8 Million alcoholics in the US

500,000 episodes of withdrawal requiring

medication per year
Daily drinking for 7-34 days will cause minor
withdrawal in most people
Daily drinking for 36-84 days will cause major
withdrawal symptoms
EtOH is a CNS depressant
Abrupt withdrawal causes compensatory over
stimulation
GABA: major CNS inhibitor, and receptor is
downregulated with EtOH consumption
NE: elevates with EtOH withdrawal due to a decrease in
the alpha-2 receptor-mediated inhibition of presynaptic
norepinephrine release
Serotonin: implicated in tolerance and craving for
alcohol
Insomnia
Tremulousness
Mild anxiety
Gastrointestinal upset
Headache
Diaphoresis
Palpitations
Anorexia

Present within 6 hours of last drink
Even if BAL is still elevated
Resolves in 24-48 hours
Generalized tonic-clonic convulsions
Occur within 48 hours of last drink, but may
occur as soon as 2 hours from last drink
3 percent of chronic alcoholics have
withdrawal-associated seizures
of those, 3 percent develop status epilepticus
Not synonymous with delirium tremens
develop within 12 to 24 hours of abstinence
resolve within 24 to 48 hours (when DT starts)
Usually visual, may be tactile or auditory
5% of alcoholics
hallucinations, disorientation, tachycardia,
hypertension, low grade fever, agitation, and
diaphoresis
48-96 hours after last drink, and lasts 1-5 days
Risk Factors
A history of sustained drinking
A history of previous DTs
Age greater than 30
The presence of a concurrent illness
A greater number of days since the last drink (for example,
patients who present more than two days after their last
drink for treatment of alcohol withdrawal are more likely
to experience DTs than those who present within two
days)

Mortality rate of 5%
Mortality associated with
Arrhythmias
Pneumonia
Clinical manifestation
hallucinations, disorientation, tachycardia,
hypertension, low-grade fever, agitation,
diaphoresis, elevated cardiac indices, oxygen
delivery, and oxygen consumption
Respiratory alkalosis
Hypokalemia and hypomagnesemia
Syndrome Clinical Findings Onset
Minor Tremulousness, mild anxiety,
headache, diaphoresis,
palpitations, anorexia, GI
upset
6-36 h
Seizure Generalized, tonic-clonic
seizures, status epilepticus
(rare)
6-48 h
Alcoholic
Hallucinosis
Visual, auditory, and/or tactile
hallucinations
12-48 h
Delirium
Tremens
Delirium, tachycardia,
hypertension, agitation, fever,
diaphoresis
48-96 h
Bad actor
infection, trauma, metabolic derangements, drug
overdose, hepatic failure, or gastrointestinal bleeding
Rule out comorbid conditions
Frequent assessment
Correct metabolic derrangements
Quiet and protective environment
Thiamine first, then glucose infusion for volume
deficit

Benzos
treat the psychomotor agitation
prevent progression from minor withdrawal
symptoms to major ones
Valium and Librium most common
PO route preferred but may give IV prn
Intravenous diazepam, 5 to 10 mg IV every five
minutes until the patient is calm
Fixed schedule therapy, in which a
benzodiazepine is given at fixed intervals
even if symptoms are absent, is most useful
in patients at high risk of major withdrawal
symptoms
Healthy pts should be kept lightly sedated
Pts with comorbidities, especially cardiac,
should be more heavily sedated
Symptom-triggered therapy
Clinical Institute Withdrawal Assessment for
Alcohol Scale
Given when >8
Fewer benzos given, shorter course of therapy

Nausea and vomiting (0-7)
Headache (0-7)
Paroxysmal sweats (0-7) Auditory disturbances (0-7)
Anxiety (0-7)
Visual disturbances (0-7)
Agitation (0-7) Tactile disturbances (0-7)
Tremor (0-7)
Orientation and clouding of
sensorium (0-4)
Total score is a simple sum of each item score
(maximum score is 67).
Score:<10: Very mild withdrawal
10-15: Mild withdrawal
16-20: Modest withdrawal
>20: Severe withdrawal
Refractory DT
Probably d/t low GABA
Barbituates used (phenobarbital) or propofol
Do NOT use anti-psychotics (lowers sz threshold),
anticonvulsants, baclofen, clonidine
Careful H&P to determine risk of withdrawal and DT
Pts with h/o sz, DT or major EtOH withdrawal
should be on scheduled dosing of Valium or Librium
Pts at risk for withdrawal should be closely
monitored and treated if Clinical Institute
Withdrawal Assessment for Alcohol Scale is >8
DT treated with IV valium until stable
Refractory DT treated with phenobarbital or
propofol