Draft

39  Alcohol Withdrawal

39.1 What this covers

  • Who’s at risk?
  • Timeline and Terms
  • Treating

39.2 Learning objectives

  • Who’s at risk?
  • Timeline and Terms
  • Treating
  • Phenobarbital

39.3 Bottom line / summary

  • PAWSS score - https://www.mdcalc.com/prediction-alcohol-withdrawal-severity-scale
  • Reasons to go to an ICU?
  • 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)
  • Withdrawal Seizures - 0-48 hours (12-24 after cessation highest risk)
  • Note: this might be delayed if getting GABA dsrugs

39.4 Approach

  1. Delirium tremens? (Hemodynamic instability, agitation and hallucinations)
  2. Using Ativan every 1-2 hours
  3. CIWA scores in the 20s that aren’t all symptom trigger
  4. Concerns about over sedation / airway protection.
  5. Up front dose of 10 mg/kg

39.5 Red flags / when to escalate

  • TODO: List red flags that require urgent escalation.

39.6 Common pitfalls

  • TODO: Capture common errors or missed steps.

39.7 References

  • https://www.mdcalc.com/prediction-alcohol-withdrawal-severity-scale
  • https://www.vumc.org/trauma-and-scc/sites/default/files/publicfiles/Protocols/TICU%20Substance%20Abuse%20PMG.pdf
  • https://emcrit.org/ibcc/etoh/

39.8 Source notes

39.8.1 Alcohol Withdrawal

40 Alcohol Withdrawal

40.1 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)

40.2 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.

40.3 Treating

40.3.1 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/

40.4 Source materials