Alcohol Withdrawal Syndrome
last authored: August 2011, David LaPierre
last reviewed:
Introduction
Alcohol withdrawal syndrome (AWS) is a set of symptoms that results from an abrupt discontinuance of alcohol in someone who is dependent on it. It is likely to occur if alcohol is consumed in large quantities for a period of greater than two weaks, and then is abruptly discontinued.
Alcohol affects the central nervous system, including the autonomic nervous system and cognitive function.
Symptoms, which can begin within 5 hours and last for days, can range from mild to fatal.
Alcohol withdrawal occurs in a series of stages.
Stage I: 5-8 hours
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Stage II: 24-72 hours
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Stage III: 72-96 hours
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The Case of John R
John is a 46 year-old man who comes to the emergency department with chest pain. He describes a fall 2 days ago that took place when he was very drunk. He has not had a drink since, and has been feeling very shakey. Your investigations reveal a rib fracture. You decide to admit him for alcohol withdrawal.
- What further questions and physical exam is required?
- How do you treat John?
- What warning signs do you watch for?
Causes and Risk Factors
Risk factors for the development of alcohol withdrawal syndrome include:
- excessive amounts of alcohol
- extended duration of alcohol dependence
- previous alcohol withdrawal episodes, seizures
- co-existing benzodiazepone dependence
- older age
- medical co-morbidities
Pathophysiology
Alcohol acts on the inhibitory GABA receptors in the brain. With extended use, GABA receptors are downregulated. At the same time, inhibition of glutamate signaling by alcohol results in upregulation of excitatory NMDA receptors.
Abrupt cessation of alcohol leaves the brain in a hyper-excitable state due to downregulation of inhibitory GABA and upregulation of excitatory NMDA.
Delerium tremens represents a hyperadrenergic state with multiple abnormalities of autonomic factors: pulse, blood pressure, temperature, respiratory rate, and diaphoresis. Cognitive changes also occur, including impaired attention, disorientation, and hallucinations.
Signs and Symptoms
Diagnosis is likely if two or more of the following symptoms are present:
- agitation
- anxiety
- autonomic hyerpactivity (tachycardia, diaphoresis)
- increased hand tremor
- insomnia
- nausea or vomiting
- hallucinations or illusions
- tonic-clonic seizures
- history
- physical exam
- diagnostic tools
History
Important details to ask about include:
- quantity and duration of alcohol use
- time of last drink
- previous withdrawals
- previous seizures
- medical and psychiatric conditions
- other substance use
- living situation
Physical Exam
On exam, evaluate for:
- autonomic instability: diaphoresis, tachycardia, hypertension
- tremor
- congestive heart failure
- arrhythmia
- signs of liver disease
- infections
Diagnostic Tools
Validated tools should be done to assess for severity of AWS. The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised) is often used (outside link)
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
CBC: macrocytosis, pancytopenia
electrolytes
renal function tests
glucose
TSH
liver enzymes
magnesium
blood alcohol level
microbiology: blood C&S, urinalysis, urine C&S
Diagnostic Imaging
ECG
consider chest X-ray, CT head
Differential Diagnosis
The differential diagnosis includes:
- intoxication with cocaine or other stimulants
- mania
- psychosis
- thyroid toxicosis
- neuroleptic malignant syndrome
Treatments
The goal of treatment of AWS is to reduce symptoms, as well as the chances of DTs, and death. It is also helpful to support long-term abstinence. Symptoms normally subside within one week.
Mild or moderate AWS may be treated as an outpatient, as it is normally safe, effective, and less expensive than inpatient care. However, if serious psychiatric or medical conditions are present, inpatient withdrawal management is likely preferable (Muncie, Yasinian, and Oge, 2013). Outpatient care should not be used if drug abuse is also present, and should include close contact with trusted friends or family, as well as primary care. Community support should be ensured.
Daily monitoring is normal until symptoms and medication use are reduced; once this occurs and alcohol intake has stopped for at least three days, it is recommended to enroll a patient in a long0term treatment program.
Acute treatment involves ABCs:
- provide oxygen as needed
- start an IV and blous with normal saline
Benzodiazepines such as lorazepam, diazepam, oxazepam, or chlordiazepoxide are used most commonly to reduce symptoms of AWS and prevent the onset of seizures. They may be used in fixed- or symptom-specific dosing. The former is easier to use in an outpatient setting, as it requires less scoring (eg, with the CIWA-Ar or SAWS tools). As-needed medications may also be used.
Anticonvulsants such as carbamazepine, gabapentin, oxcarbazepine, or valproic acid may also be used, but with more troubling adverse effects (eg dizziness, nausea, vomiting).
Clonidine or beta-blockers (especially atenolol) can be used to control authonomic instability.
Nutritional and vitamin support should include thiamine (100mg daily), which should be given before glucose, as well as folic acid (1mg daily).
Counselling should be offered once stabilized.
Consequences and Course
Alcohol withdrawal can be life-threatening.
Resources and References
Muncie HL, Yasinian Y, Oge', Linda. 2013. Outpatient management of alcohol withdrawal syndrome. AFP. 88(9):589-595.
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