Signs and Symptoms
- CNS effects occur on a spectrum:
- Relaxation
- Euphoria
- Sedation
- Memory loss
- Impaired judgment
- Ataxia
- Slurred speech
- Obtundation/coma
- May also cause GI upset
Alcohol Withdrawal Syndrome
- Early or minor withdrawal:
- <8 hr after last drink:
- Symptoms of a hangover
- Headache
- Nausea/vomiting
- 12 hr after last drink:
- Mild tremors/anxiety
- Anorexia, nausea, vomiting
- Weakness
- Myalgias
- Vivid dreams/nightmares
- 12-36 hr after last drink:
- Irritability/agitation
- Tachycardia/HTN
- Tremors in hand s and tongue
- 24-48 hr after last drink: Alcoholic hallucinosis:
- Visual hallucinations most common (bug crawling)
- Auditory hallucinations (buzz, clicks)
- Present in minor and major withdrawal
- Alcoholic withdrawal seizures:
- 8-12 hr after last drink
- Brief, spontaneously abating tonic-clonic activity
- Precedes delirium tremens (DTs)
- Late alcohol withdrawal or major withdrawal:
- 48 hr after last drink
- DTs:
- Clouded consciousness and delirium
- Confusion/disorientation
- Agitation/combativeness
- Tachycardia/HTN
- Hyperpyrexia
- Diaphoresis
History
- Often provided by EMS, family, or friends
- Beware the “frequent flyer” in the ED:
- Can sometimes have other causes of AMS:
- Hepatic disease/encephalopathy
- Seizures (postictal)
- Hypoglycemia
- Head injury or intracranial bleeding
Physical Exam
- Vital signs:
- Acute intoxication: Normal or depressed
- Withdrawal: Usually elevated
- Mental status:
- Acute intoxication: Somnolent, obtunded, or comatose
- Withdrawal: Hyperalert, agitated
- Signs of hepatic injury:
- Jaundice
- Icterus
- Spider angiomata
- Asterixis
- Hepatomegaly
- Signs of malnutrition:
- Alopecia
- Poor dentition
- Poor muscle mass
- Abdominal wasting
- Temporal wasting
Essential Workup
- Obtain accurate alcohol ingestion and abstinence history
- Investigate for life-threatening causes of seizures:
- Hypoglycemia (get rapid bedside glucose)
- Intracranial hemorrhage
- CNS infection
- Electrolyte abnormalities
- Evaluate for occult trauma
- Monitor all vital signs frequently:
- Hyperthermia predicts poorer outcomes
Diagnostic Tests & Interpretation
Lab
- Alcohol level if abnormal mental status
- Urine toxicology panel to screen for coingestants
- Electrolytes, BUN, creatinine, and glucose
- CBC
- Magnesium, calcium, and phosphate
- PTT, PT/INR if coagulopathy suspected
- LFTs if liver disease suspected
- Ammonia level if hepatic encephalopathy suspected
- Urinary ketones or serum acetone if alcoholic ketoacidosis suspected
Imaging
- CT of head if:
- Alteration in mental status is out of proportion to expected AMS based on serum alcohol level
- Suspected head trauma
- Signs of increased intracranial pressure or focal findings on neurologic exams
- New-onset seizure
- Unimproved or deteriorating level of consciousness
- EEG differentiates alcohol withdrawal seizures from idiopathic epilepsy
- Chest radiograph if suspected aspiration or pneumonia
Differential Diagnosis
- Acute alcohol intoxication:
- Hypoglycemia
- Carbon dioxide narcosis
- Mixed-drug overdose
- Ethylene glycol, methanol, or isopropanol poisoning
- Hepatic encephalopathy
- Psychosis
- Severe vertigo
- Psychomotor seizure
- Alcohol withdrawal and seizures:
- Sedative-hypnotic withdrawal
- Acute intoxication or poisoning:
- Carbon monoxide
- Isoniazid (especially if prolonged seizures not responding to stand ard therapy)
- Amphetamine
- Anticholinergic
- Cocaine
- Secondary seizure disorders:
- Infection
- Meningitis
- Encephalitis
- Brain abscess
- Trauma
- Intracranial hemorrhage
- CVA
- Tumor
- Anticonvulsant noncompliance
- Thyroid disorder
Prehospital
- Administer benzodiazepines for seizures
- Give naloxone, oxygen, and dextrose for comatose individuals
- Intubate as necessary for airway protection to prevent aspiration
- C-spine immobilization if suspected trauma
Initial Stabilization/Therapy
- Airway, breathing, circulation (ABCs)
- Evaluate C-spine if suspected trauma
- Initial IV rehydration with 0.9 NS, then D5 0.45 NS
- Administer naloxone, thiamine, and glucose (or Accu-Chek) if altered mental status
