Alcohol withdrawal syndrome

Question 1

NT dysfunction

Answer 1

decrease GABA, increase glutamate, increase noradrenergic

Question 2

Early/uncomplicated

Answer 2

6-36 hours

Anxiety, fine tremor (anxiety), tachycardia (anxiety), headache, palpitations, anorexia, GI upset, general malaise

Question 3

Seizure

Answer 3

6-48 hours

Generalized, tonic-clonic seizures, status epilepticus (rare)

Question 4

Hallucinosis

Answer 4

12-48 hours

Visual, auditory, and/or tactile hallucinations

Question 5

Delirium Tremens

Answer 5

48-96 hours

Delirium, tachycardia, hypertension, agitation, fever, diaphoresis, coarse tremor

Question 6

Risk factors for alcohol withdrawal delirium

Answer 6

History of past seizure or delirium tremens
Seizure prior to admission
Acute concurrent medical illness
More days since last drink (2 or more days)
Elevated admission BAC
Heavier and longer drinking history
Sx of autonomic hyperactivity w/ BAC > 0.1g/dL
AGE > 40
Burn related injuries
Falls, particularly with long bone fractures

Question 7

Alcohol withdrawal assessment

Answer 7

Clinical Institute Withdrawal Assessment for Alcohol- Revised (CIWA-AR)

Question 8

Pharmacologic management of AWS

Answer 8

Benzodiazepines
Antiepileptic drugs (AEDs)
Ethanol
Dexmedetomidine
Propofol

Question 9

Augmentation agents managing AWS

Answer 9

Beta Blockers
Clonidine
Haloperidol

Question 10

Wernicke’s treatment/prophylaxis

Answer 10

Signs: thiamine 500mg IV TID
Risk: thiamine 200mg IV/IM daily

Question 11

Common AWS Protocols

Answer 11

Symptom-triggered benzodiazepine-based detox
Standing benzodiazepine-based detox
Standing phenobarbital-based detox

Question 12

Symptom-Triggered Detox place in therapy

Answer 12

Able to communicate
Not already in severe withdrawal
Not delirious

Question 13

Symptom-Triggered Detox common meds

Answer 13

Lorazepam (good for liver failure)
Diazepam
Chlordiazepoxide

Question 14

Symptom-Triggered Detox caution in patients

Answer 14

< 18 YO
H/o sedative hypnotic abuse
With toxic BAC
Using clonidine or beta-blockers
Risk of paradoxical BZD disinhibition
Acute or chronic TBI
Neurodegenerative d/o’s
H/o etoh-related blackouts and/or assaultive behavior

Question 15

Symptom-Triggered Detox avoid in patients

Answer 15

H/o delirium tremens
H/o etoh w/d seizures
H/o BZD non-response or BDZ-resistance
H/o prior ICU admission for etoh detox
Current sx of delirium/encephalopathy
W/ (or at risk for) respiratory compromise

Question 16

Symptom-Triggered Detox CI

Answer 16

Active DTs or severe w/d sx no responding to BDZs
Altered mental status and/or delirium

Question 17

Standing BZD-Based Detox for patients with

Answer 17

CIWA is contraindicated
CIWA score > 16
H/o DTs
H/o etoh withdrawal seizures
H/o BDZ non-response or BDZ resistance
H/o prior ICU admission for etoh detox

Question 18

Standing BZD-Based Detox caution for patients

Answer 18

W/ polypharmacy
W/ active DTs or severe w/d sx not responding to BDZs
W/ AMS and/or high risk for delirium
At risk for paradoxical disinhibition from BDZs
Acute or chronic TBI
Neurodegenerative d/o’s
H/o etoh-related black-outs and/or assaultive behavior