# Alcohol Withdrawal

## Who's at risk?

PAWSS score - https://www.mdcalc.com/prediction-alcohol-withdrawal-severity-scale

Reasons to go to an ICU?

- Delirium tremens? (Hemodynamic instability, agitation and hallucinations)
- Using Ativan every 1-2 hours
- CIWA scores in the 20s that aren't all symptom trigger
- Concerns about over sedation / airway protection.

If high risk for severe withdrawal (aka legit history of prior seizures or confounding seizure disorder, withdrawal symptoms with detectable BAL - consider long acting in addition to symptom driven protocol)

## Timeline and Terms

Withdrawal Seizures - 0-48 hours (12-24 after cessation highest risk)

Note: this might be delayed if getting GABA dsrugs

Delirium tremens - onset 48-96h after cessation

Alcohol Hallucinosis?  Perceptual disturbances after cessation of drinking that is not associated with withdrawal and persists a lot longer. 

## Treating

### Phenobarbital 

Advantages: pharmacokinetics (2-4 day half life means auto-taper), predictable levels due to reliable distribution, IV onset 5 minutes, peak 15 so can be redosed q15-30. Also hits glutamate receptors so likely better mono therapy that benzo. 1:1 PO to IV conversion

Disadvantage: synergistic with Benzos for respiratory depression. Long half life means diagnosis should be right. 

Usage: 

MONOTHERAPY (or if minimal use of bento):

- Up front dose of 10 mg/kg
- Soft stop around 20 mg/kg
- Hard stop around 30 mg/kg

If you give 10mg/kg up front and there is not response, you can repose 130-260 mg q15-30 minutes until RAAS 0 or -1 or maximum hit. 

RESCUE THERAPY

Probably skip the bolus and start with 130 or 260 mg doses. 

Vanderbilt Protocol: https://www.vumc.org/trauma-and-scc/sites/default/files/public_files/Protocols/TICU%20Substance%20Abuse%20PMG.pdf

IBCC protocol https://emcrit.org/ibcc/etoh/