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| | {| class="infobox" style="float:right;" |
| | | [[File:Siren.gif|30px|link= Alcohol withdrawal resident survival guide]]|| <br> || <br> |
| | | [[Alcohol withdrawal resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| __NOTOC__ | | __NOTOC__ |
| '''For patient information, click [[Alcohol withdrawal (patient information)|here]]''' | | {{Alcohol withdrawal}} |
| {{SI}}
| | '''For patient information click [[Alcohol withdrawal (patient information)|here]].''' |
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| {{CMG}} ; {{AE}} {{ADI}} | | {{CMG}}; {{AE}} {{SHA}}, {{ADI}} |
| | ==[[Alcohol withdrawal overview|Overview]]== |
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| == Overview == | | ==[[Alcohol withdrawal historical perspective|Historical Perspective]]== |
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| Alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every day '''suddenly stops''' drinking alcohol. | | ==[[Alcohol withdrawal classification|Classification]]== |
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| == Pathophysiology == | | ==[[Alcohol withdrawal pathophysiology|Pathophysiology]]== |
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| * Prolonged exposure to alcohol results in inhibition of the inhibitory GABA A-type and NMDA-type glutamate receptors located in the CNS. Without the alcohol, greater CNS excitability results.
| | ==[[Alcohol withdrawal causes|Causes]]== |
| * Elevated norepinephrine has been found in the CSF of withdrawing patients. It is postulated that 2-receptors are decreased resulting in less inhibition of presynaptic norepinephrine release.
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| == Epidemiology and Demographics == | | ==[[Alcohol withdrawal differential diagnosis|Differentiating Alcohol withdrawal from other Diseases]]== |
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| * Alcohol abuse or dependence afflicts up to 15 million persons in the United States. It accounts for 100,000 deaths and an economic burden of over 100 billion dollars per year. The lifetime prevalence of alcohol abuse is approximately 14% and of alcohol dependence is 8%. Approximately 500,000 patients/year develop withdrawal that is severe enough to prompt pharmacologic management. <br><br>
| | ==[[Alcohol withdrawal epidemiology and demographics|Epidemiology and Demographics]]== |
| * Between 13% and 71% of persons admitted for detoxification have evidence of withdrawal.
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| * Approximately 3% of chronic alcoholics develop withdrawal seizures. Five percent of patients with alcohol withdrawal develop delirium tremens (DTs), which is associated with approximately 5% mortality.
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| == Natural history, Complications and Prognosis == | | ==[[Alcohol withdrawal risk factors|Risk Factors]]== |
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| How well a person does depends on the amount of organ damage and whether the person can stop drinking completely. Alcohol withdrawal may range from a mild and uncomfortable disorder to a serious, life-threatening condition. People who continue to drink a lot may develop health problems such as liver and heart disease. Most people who go through alcohol withdrawal make a full recovery. However, death is possible, especially if [[delirium tremens]] occurs.
| | ==[[Alcohol withdrawal natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| == Diagnosis == | | ==Diagnosis== |
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| === Criteria ===
| | [[Alcohol withdrawal diagnostic criteria|Diagnostic Criteria]] | [[Alcohol Withdrawal Calculator]] | [[Alcohol withdrawal history and symptoms| History and Symptoms]] | [[Alcohol withdrawal physical examination | Physical Examination]] | [[Alcohol withdrawal laboratory findings|Laboratory Findings]] | [[Alcohol withdrawal CT|CT]] | [[Alcohol withdrawal other imaging findings|Other Imaging Findings]] | [[Alcohol withdrawal other diagnostic studies|Other Diagnostic Studies]] |
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| # History of cessation or reduction in heavy and prolonged alcohol use.
| | ==Treatment== |
| # 2 or more of:
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| #:* autonomic hypereactivity
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| #:* hand tremor
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| #:* insomnia
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| #:* nausea and vomiting
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| #:* transient tactile
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| #:* visual or auditory hallucinations
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| #:* psychomotor agitation
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| #:* anxiety
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| #:* grand mal seizures
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| #:*:* Note history of blackouts, morning shakes, prior detoxifications or DTs and frequency, amount and type of alcohol.
