Episode 87 – Alcohol Withdrawal and Delerium Tremens: Diagnosis and Management [link is to the show notes and podcast] is another bases loaded home run by Dr. Anton Helman and his colleagues at Emergency Medicine Cases.
Here is a link to the Episode 87 show notes in PDF format.
What follows is from the Episode 87 show notes:
The ideal management of alcohol withdrawal involves 4 steps:
- Identify which patients actually have alcohol withdrawal and require treatment
- Use a standardized, symptom guided approach to assess symptom severity and guide treatment. Protocols for treating alcohol withdrawal standardize care, they ensure clinicians identify the appropriate symptoms and monitor treatment. Protocols for alcohol withdrawal have been shown to improve the quality and consistency of care patients receive.*The CIWA protocol is a 10-item scale. It has been well validated in patients with alcohol withdrawal, but should not be used for patients with delirium tremens. The CIWA calls for patients to be assessed hourly and treated if the total score is 10 or greater. When 2 sequential scores are < 10 they may be considered for discharge.*CIWA on MDCalc Here
- Ensure that patients are fully treated prior to ED discharge
- Provide a pathway to support patients who are trying to quit
Timing of Alcohol Withdrawal and Delirium Tremens
Symptoms from alcohol withdrawal usually start within 6-8 hours after the blood alcohol level decreases, peak at 72 hours, and diminish by days 5 to 7 of abstinence. Delirium Tremens can occur anytime from 3 to 12 days after abstinence.
Patients who are severely dependent on alcohol become tolerant to alcohol and their nervous systems have been reset to compensate for the sedating effects of alcohol. The likelihood of developing withdrawal is dependent on the usual amount consumed and the duration of consumption. Therefore, patients who consume large amounts of alcohol on a regular basis are more likely to develop withdrawal requiring pharmacologic management compared to those who binge sporadically.
And here is a link to another good resource, Benzodiazepine-Refractory Alcohol Withdrawal, from R.E.B.E.L. EM. The post topic is also covered in EMC Episode 87 but I wanted to quote the following:
Severe alcohol withdrawal syndrome (AWS) accounts for only 10% of the roughly 500,000 annual cases of AWS episodes that require pharmacologic treatment. AWS is characterized by an imbalance between inhibitory GABA and excitatory NMDA receptor stimulation secondary to chronic ethanol intake. Treatment is typically centered around supportive care and symptom-triggered benzodiazepines. However, some patients are refractory to benzodiazepines, defined as > 10 mg lorazepam equivalents in 1 hour or > 40 mg lorazepam equivalents in 4 hours. Doses exceeding this threshold provide little benefit and put patients at risk for increase morbidity and mortality, over sedation, ICU delirium, respiratory depression and hyperosmolar metabolic acidosis.
