CURRENT Essentials of Critical Care.pdf

226 Current Essentials of Critical Care■■■Alcohol WithdrawalEssentials of Diagnosis• Generalized coarse tremors starting 6–8 hours after last drink,intensifying up to 24–36 hours• Anxiety, insomnia, anorexia, sweating, facial flushing, mydriasis,tachycardia, and hypertension seen in first days; altered mentalstatus, nightmares, auditory hallucinations in 25% of patients,peaking 24–36 hours• Generalized tonic-clonic seizures in one third of patients, usuallywithin 12–24 hours; status epilepticus in 3%; patients withprevious alcohol withdrawal seizures more likely to have recurrentseizures• Delirium tremens in 5%, 2–4 days after last drink; confusion,insomnia, vivid hallucinations, delusions, tremor, mydriasis,tachycardia, fever, diaphoresis; may last 1–3 days and relapseover weeksDifferential Diagnosis• Hypoglycemia• Anticholinergic or stimulant overdose• Sedative withdrawal• CNS infection, sepsis, thyrotoxicosisTreatment• Supportive care, including IV fluids as needed• Thiamine 100 mg intravenously, folate, multivitamins• Benzodiazepines for withdrawal symptoms on an as-needed basis,rather than scheduled dosing• Benzodiazepines for seizures• For delirium tremens, aggressive intravenous hydration, may requirehigh-dose benzodiazepines, such as diazepam 5–10 mg intravenouslyevery 1–4 hours■ PearlWatch for the presence of other behavioral health problems such asdepression in alcoholic patients.ReferenceKorsten TR, O’Connor PG: Management of drug and alcohol withdrawal. NEngl J Med 2003;348:1786. [PMID: 12724485]