Alcohol Withdrawal
OVERVIEW
- common and can be fatal
- manifests within 48 hours of stopping drinking
CLINICAL FEATURES
Stage I – 6-24 hrs
- anxiety
- restlessness
- decreased attention
- tremulousness
- insomnia
- craving
Stage II – 24 hrs
- hallucinations (visual, auditory, tactile)
- misperceptions
- irritability
- vivid dreams
- confused
- hypervigilant
Stage III – 48 hrs
- generalised tonic-clonic seizures
Stage IV – after 48 hrs
- global confusional state
- autonomic hyperactivity
- tremors
- hallucinations
- seizures
- hyperadrenergic: diaphoresis, flushing, mydriasis, tachycardia, hypertension, low-grade fever
INVESTIGATIONS
- macrocytosis without anaemia
MANAGEMENT
- quite environment
- frequent verbal orientation
- reassurance
Resuscitate
- secure airway if prolonged seizure activity or not protecting airway
- clonidine to decrease autonomic symptoms
- beta-blockers generally not advised but can be used in selected cases
- benzodiazepines for seizure control
Acid-base and Electrolytes
- thiamine
- Magnesium and other deficiencies associated with chronic alcohol abuse
Specific Treatment
- goal = achieve light sedation to abate withdrawal symptoms, provide relief and protect patient.
- benzodiazepines (midazolam, diazepam)
- barbiturates
- propofol if intubated
Underlying Cause
- stop intake
References and Links
CCC Toxicology Series
General
Approach to acute poisoning, ECGs in Tox, Evidenced-based Tox, Toxicology literature summaries, Does anti-venom work?
Toxins / Overdose
Amphetamines, Barbituates, Benzylpiperazine, Beta Blockers, Calcium Channel Blocker, Carbamazepine, Carbon Monoxide, Ciguatera, Citrate, Clenbuterol, Cocaine, Corrosive ingestion, Cyanide, Digoxin, Ethanol, Ethylene Glycol, Iron, Isoniazid, Lithium, Local anaesthetic, Methanol, Monoamine oxidase inhibitor (MAOI), Mushrooms (non-hallucinogenic), Opioids, Organophosphate, Paracetamol, Paraquat, Plants, Polonium, Salicylate, Scombroid, Sodium channel blockers, Sodium valproate, Theophylline, Toxic alcohols, Tricyclic antidepressants (TCA)
Envenomation
Marine, Snakebite, Spider, Tick paralysis
Syndromes
Alcohol withdrawal, Anticholinergic syndrome, Cholinergic syndrome, Drug withdrawals in ICU, Hyperthermia associated toxidromes, Malignant hyperthermia (MH), Neuroleptic malignant syndrome (NMS), Opioid withdrawal, Propofol Infusion Syndrome (PrIS) Sedative toxidrome, Serotonin syndrome, Sympatholytic toxidrome, Sympathomimetic toxidrome
Decontamination
Activated Charcoal, Gastric lavage, GI Decontamination
Enhanced Elimination
Enhanced elimination, Hyperbaric therapy for CO
Antidotes
Antidote summary, Digibind, Glucagon, Flumazenil, HIET – High dose euglycaemic therapy, Intralipid, Methylene Blue, N-Acetylcysteine (NAC), Naloxone
Miscellaneous
Cocaine chest pain, Digoxin and stone heart theory, Hyperbaric oxygen, Hypoxaemia in tox, Liver failure in tox, Liver transplant for paracetamol, Methaemoglobinaemia, Urine drug screen
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC