Alcohol Withdrawal

Snapshot

A 38-year-old man is brought to the emergency department after being in a motor vehicle accident. The patient fractured his femur and required surgery. On postoperative day 2, the patient reports trouble falling asleep, palpitations, and feeling anxious. Medical history is significant for hypertension and alcohol use disorder. His blood pressure is 165/98 mmHg, pulse is 105/min, and respirations are 20/min. Physical exam is significant for tremulousness and diaphoresis. He is started on lorazepam.

Introduction

Definition
- progression of signs and symptoms that occur after withdrawal from heavy and prolonged use of alcohol
Epidemiology
- incidence
  - typically seen in hospitalized patients who have alcohol dependence
Pathogenesis
- prolonged use of alcohol downregulates GABA receptors and upregulates glutamate receptors in order to maintain arousal
- when alcohol is abruptly withdrawn, there is overexcitation of glutamate receptors
Associated conditions
- Wernicke encephalopathy
  - triad
    - ophthalmoplegia
    - encephalopathy
    - ataxia
  - thiamine and magnesium depletion results in necrosis of the mammillary bodies, thalamus, and hippocampus
- Korsakoff syndrome
  - memory impairment and confabulations
  - precipitated if giving dextrose prior to giving thiamine
Prognosis
alcohol withdrawal seizures and delirium tremens are life-threatening

Presentation

Studies

Labs
- thiamine and magnesium deficiency
- AST > ALT (2:1)
- serum γ-glutamyltransferase (GGT)
a sensitive indicator of alcohol use

Withdrawal

Alcohol Withdrawal
Time (Hours)	Syndrome	Clinical Findings
6-36	Minor withdrawal	AnxietyTremulousnessDiaphoresisPalpitations
6-48	Seizures	Tonic-clonic seizuresshort post-ictal period
12-48	Alcoholic hallucinosis	Visual, auditory, and/or tactile hallucinationsintact orientationnormal vital signs
48-96	Delirium tremens	DeliriumAgitationTachycardiaHypertensionFeverDiaphoresis

Treatment

Complications