Some alcoholics exhibit one or more symptoms of withdrawal upon discontinuation of ethanol intake. Symptoms and signs include tremor, anxiety, agitation, and signs of autonomic hyperactivity, including cardiac dysrhythmias, most frequently sinus tachycardia or atrial fibrillation. Seizures may occur, while hallucinations, usually visual, reflect moderate-to-severe withdrawal. Signs and symptoms of withdrawal are most likely to reach peak intensity at 48 h after the patient's last drink. There is wide variation in the timing of onset and peak severity of alcohol withdrawal, which reflects differences in patterns of ethanol intake, individual susceptibility to withdrawal, and concomitant illness. For example, significant withdrawal may occur while alcoholics still have detectable blood ethanol levels or within a short time after the last drink. Such situations probably reflect a recent pattern of decreased but continued intake of ethanol, or alcoholics' common practice of self-treatment with ethanol when symptoms first appear, followed by presentation for medical care if those symptoms fail to resolve.
Since ethanol withdrawal is a syndrome complex, more than one sign is present in most cases. When alcoholic patients present with a single sign typical of ethanol withdrawal, other causes should be considered. Seizures, in particular, can be due to other causes, most notably recent or remote head trauma, whether the patient recounts a history of head injury or not. Hallucinations may be secondary to a psychiatric disorder (although alcohol withdrawal hallucinations are more likely to be auditory, not visual) or concomitant drug use.
After the diagnosis of alcohol withdrawal is established, an examination for complicating medical conditions or injury should be performed. Patients with alcohol withdrawal may be volume depleted and require crystalloid infusion. If possible, patients should be placed in a quiet area with a minimum of stimulation. For patients who have experienced seizures, CT examination is indicated for focal seizures, when a focal neurologic finding is elicited, or when the patient has a persistent postictal defect in consciousness.11
Benzodiazepines are indicated for treatment of withdrawal, with most studies suggesting that lorazepam is the drug of choice, particularly in the elderly and those with significant liver disease.12 The initial dose is 2 mg IV, followed by doses of 2 to 4 mg IV every 15 to 30 min until light sedation is attained. At the same time, 1 L of 5% dextrose in normal saline solution with 100 mg of thiamine and 4 g of magnesium sulfate is given IV over 1 to 2 h. Although magnesium has not been shown to be effective against ethanol withdrawal in general, hypomagnesemia has been closely associated with tremor in alcoholics and may play a role in the genesis of seizures. An alternative primary drug is phenobarbital, starting with a dose of 260 mg administered intravenously over 15 min, followed by doses of 130 mg every 30 to 45 min as needed. Phenobarbital has a relatively long half-life, 24 to 96 h, obviating the need for outpatient prescriptions if the patient is discharged. 13 Clinicians should approach treatment of alcohol withdrawal prepared to administer lorazepam (or phenobarbital) repeatedly and in cumulatively large doses. There is no evidence that prophylactic phenytoin prevents ethanol withdrawal seizures. 14
Patients with alcohol withdrawal and complicating medical problems, such as infections or congestive heart failure, should be admitted to the hospital. Patients who fail to respond to one or two doses of sedative medications should also be admitted. Administration of more than 8 mg of lorazepam or 500 mg of phenobarbital is in most cases an indication for admission to a nursing unit where the patient can receive close observation by both nursing and physician staff, in many hospitals, an intensive care unit. Patients with mild alcohol withdrawal that respond to treatment may be discharged. If they have been given phenobarbital, no outpatient prescription is necessary. In any case, the benefit of prescribing outpatient benzodiazepines is doubtful if a patient is likely to resume drinking after discharge from the emergency department.
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