Alcohol

Withdrawal/Delirium
Tremens
Juan I. Irizarry Nieves
Intern Hospital San Cristobal
Epidemiology
• Alcohol abuse and dependence DSM-V (must meet at least 2
criteria)
• About 14% in the population
• Up to 40% in hospitalized patients
• Up to 50% experience withdrawal when they stop/reduce
drinking
• Up to 20% of patients experience severe symptoms of
withdrawal
• Some hospitals have had up to 10% intensive care admissions
due to alcohol withdrawal symptoms
DSM-5 diagnostic criteria for alcohol withdrawal

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days
after the cessation of (or reduction in) alcohol use described in criterion A:
1. Autonomic hyperactivity
2. Increased hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient visual, tactile, or auditory hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Generalized tonic-clonic seizures
C. The signs or symptoms in criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are
not better explained by another mental disorder, including intoxication or
withdrawal from another substance.
Pathophysiology
• Ethanol is a CNS depressant: enhances inhibitory tone and inhibits
excitatory tone
• GABA- Main inhibitory amino acid from the brain.
• GABA receptors have great affinity for ethanol
• More inhibitory molecule is required to maintain constant inhibitory tone
• Cessation causes reduced inhibitory tone
• Glutamate- major excitatory AA that binds NMDA (excites neurons
by releasing Ca+)
• Ethanol inhibits glutamate function
• Adaptation ↑ NMDA receptors
• Cessation leads to unregulated excitation
 Minor Withdrawal
• Still have high blood alcohol percentage
• Insomnia
• Tremulousness
• Mild anxiety
• GI upset
• Headache
• Diaphoresis
• Palpitations
Seizures

• In patients with long history of chronic

alcoholism
• There have been cases as early as 2 hours since last
drink
• Typical onset is 4th and 5th decades of life
• Generalized tonic-clonic convulsions
• Single seizure or brief flurry of seizures over short period
of time
• Status epilepticus is NOT consistent with withdrawal
Alcoholic hallucinosis
• Occur in about 30% of patients
• NOT the same as delirium tremens
• Visual > tactile/auditory
• Steady vital signs
• Normal mental status
• No clouding of sensorium
• Self resolving, usually <48hrs
Delirium tremens
• Approximately 5%
• Can last 1-5 days
• Risk factors:
• Disorientation • History of DT
• Tachycardia • >30 years old
• Hypertension • Associated illness (cirrhosis,
malnutrition, GI, cardiac, respi)
• Hyperthermia
• Withdrawal with elevated
• Diaphoresis ethanol in blood
• Vomiting • Longer time since last drink
(withdrawal S/S after 2 days)
Delirium Tremens

• Elevated cardiac index

• ↑ oxygen delivery • Death is typically due to:
• ↑ oxygen consumption • Arrhythmia
• Pneumonia
• Respiratory alkalosis • Pancreatitis
(↓ brain BF) • Hepatitis
• Hypovolemia • CNS injury
• ↓ K+, ↓ Mg+, ↓ P+ • Core temp >40
• Rhabdomyolysis • Pre-existing disease
Post Acute Withdrawal Symptoms
(PAWS)
• Up to 14 days after initial withdrawal symptoms
• Anxiety
• Decreased energy
• Depression
• Reduced sexual interest
• Sleep disorders
• Tremors
Identifying
Patients
Initial Treatment
• Any CIWA-Ar >15 should get admitted
• Identify since diagnosis is mainly clinical
• R/O alternate causes: LP, CT, OD
• Comorbid conditions
• Place in quiet protected environment w/ restraints if
necessary
• NPO
• Correct electrolyte disbalance and hydration
Treatment
• Nutrition should be IV for first 2 days
• Banana bag?
• Thiamine, folate, MV, saline , 5% dextrose
• Symptom-triggered therapy
• Providing medications only when they present symptoms
• Severe withdrawal – Evaluate q 10-15min, tx with IV meds
• Mild withdrawal – Evaluate q 4-6 hr is appropriate
• Treat whenever CIWA-Ar is >8
• Intubated patient
• RASS 0 to -2
Benzodiazepines
• Acute withdrawal / Seizures / DT
• Diazepam 5-10mg IV
• Lorazepam 2-4mg IV (liver disease is involved)
• Stable withdrawal
• Chlordiazepoxide 25-100mg PO
• Oxazepam 10-30mg PO (liver disease is involved)
• Refractory DT (multiple doses after first hour)
• Phenobarbital 130-260mg IV q 15-20min
• Propofol
• Please make sure patients are intubated. Thanks!
Prophylaxis
• History of seizures, DT or heavy chronic alcoholism
• Chlordiazepoxide 25-100mg q 6hr for 1 day then 25-
50mg q 6hr for 2 more days
• Oxazepam 10-30mg similar dosing for hepatic patients
Contraindicated or Not Recommended
• Ethanol (gasolina, DonQ, Palo Viejo)
• Antipsychotics (haloperidol)
• Anticonvulsants (carbamazepine)
• Central alpha-2 agonist (clonidine, dexmedotomidine)
• Beta blockers (Propanolol)
• Baclofen
Questions?

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