Alcohol withdrawal

From Ganfyd

WHEN TO USE PARENTAL VITAMIN B Incipient Wernicke's encephalopathy confusion ± ataxia memory disturbance ophthalmoplegia At risk group Significant weight loss Poor diet Signs of malnutrition[1]

A common cause of confusion, both in patients and the doctor who fails to recognise the reason for a patient's new confusion. The diagnosis may not be straight forward due to the stigmata associated with admitting to excess alcohol use. While much alcohol withdrawal can be managed in the community there are catches. The most important are:

1. the prevention of Wernicke's encephalopathy. In those at risk this requires 3 days of parental thiamine, not just oral thiamine
2. in advanced hepatitic disease or alcoholic hepatitis chlordiazepoxide is safer than diazepam or lorazepam.
3. use of iv benzodiazepines is not without risk
4. Clomethiazole (chlormethiazole), particularily the iv preparation, is associated with a higher life-threatening complication rate than benzodiazipines

Chronic alcohol use leads to gradual upregulation of N-methyl-d-aspartate receptors; withdrawal of alcohol leads to overwhelming excitatory action mediated by the glutamatergic system.

Symptoms & Signs

Acute withdrawal usually occurs between 6 and 12 hours after last alcohol consumption. Symptoms may last 4-5 days.

• Autonomic hyperactivity
  • Hand tremor, insomnia, sweating, tachycardia, hypertension, anxiety
• Perceptual disturbances
  • Transient visual, tactile or auditory hallucinations or illusions
  • Reality testing is generally intact i.e. person recognises these as hallucinations
• Withdrawal seizures
  • These are not associated with "latent epilepsy" as EEG is normal before and after seizures

Delirium Tremens

An acute confusional state caused by withdrawal from alcohol. Usually begins 3-4 days after withdrawal, though may occur while individual is still drinking (possibly due to a reduced alcohol level). It is either of sudden onset or there is a prodromal phase of restlessness, anxiety and insomnia, with above symptoms of alcohol withdrawal. Additionally there is reduced level of consciousness, disorientation in time and place, impairment of sensory stimuli with hallucinations. Visual hallucinations may be Lilliputian, complex, frightening or vivid. The symptoms are worse at night and last for 2-3 days. If untreated, they may end with a deep prolonged sleep, waking symptom-free & with no memory of delirium.

Management of Alcohol Withdrawal

• Rehydration
• Correct any electrolyte imbalance
• Correct hypoglycaemia with caution
  • Risk of precipitating Wernicke’s encephalopathy
• Oral/parenteral thiamine
• Reducing regimen of benzodiazepines or Chlordiazepoxide
• Treat seizures with rectal or IV diazepam
  • Consider anticonvulsant for elective withdrawal if there is a history of withdrawal seizures

References