Ethanol withdrawal case file

Ethanol withdrawal case file

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 55

A 50-year-old man presents to the emergency department (ED) with anxiety, insomnia, and nausea. He denies having any hallucinations or seizures. He states that he had been drinking about a half bottle of hard liquor each day for years. After his wife threatened to divorce him and he was fired as a result of his alcoholism, he decided to stop drinking “cold turkey.” His last alcohol intake was two days ago. He has a history of hypertension, for which he takes hydrochlorothiazide. He does not smoke or use illicit drugs.

On examination, his temperature is (100.4οF), blood pressure is 175/95, heart rate is 120 beats per minute, and respiratory rate is 24 breaths per minute. He is tremulous and diaphoretic. He appears mildly dehydrated with dry mucous membranes. The lungs are clear to auscultation, and the heart sounds are regular although tachycardic. He is alert and oriented, and he does not have any focal neurologic deficits except for bilateral distal sensory loss in the hands and feet (in a stocking-glove distribution).

⯈ What are potential complications?

⯈ What is the best treatment for this patient?

ANSWER TO CASE 55:

Ethanol Withdrawal

Summary: This is a 50-year-old man with acute alcohol withdrawal as evidenced by his anxiety, tremor, and signs of autonomic hyperactivity (hyperthermia, hypertension, tachycardia, tachypnea, diaphoresis). However, he does not currently exhibit the more serious signs of alcohol withdrawal, such as seizure, hallucinations, or delirium.

• Potential complications: seizures, hallucinations (auditory, visual, or tactile), delirium (delirium tremens or DTs).
• Treatment: Intravenous (IV) fluids, repletion of electrolytes as needed, benzodiazepines to control symptoms and prevent more serious manifestations of withdrawal (listed above).

ANALYSIS

Objectives

1. Recognize the clinical signs and symptoms of ethanol withdrawal (including seizures, hallucinations, and delirium).
2. Understand the evaluation and treatment of patients with ethanol withdrawal.

Considerations

Because ethanol abuse is prevalent in the community, emergency physicians need to be prepared to treat those who present with alcohol withdrawal. Symptoms may range from mild anxiety, nausea or vomiting, insomnia, and tremor to hallucinations, seizures, and delirium. Mild cases of withdrawal may be treated with oral benzodiazepines; however, patients with more serious symptomatology may require large doses of IV benzodiazepines, IV hydration, repletion of electrolytes, and hospital admission.

Approach To:

Ethanol Withdrawal

CLINICAL APPROACH

Among patients presenting to the ED for any complaint, the prevalence of alcoholism or inappropriate drinking is estimated to be between 8% to 40%. Some patients arrive at the ED due to a desire to stop drinking; others have already ceased their alcohol intake and require relief of the symptoms of withdrawal. In addition, alcohol dependent patients with prolonged ED stays may be unable to maintain their usual ethanol intake and begin to manifest anxiety or tremors. Thus, emergency physicians will encounter many patients with alcohol withdrawal and must be prepared to treat this syndrome.

Because ethanol has a depressant effect on the central nervous system (CNS), withdrawal leads to CNS excitation. Symptoms may range from mild anxiety, nausea or vomiting, insomnia, and tremor to agitation, hallucinations, seizures, and delirium. Patients often manifest signs of autonomic hyperactivity (hyperthermia, hypertension, tachycardia, tachypnea, diaphoresis, hyperreflexia). Withdrawal may occur as soon as the blood alcohol level starts to fall following an abrupt reduction in or cessation of alcohol intake. Minor withdrawal tends to begin earlier with a peak at 24 to 36 hours while major withdrawal usually occurs after 24 hours with a peak at 50 hours.

Alcohol withdrawal hallucinations may be auditory, visual, or tactile although auditory ones are most common. Patients with this condition have a clear sensorium. Alcohol withdrawal seizures are tonic-clonic and may occur singly or multiply. Up to one-third of these patients progress to DTs. Delirium tremens is the most severe form of alcohol withdrawal. It is characterized by fluctuating levels of consciousness, cognitive disturbances, profound confusion, and severe autonomic hyperactivity. With treatment, the mortality of DTs is 1% to 10%.

The differential diagnosis of alcohol withdrawal is broad and includes infections (eg, meningitis, encephalitis), other seizure disorders (eg, epilepsy), endocrine disorders (eg, thyrotoxicosis or thyroid storm), trauma (eg, subdural hemorrhage), metabolic abnormalities (eg, hypoglycemia), psychiatric disorders (eg, schizophrenia), drug intoxications (eg, sympathomimetics, antihistamines), and other types of withdrawal syndromes (eg, benzodiazepines). Benzodiazepines are widely used as anxiolytics, sleep aids, anticonvulsants, and muscle relaxants. Because benzodiazepines are also CNS depressants, withdrawal from these agents may be clinically indistinguishable from alcohol withdrawal. A history of prolonged or high dose benzodiazepine use may be helpful to differentiate between the two. Abrupt discontinuance of short-acting benzodiazepines may be symptomatic after 2 to 3 days while withdrawal from long-acting agents may present up to 7 days after cessation.

