In this episode of "IM Basics," host Dr. Eric Acker is joined by Dr. Michael Bass to tackle the frequently encountered topic of alcohol withdrawal. They provide a comprehensive overview, starting with the fundamental definitions and pathophysiology, moving through patient presentation, workup, and the nuances of treatment. Learn to look beyond simply ordering a protocol and gain a deeper understanding of how to manage these complex patients dynamically.

In this episode, you will learn about:

• Defining and Scoring Alcohol Withdrawal:
  • Symptoms are categorized as mild (anxiety, tremors, insomnia, palpitations) or severe (hallucinations, seizures, delirium tremens). Only about 20% of patients develop severe symptoms.
  • The DSM-5 criteria for diagnosis require two or more specific symptoms following the cessation or reduction of alcohol use.
  • The CIWA is a common scoring system used by nursing staff to guide treatment based on symptom severity.
• The Pathophysiology of Withdrawal:
  • Chronic alcohol use enhances the effect of the inhibitory GABA receptors and inhibits the excitatory NMDA receptors.
  • The body adapts by decreasing the sensitivity of GABA receptors and increasing the sensitivity of NMDA receptors.
  • When alcohol is stopped, the brain is left in a state of uninhibited excitatory stimulation.
• Timeline of Symptoms:
  • 6-36 hours after last drink: Mild symptoms like tremors, sweats, and agitation may appear.
  • 6-48 hours: Seizures can occur.
  • 12-48 hours: Hallucinations (visual, auditory, or tactile) may develop.
  • 48-96 hours: The most severe manifestation, delirium tremens (DTs), can set in.
• Patient Workup:
  • A thorough history is the most critical part of the workup, especially the timing of the last drink and the quantity consumed.
  • Labs are essential to rule out other conditions and should include a blood glucose, CBC, electrolytes, and blood cultures.
  • An ethanol level can be checked, but a patient can be in withdrawal even with a detectable alcohol level.
• Treatment Strategies:
  • Symptom-Triggered Therapy: This is the most recommended approach, where benzodiazepines are given based on a CIWA score threshold (e.g., a score greater than 8 or 10).
  • Benzodiazepines: These are the mainstay of treatment and work by stimulating the GABA receptor.
    • Lorazepam (Ativan): Slower onset (15-30 mins) but shorter duration.
    • Diazepam (Valium): Faster onset (2-3 mins) but longer half-life, which can lead to accumulation.
  • Refractory Withdrawal: For patients who don't respond to high doses of benzodiazepines, phenobarbital is an option. It can be used as a dual therapy with benzos or as a monotherapy.
  • Front-Loading: For patients at high risk of severe withdrawal (e.g., history of DTs), proactively administering high doses of benzodiazepines can be considered.
• Pearls and Pitfalls:
  • Be aware that benzodiazepines can cause paradoxical agitation in elderly patients,
  • Don't get anchored on alcohol withdrawal, especially considering hepatic encephalopathy in patients with cirrhosis.
  • Remember supportive care: thiamine, along with a multivitamin and electrolyte repletion
  • Always reassess your patient if the treatment isn't working.