A 32 year old woman rolls into the ER on a quiet springtime afternoon – you are told that she had just had a tonic clonic seizure.
She took a sabbatical after finishing her EM/IM residency and opened a moonshine distillery on Nostrand and Church. She typically “tastes” one pint of her product per day.
Her last drink was 47 hours ago.
Her GCS is 9, she is groaning, opening her eyes and localizing pain. You see no overt signs of trauma and her shirt is full of vomit.
What are the DSM-5 criteria for substance abuse?
Just Kidding
What are the different types of alcohol withdrawal syndromes?
6-36 hours – EARLY UNCOMPLICATED: psychomotor agitation, tremor, tachycardia and hypertension.
6-48 hours – WITHDRAWAL SEIZURES (likely what our friend has): 60% have multiple seizures, 3% progress to status epilepticus, 1/3 develop to DTs. If occurs with elevated ETOH level, poor prognostic sign.
12-48 – ALCOHOLIC HALLUCINATIONS: Visual, auditory and/or tactile with intact sensorium and normal vital signs.
48-96 hours – DELIRIUM TREMENS: Loss of consciousness/change in cognition, agitation, tachycardia, hypertension, fever, diaphoresis
** Don’t forget!! NOT EVERYTHING THAT HAPPENS TO ALCOHOLICS IS DUE TO THAT SWEET ETHANOL. You must consider: Head trauma, hypo/hyperglycemia, non-adherence with seizure medications, use of other recreational drugs or toxic alcohols, metabolic derangements and many other etiologies. That is why a head CT, basic labs and a tox screen are a good idea.
What scoring system can you use to guide our management?
Although not studied in the ED, CIWA-Ar can be used to monitor treatment or guide you when the case is equivocal (not in our case..).
Is there room for neuroleptics in the management of alcoholic withdrawal?
As most of you know, the mainstay treatment for alcohol withdrawal is a combination of long and short acting benzodiazepines – in particular lorazepam and chlordiazepoxide. It is not recommended to use neuroleptics for anything but ISOLATED ALCOHOLIC WITHDRAWAL HALLUCINATION due to their QT prolongation, since these patients are at high risk for torsades de pointes as a result of hypomagnesemia. Even for delirium tremens it is recommended to use large doses of sedative hypnotic agents such as benzodiazepines (to “a level of light somnolence with arousal when stimulated”) as this decreases mortality from 20% to <1%.
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References:
Tintinallis Emergency Medicine: A Comprehensive Study Guide.
Goldfrank’s Toxicologic Emergencies
Uptodate
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By Dr. Itamar
Special thanks to Dr. Willis
Itamar Goldstein
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It’s important to realize that you can get to DTs from any of the withdrawal syndromes. They don’t typically happen sequentially; anyone with tremulousness, a withdrawal seizure, or hallucinations is at risk for DTs.
Thanks Nathan. It is always amazing to realize how far real people fall from our multiple-choice-oriented tables and algorithms.