Alcohol withdrawal: Clinical sciences

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Introduction0:00–0:35

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.

Unstable0:35–1:16

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, BP 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, lets go back to the ABCDE assessment and take a look at stable individuals.

Stable1:16–1:35

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 eight or more drinks per week in biological females and 15 or more drinks per week.

History and physical1:35–3:01

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 five 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.

Suspect alcohol withdrawal3:01–4:20

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 patients 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 five diagnostic criteria for alcohol withdrawal, you should consider an alternative diagnosis.
However, if your patient meets the criteria, you can diagnose alcohol withdrawal. Once you diagnose it, assess the severity of withdrawal.

Alternative diagnosis/Alcohol withdrawal4:20–4:34

Using the clinical Institute withdrawal assessment of alcohol scale, revised or sr score for short, the SIU score measures 10 symptoms of alcohol withdrawal and assigns each one a numeric score based on severity.

Assess severity4:34–5:02

The total score is used to classify patients as having mild, moderate, severe and complicated alcohol withdrawal. Ok.
Let's start with individuals that are experiencing mild to moderate alcohol withdrawal symptoms. In this case, your first step is to assess the patients risk for developing severe or complicated withdrawal, which is associated with severe manifestations such as seizures.
Your patient is at risk if they have a history of withdrawal, seizures or delirium, numerous prior episodes of alcohol withdrawal, long term heavy alcohol consumption or concomitant, psychiatric or medical illness.

Mild/ Moderate withdrawal5:02–5:44

Also, the patient is at risk if they are over 65 years of age or if they are pregnant. If your patient has no risk factors, you can consider outpatient management depending on the resources available in the community.
For pharmacologic therapy, treat mild symptoms with anti convulsants such as carBAMazepine or gabapentin and moderate symptoms with benzodiazepines like LORazepam or chlordiazePOXIDE.

No risk factors5:44–7:11

But use the latter with caution in patients with liver cirrhosis also don't forget to supplement with oral thiamine. Here's a high yield fact, chronic alcohol consumption is associated with thiamine deficiency.
Thiamine plays a huge role as a cofactor for several enzymes related to glycolysis and Krebs cycle. Both of which use glucose to generate ATP for cellular energy.
This means that you must give thiamine before you administer an IV glucose infusion to your patient. If you administer glucose without giving thiamine first, these biochemical processes grind to a halt and lactic acid accumulates in the body which can cross the blood brain barrier leading to Wernicke encephalopathy.
This is a reversible condition characterized by ophthalmoplegia, ataxia and altered mental status. If left untreated Wernicke encephalopathy can progress to Korsakoff Syndrome, which is an irreversible condition associated with anterograde and retrograde amnesia as well as confabulation and personality changes.
Ok. Now, once you initiate treatment, be sure to assess the patient's response daily if they have an adequate response and their symptoms are improving wean pharmacologic therapy.
However, if they have an inadequate response and withdrawal symptoms fail to improve or worsen, you should consider transitioning them to inpatient management.
Ok. Now let's go back and look at patients that have severe or complicated withdrawal from the get go as well as those with risk factors for developing it.

Assess treatment response7:11–7:35

These patients require inpatient management and pharmacologic therapy, which relies on either benzodiazepines or barbiturates.
More specifically PHENobarbital additionally, be sure to supplement with IV thiamine and if needed, consider folate phosphorus and magnesium supplementation.

Risk factors present/Severe or complicated withdrawal7:35–8:05

Once you initiate the treatment, assess the patient's response every 1 to 4 hours. If the patient has an adequate response to treatment and their symptoms improve, you can slowly begin to wean pharmacologic therapy.
However, if the patient has an inadequate response, meaning there's no improvement in their withdrawal symptoms, then continue current management and consider increasing their medication dosages.
Here's one last clinical pearl beta blockers can mask symptoms of sympathetic overactivity such as palpitations, tachycardia, and hypertension, which are extremely important to recognize if your patient is progressing to a more severe form of withdrawal.

Assess treatment response8:05–8:56

Additionally, sympathetic masking can result in inadequate siwa R scoring and possibly inappropriate management. All right, as a quick recap.
Once you diagnose alcohol withdrawal, using DSM five diagnostic criteria for alcohol withdrawal, assess the severity of alcohol withdrawal using the sr score.
If the patient presents with mild or moderate symptoms, assess their risk for developing severe or complicated withdrawal.
If there's no risk of progression, you can consider outpatient management and pharmacologic therapy such as anti convulsants or benzodiazepines.
In combination with thiamine on the flip side. If your patient presents with risk factors of progression or presents with severe or complicated withdrawal from the get go proceed with inpatient management and start benzodiazepines or PHENobarbital in combination with IV thiamine if needed.

Review8:56–9:15

Don't forget to provide supplemental folate phosphorus and magnesium.