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| === Symptoms ===
| | [[Alcohol withdrawal medical therapy|Medical Therapy]] | [[Alcohol withdrawal surgery|Surgery]] | [[Alcohol withdrawal primary prevention|Primary Prevention]] | [[Alcohol withdrawal secondary prevention|Secondary Prevention]] | [[Alcohol withdrawal cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Alcohol withdrawal future or investigational therapies|Future or Investigational Therapies]] |
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| * '''Common symptoms include:'''
| | ==Case Studies== |
| :* [[Anxiety]] or nervousness
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| :* [[Clinical depression|Depression]]
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| :* Not thinking clearly
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| :* [[Fatigue ]]
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| :* Irritability
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| :* Jumpiness or shakiness
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| :* Mood swings
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| :* [[Nightmares]]
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| * '''Other symptoms may include:'''
| | [[Alcohol withdrawal case study one|Case#1]] |
| :* Clammy skin
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| :* Enlarged (dilated) pupils
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| :* [[Headache ]]
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| :* [[Insomnia ]] (sleeping difficulty)
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| :* Loss of appetite
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| :* [[Nausea]] and [[vomiting]]
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| :* Pallor
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| :* Rapid heart rate
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| :* [[Sweating]]
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| :* [[Tremor]] of the hands or other body parts
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| * A severe form of alcohol withdrawal called '''[[Delirium tremens ]]''' can cause:
| | ==Related Chapters== |
| :* [[Agitation]]
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| :* [[Confusion ]]
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| :* Seeing or feeling things that aren't there ([[Hallucination]])
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| :* [[Fever]]
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| :* [[Seizures]]
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| === Physical examination ===
| | * [[Mixing alcohol with medicines]] |
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| :* Abnormal eye movements
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| :* Abnormal heart rhythms
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| :* Not enough fluids in the body ([[dehydration]])
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| :* Rapid breathing
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| :* Rapid heart rate
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| :* Shaky hands
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| :* Blood and urine tests, including a [[toxicology screen]]
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| == Treatment ==
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| * No clinical findings can reliably predict who will or will not develop withdrawal. Risk factors for DTs: Previous DTs or detoxifications, Age >30, high degree of alcohol dependence, duration of abuse, the presence of moderate symptoms (CIWA >14) left untreated and concurrent medical illness are all strongly predictive. These findings should prompt intervention. Time abstinent may be a helpful negative predictor. In one large study, patients who were asymptomatic 36 hours after their last drink did not develop symptoms.
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| * All patients with alcohol abuse should receive 1mg Folate QD, Magnesium/ phosphate/potassium/fluid volume repletion and Thiamine 100 mg IV/IM x1 then 100 mg QD.
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| * Treatment of alcohol related seizures is on an as needed basis with benzodiazepines. They tend to be transient phenomenon. Phenytoin is ineffective in the management of withdrawal seizures, but may be indicated if another seizure disorder or status epilepticus is present. Long term medical suppression or prophylaxis is not indicated for withdrawal seizures. Neuroleptics lower the seizure threshold and should not be used in these patients; however, haloperidol has been used safely in conjunction with benzodiazepines (BDZs).
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| * BDZs are the cornerstone of therapy for minor withdrawal, seizures and DTs. Fixed schedule therapy, front-loading therapy and symptom-triggered therapy have all been evaluated with similar efficacy. Symptoms triggered therapy was associated with less total administration of drug and shorter length of stay but has only been evaluated in patients without acute comorbid illness or seizures and should be restricted to only this limited group of patients.
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| * Guidelines at BIDMC suggest use of the front loaded regimen preferably with long acting BDZs. Use of short acting BDZs is reserved for patients with liver dysfunction and/or medical instability. Treatment efficacy is assessed using the CIWA Scale (see below).
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| * In the medically stable patient with no liver dysfunction 10 mg PO/IV is administered every hour till CIWA <10 or sedated. If the patient is stable but has liver disease, give 2 mg Lorazepam IV/PO Q 1H till CIWA <10 or sedated. Calculate the total dose used and give this Q6H for 24 hrs. Use that latter regimen for the unstable patient.
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| * If CIWA is stable x24 hours then decrease the dose by 20%/day. If there is a history of DTs or seizures or the patient is unstable decrease the dose by 10%/day. Give prn doses of lorazepam recurrence of withdrawal (CIWA >10).
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| [[Image:Alcoholwithdrawal.PNG]] | |
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| == References ==
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| 1. Saitz R, SS OM. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am 1997; 81:881-907.
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| 2. PG OC, Schottenfeld RS. Patients with alcohol problems. N Engl J Med 1998; 338:592-602.
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| 3. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997; 278:144-51.
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| [[ro:Sindromul de abstinenţă la alcool]]
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| [[Category:Disease]] | | [[Category:Disease]] |
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| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Toxicology]] | | [[Category:Toxicology]] |
| | [[Category:Intensive care medicine]] |