Important historical information includes current symptomatology, usual amount of alcohol consumption, timing of last alcohol intake, comorbidities, and any other medication or other drug use. The initial evaluation of the patient should involve the assessment (and stabilization if necessary) of the ABCs. A complete set of vital signs is paramount in order to identify any autonomic hyperactivity. The patient should be examined from head to toe looking for evidence of alternative etiologies for the patient symptoms (eg, signs of trauma associated with intracranial hemorrhage, nuchal rigidity with meningitis, thyromegaly with thyrotoxicosis, etc). In addition, a thorough neurologic examination should be performed to identify any alterations in level of consciousness or mental status as well as any focal deficits.

Diagnostic studies are largely useful in ruling out alternative diagnoses and concomitant medical conditions. Patients with mild alcohol withdrawal may not require any laboratory studies or imaging. Those with severe withdrawal may require a more extensive workup including any or all of the following: complete blood count, electrolytes, renal function tests, glucose, liver enzymes, blood gas, thyroid function studies, cardiac enzymes, urinalysis, urine drug screen, ECG, chest x-ray, computed tomography of the head, and/or lumbar puncture.

Treatment

Treatment of alcohol withdrawal serves several purposes: symptomatic relief, calming of the patient to allow an adequate evaluation, and prevention of progression of symptoms. The mainstay of treatment is benzodiazepines, most commonly chlordiazepoxide, diazepam, and lorazepam. These medications are titrated to control the patient agitation, and very high doses may be required. Neuroleptics such as haloperidol or ziprasidone may be considered for patients who do not respond adequately to benzodiazepines. In addition, a continuous propofol infusion may be beneficial in patients with severe withdrawal who are refractory to high dose benzodiazepines. The alpha-agonist clonidine may be a useful adjunct to counteract the autonomic hyperactivity associated with alcohol withdrawal. β-Blockers may also help control tachycardia and hypertension; however, they may mask some of the earlier signs of impending DTs. Depending on the patient fluid and nutrition status, IV hydration and repletion of electrolytes (eg, potassium, magnesium, and phosphorus) may be needed. Malnourished patients should also be given thiamine and folate replacement.

COMPREHENSION QUESTIONS

55.1 A 25-year-old woman has been taking clonazepam every day for 3 years for generalized anxiety disorder. She is in town on vacation but forgot her medication at home. When is she most likely to start showing symptoms of withdrawal?

A. 12 hours

B. 2 days

C. 6 days

D. 10 days

55.2 A 50-year-old man is admitted for a femur fracture following a motor vehicle collision. Two days after admission, he becomes very agitated, tremulous, diaphoretic, tachycardic, and hypertensive. From what substance might he be withdrawing?

A. Alcohol

B. Cocaine

C. Marijuana

D. Oxycodone

55.3 A 60-year-old homeless man presents to the ED with acute alcohol withdrawal. He has been given 2 mg of lorazepam IV, but still appears very agitated and anxious. What is the most appropriate next step?

A. Clonidine 0.2 mg PO

B. Haloperidol 5 mg IV

C. Lorazepam 2 mg IV

D. Propanolol 100 mg PO

ANSWERS

55.1 C. Clonazepam is a long-acting benzodiazepine. Abrupt discontinuance of short-acting benzodiazepines may be symptomatic after 2 to 3 days while withdrawal from long-acting agents may present up to 7 days after cessation. Treatment of benozodiazepine withdrawal involves reinstitution of a benzodiazepine followed by a gradual taper.

55.2 A. The agitation, tremor, and autonomic hyperactivity point towards alcohol withdrawal. All patients admitted to the hospital for medical or traumatic conditions should be asked about drug and alcohol use. After admission, they may not have access to the drugs and/or alcohol they regularly use and may present with withdrawal syndromes.

55.3 C. While all are appropriate treatments for alcohol withdrawal, benzodiazepine dosing is tapered to the patient agitation. It may be redosed at 10 to 30 minute intervals for patients in severe withdrawal. Very high doses may be required especially if the patient has DTs.

CLINICAL PEARLS

⯈ Alcohol is a CNS depressant. Withdrawal leads to CNS stimulation and autonomic hyperactivity.

⯈ The differential diagnosis of alcohol withdrawal includes infections, other seizure disorders, endocrine disorders, trauma, metabolic abnormalities, psychiatric disorders, drug intoxications, and other types of withdrawal syndromes.

⯈ The mainstay of treatment for alcohol withdrawal is benzodiazepines.

REFERENCES

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2009. 

Kelly JF, Renner JA. Alcohol-related disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, PA: Mosby Elsevier; 2006:2858-2882. 

Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 2003;348(18): 1786-1795. Tintinalli JE, Stapczynski JS. 

Tintinall’si Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011.

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