Alcohol withdrawal: Clinical sciences

Alcohol withdrawal refers to symptoms that develop when a person with a history of heavy alcohol use either significantly reduces their alcohol intake or stops drinking entirely. Now, remember that alcohol depresses the central nervous system, meaning that it has an inhibitory effect that slows down brain activity. Thus, if alcohol intake drops after long term use, that inhibitory effect is removed. As a result, the patient will experience hyperexcitability and hyperactivity of the central nervous system.

If your patient presents with a chief concern suggesting alcohol withdrawal, you should first perform an ABCDE assessment to determine if they are unstable.

If they are unstable, stabilize their airway, breathing, and circulation. This means you might need to intubate the patient. Next, obtain IV access, and put your patient on continuous vital sign monitoring, including heart rate, blood pressure, and pulse oximetry. Finally, don’t forget to start pharmacologic therapy with benzodiazepines to prevent severe complications of alcohol withdrawal, such as delirium tremens, seizures, and even death.

Now that we are done with unstable patients, let’s go back to the ABCDE assessment and take a look at stable individuals.

If the patient is stable, obtain a focused history and physical examination, and don’t forget to order labs including a CMP, serum phosphorus, and serum magnesium.

History often reveals a recent reduction or cessation of heavy alcohol use, which is typically defined as 8 or more drinks per week in biological females and 15 or more drinks per week in biological males. The first withdrawal symptoms can occur anywhere from several hours to over a day after the last drink, and based on severity, they can be mild, moderate and severe.

Mild and moderate symptoms include sweating, nausea, vomiting, and tremors, as well as anxiety, palpitations, and insomnia.

In severe cases, your patient could present with altered mental status, ranging from confusion to hallucinations, and generalized tonic-clonic seizures, with the latter typically occurring 24 to 48 hours after alcohol cessation.

Additionally, the physical exam usually reveals signs of sympathetic overactivity, like agitation, tachycardia, and hypertension; and, if liver function is compromised, jaundice could be present.

Finally, labs could show elevations in liver function tests like AST, ALT, and GGT; as well as macrocytic anemia, thrombocytopenia, and electrolyte imbalances like hypophosphatemia and hypomagnesemia.

If your patient presents with these signs and symptoms, you should suspect alcohol withdrawal and proceed with the DSM-5 Diagnostic Criteria for Alcohol Withdrawal.

The first criterion is a recent reduction or cessation of heavy alcohol use. The second is that at least two of the following eight clinical manifestations should be present in the first hours to days of stopping alcohol. These include autonomic hyperactivity, such as sweating and palpitations; increased hand tremor; insomnia; gastrointestinal upset, primarily nausea or vomiting; transient hallucinations; psychomotor agitation; anxiety; and finally, generalized tonic-clonic seizures. These features must also affect the patient’s quality of life and cannot be due to another condition.

Now, here’s a clinical pearl! Blood alcohol levels are not needed to diagnose alcohol withdrawal. However, in some cases, it’s useful to determine recent alcohol consumption in patients who can’t or won’t reveal details about their alcohol consumption, and it can also help with risk stratification. Individuals with alcohol withdrawal symptoms as well as elevated blood alcohol levels are at increased risk of developing severe withdrawal.

Now, if the patient does not meet DSM-5 Diagnostic Criteria for Alcohol Withdrawal, you should consider an alternative diagnosis. However, if your patient meets the criteria, you can diagnose alcohol withdrawal.