- Benzodiazepines if seizing (may require large doses)
Pediatric Considerations |
- Young children have decreased hepatic glycogen reserves
- Cannot mount an appropriate response to increased glucose needs
- Rapid bedside glucose (Accu-Chek) is ESSENTIAL:
- Administer dextrose if indicated with D5 (10 mL/kg), D10 (5 mL/kg), or D25 (2 mL/kg) depending on age and size
|
ED Treatment/Procedures
- Alcohol intoxication:
- Rehydrate with IV fluids
- Correct electrolyte abnormalities:
- Magnesium
- Potassium
- Folate
- Thiamine
- Multivitamins
- Alcoholic ketoacidosis:
- Aggressive rehydration with D5 0.9 NS
- Exclude other causes of wide anion-gap metabolic acidosis
- Alcohol withdrawal syndrome:
- CIWA-Ar
- Validated scale for assessing withdrawal severity
- Guides initial pharmacotherapy
- Gauges response to therapy and needs for repeat dosing (“symptom-triggered” therapy)
- Benzodiazepines are the agent of choice:
- Cross-tolerant with alcohol
- Increases GABAA-mediated transmission
- Anticonvulsant effect
- Large, frequent doses required with significant withdrawal
- May halt progression to DTs
- Barbiturates (phenobarbital):
- Useful if severe withdrawal or DTs refractory to large doses of benzodiazepines
- Propofol:
- Agent of choice for intubated patients
- Completely suppresses seizure activity
- Requires intubation/ventilation
- Caution if hypotensive
- β-Blocker (labetalol, esmolol, or metoprolol):
- Normalizes vital sign abnormalities
- Does not treat CNS complications of alcohol use or withdrawal
- α-Agonists (clonidine/dexmedetomidine):
- Centrally acting α2-adrenergic agonists
- Normalizes vital sign abnormalities
- Do not treat CNS complications of alcohol use or withdrawal
- Phenytoin:
- Not indicated in seizures primarily due to alcohol withdrawal
- Indicated if seizures secondary to idiopathic epilepsy, posttraumatic, or status epilepticus
Medication
- Dextrose: D50W 1 amp (50 mL or 25 g; peds: D25W 2-4 mL/kg) IV
- Dexmedetomidine (Precedex): 0.2-1.4 mcg/kg/hr IV continuous infusion
- Diazepam (Valium): 5-10 mg IV q5-10min until patient calm
- Lorazepam (Ativan): 0.5-4 mg IV/IM q5-10min until patient calm
- Naloxone (Narcan): 0.4-2 mg (peds: 0.1 mg/kg) IV or IM initial dose
- Phenobarbital: 10-20 mg/kg IV (loading dose) monitor for respiratory depression
- Phenytoin: 15-18 mg/kg IV not to exceed 25 mg/min:
- May give fosphenytoin at 15-20 mgPE/kg IV at a maximum rate of 150 mgPE/min
- Propofol: 25-75 μ/kg/min IV (loading dose) then 5-50 mcg/kg/min (maintenance dose)
- Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM
Disposition
Admission Criteria
- Inability to control seizures or withdrawal symptoms with oral medications
- Hepatic failure, infection, dehydration, malnutrition, cardiovascular collapse, cardiac dysrhythmia, or trauma
- Hallucinations, abnormal vital signs, severe tremors, or extreme agitation
- Wernicke encephalopathy
- Confusion or delirium
Discharge Criteria
- Clinically sober
- Seizure free for 6 hr (with negative workup if first seizure)
Issues for Referral
Discuss with social worker and /or police and /or department of family services for pediatric patients
Follow-up Recommendations
Substance abuse referral for patients with recurrent alcohol intoxication/use
- AllisonMG, McCurdyMT. Alcoholic metabolic emergencies . Emerg Med Clin N Am. 2014;32(2):293-301.
- GoldJA, NelsonLS. Ethanol withdrawal. In: HoffmanRS, NelsonLS, GoldfrankLR, et al., eds. Goldfrank's Toxicologic Emergencies. 10th ed.New York: McGraw-Hill; 2011.
- JesseS, BrathenG, FerraraM, et al. Alcohol withdrawal syndrome: mechanisms, manifestations, and management . Acta Neurol Scand . 2017;135(1):4-16.
- KleinLR, DriverBE, MinerJR, et al. Emergency department length of stay for ethanol intoxication encounters . Am J Emerg Med. 2018;36(7):1209-1214.
- PitzeleHZ, ToliaVM. Twenty per hour: Altered mental state due to ethanol abuse and withdrawal . Emerg Med Clin N Am. 2010;28:683-705.
- YipL. Ethanol. In: HoffmanRS, NelsonLS, GoldfrankLR, et al., eds. Goldfrank's Toxicologic Emergencies. 10th ed.New York: McGraw-Hill; 2011.
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