inpatient / psychiatry and addiction
Alcohol Withdrawal
# Alcohol Withdrawal
Checklist
-- ABC: calculate PAWSS; does the patient need ICU for checks q1-2, CIWA >20, already in DTs, or concern about airway protection?
-- Chart Check: prior admissions, seizures, intubations
-- HPI Intake: quantity and type of EtOH, last drink, hx of seizure, ICU, intubation, DTs, hx patient-initiated discharge, other drug use
-- Can't Miss: seizure, delirium tremens
-- Admission Orders: CIWA at least q4
-- Initial Treatment to Consider: give IV thiamine if c/f Wernicke's, D5LR if c/f ketoacidosis; decide on PRN vs standing benzos
Assessment:
-- History: *** quantity and type of EtOH, last drink, hx of seizure, ICU, intubation, DTs, hx patient-initiated discharge, other drug use
-- Clinical/Exam: *** tremors, sweats, tachy, HTN, headache, anxiety, seizure, hallucinations (visual/tactile > auditory), DT’s is disorientation, hyperactivity, hallucinations
-- Data: *** CBC, CMP, CK, UDS, serum EtOH
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Labs - CBC, CMP, CK, UDS, serum EtOH
Treatment
-- IV thiamine 200-500mg IV TID for 4-7 days if c/f Wernicke’s, D5LR if c/f ketoacidosis
-- CIWA q2-4 with *** (PRN vs standing; benzo, phenobarb) protocol
-- Folate 1mg daily, multivitamin daily
-- Consider initiating naltrexone 25mg PO daily, acamprosate 666mg TID
-- Recommend AA
PDF coming soon!
If You Remember Nothing Else
Alcohol withdrawal can be life-threatening. Those at risk for severe withdrawal (largely based on a known history of previous severe withdrawal) should have standing benzos ordered, otherwise order them PRN based on CIWA score. It doesn't hurt to give IV thiamine if there is concern for Wernicke encephalopathy. Chronic changes of alcohol use may also include cytopenias and decreased renal tubule and GI absorption leading to low K, Mag, Ca, Phos, and Vitamin D.
Clinical Pearls
- Drinking is considered "risky" if >4 drinks/occasion or >14/week in men; >3/occasion or >7/week for women
- Withdrawal is an imbalance of GABA and glutamate - when stop EtOH, GABA drops and excess glutamate leads to noradrenergic surge and symptoms
- CIWA depends on interaction with patient; if AMS consider based on RAAS goals (HR and BP), though this is not validated
- 5 C’s of Alcohol Use Disorder (AUD) - control, cravings, consequences, compulsion, cut back
- Chronic changes of alcohol use - cytopenia, ketoacidosis, lactic acidosis, decreased renal tubule and GI absorption leads to low K, Mag, Ca, Phos, VitD
- Wernicke Encephalopathy causes oculomotor and cerebellar dysfunction, AMS, and dietary deficiency - give thiamine
- Korsakoff - memory deficits (confabulation), apathy
Trials and Literature
- Will This Patient Develop Severe Alcohol Withdrawal? (JAMA, 2018)
- Clinical Management of the Alcohol Withdrawal Syndrome (Addiction, 2022)
Other Resources
- MD Calc - PAWSS - "the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 when patients had 4 or more individual findings and an LR of 0.07 when there were 3 or fewer findings."
- MD Calc - CIWA-Ar
- Curbsiders Podcast - #212 Managing Inpatient Alcohol Withdrawal
