointestinal upset
  • Headache
  • Diaphoresis
  • Palpitations
  • Anorexia

5
Minor
  • Present within 6 hours of last drink
  • Even if BAL is still elevated
  • Resolves in 24-48 hours

6
Withdrawal Seizures
  • Generalized tonic-clonic convulsions
  • Occur within 48 hours of last drink, but may
    occur as soon as 2 hours from last drink
  • 3 percent of chronic alcoholics have
    withdrawal-associated seizures
  • of those, 3 percent develop status epilepticus

7
Alcoholic Hallucinosis 
  • Not synonymous with delirium tremens
  • develop within 12 to 24 hours of abstinence
  • resolve within 24 to 48 hours (when DT starts)
  • Usually visual, may be tactile or auditory

8
DELIRIUM TREMENS 
  • 5 of alcoholics
  • hallucinations, disorientation, tachycardia,
    hypertension, low grade fever, agitation, and
    diaphoresis
  • 48-96 hours after last drink, and lasts 1-5 days

9
DT
  • Risk Factors
  • A history of sustained drinking
  • A history of previous DTs
  • Age greater than 30
  • The presence of a concurrent illness
  • A greater number of days since the last drink
    (for example, patients who present more than two
    days after their last drink for treatment of
    alcohol withdrawal are more likely to experience
    DTs than those who present within two days)

10
DT
  • Mortality rate of 5
  • Mortality associated with
  • Arrhythmias
  • Pneumonia

11
DT
  • Clinical manifestation
  • hallucinations, disorientation, tachycardia,
    hypertension, low-grade fever, agitation,
    diaphoresis, elevated cardiac indices, oxygen
    delivery, and oxygen consumption
  • Respiratory alkalosis
  • Hypokalemia and hypomagnesemia

12
(No Transcript)
13
Treatment
  • Bad actor
  • infection, trauma, metabolic derangements, drug
    overdose, hepatic failure, or gastrointestinal
    bleeding
  • Rule out comorbid conditions
  • Frequent assessment
  • Correct metabolic derrangements
  • Quiet and protective environment
  • Thiamine first, then glucose infusion for volume
    deficit

14
Treatment
  • Benzos
  • treat the psychomotor agitation
  • prevent progression from minor withdrawal
    symptoms to major ones
  • Valium and Librium most common
  • PO route preferred but may give IV prn
  • Intravenous diazepam, 5 to 10 mg IV every five
    minutes until the patient is calm

15
Treatment
  • Fixed schedule therapy, in which a benzodiazepine
    is given at fixed intervals even if symptoms are
    absent, is most useful in patients at high risk
    of major withdrawal symptoms
  • Healthy pts should be kept lightly sedated
  • Pts with comorbidities, especially cardiac,
    should be more heavily sedated

16
Treatment
  • Symptom-triggered therapy
  • Clinical Institute Withdrawal Assessment for
    Alcohol Scale
  • Given when gt8
  • Fewer benzos given, shorter course of therapy

17
Clinical institute withdrawal assessment scale
for alcohol, revised (CIWA-Ar)
18
CIWA-Ar
  • Total score is a simple sum of each item score
    (maximum score is 67).
  • Scorelt10 Very mild withdrawal
  • 10-15 Mild withdrawal
  • 16-20 Modest withdrawal
  • gt20 Severe withdrawal

19
Treatment
  • Refractory DT
  • Probably d/t low GABA
  • Barbituates used (phenobarbital) or propofol
  • Do NOT use anti-psychotics (lowers sz threshold),
    anticonvulsants, baclofen, clonidine

20
In summary
  • Careful HP to determine risk of withdrawal and
    DT
  • Pts with h/o sz, DT or major EtOH withdrawal
    should be on scheduled dosing of Valium or
    Librium
  • Pts at risk for withdrawal should be closely
    monitored and treated if Clinical Institute
    Withdrawal Assessment for Alcohol Scale is gt8
  • DT treated with IV valium until stable
  • Refractory DT treated with phenobarbital or
    propofol
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