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ALCOHOL WITHDRAWALPathophysiology• Alcohol is CNS depressant• Chronic use S insensitivity to inhibitory neurotransmitter -aminobutyric acid (GABA)• Abrupt alcohol cessation S CNS overactivityClinical manifestations• Minor withdrawal sx (6–48 h after last drink): mild anxiety, tremulousness, HA• Withdrawal seizures: typically w/in 48 h after last drink; if unRx’d, 1 ⁄3 S delirium tremens• Alcoholic hallucinosis: isolated hallucinations (typically visual) 12–48 h after last drink• Delirium tremens (DT): disorientation, agitation, hallucinations, c HR & BP, fever,diaphoresis; begins 48–96 h after last drink, lasts 5–7 d• Need to consider other dx: CNS infxn, CNS bleed, drug O/D, acute liver failure, GIBClinical Institute Withdrawal Assessment scale for alcohol (CIWA-Ar)• Assign points for each of the 10 criteria; add points to calculate scoreCIWA-Ar ScalePoints Anxiety Agitation Tremor HA Orientation0 None None None None Oriented1 Somewhat Not visible, but Very mild Cannot do serialfelt at fingertipsadditions2 Mild Disorient. by 2 d3 Moderate Disorient. by 2 d4 Guarded Restless Moderate w/ Mod severe Disoriented tohands extendedperson or place5 Severe n/a6 Very severe n/a7 Panic Pacing or Severe Extremely n/athrashingseverePoints N/V Sweats Auditory Visual Tactile disturbhalluc. halluc.0 None None None None None1 Moist palms Very mild Very mild Very mildphotosens. paresthesias2 Mild Mild Mild paresth.photosens.3 Moderate Mod Mod paresth.photosens.4 Intermit. w/ Beads Mod severe Mod severe Mod severedry heaves visual halluc. hallucinations5 Severe Severe Severe6 Very severe Very severe Very severe7 Constant Drenching Cont. Continuous ContinuousSCORE: 8 none to minimal withdrawal; 8–15 mild; 16–20 moderate, 20 severe(Each criterion is a continuum that ranges from 0–7 points [except 0–4 for Orientation]; selected cellshave text to provide guidance for assigning points.)Treatment (NEJM 2003;348:1786)• Benzodiazepines (BDZ)Drug: diazepam (long-acting w/ active metab; T risk of recurrent withdrawal), lorazepam(short half-life), chlordiazepoxide, oxazepam (no active metabs; good if cirrhosis)Route: start IV, transition to PODosing: typically start w/ diazepam 10–15 mg IV q10–15 min (or lorazepam 2–4 mg IVq15–20 min) until appropriate sedation achieved, then titrate to CIWA-Ar scale, evaluatingq1h until score 8 8h, then q2h 8h, and if stable then q4h (JAMA 1994;272:519)• If refractory to BDZ prn, consider BDZ gtt, phenobarbital or propofol (& intubation)• Do not give haloperidol (T seizure threshold) or B / central 2-agonists (mask sx)• Mechanical restraints as needed until chemical sedation achieved• Volume resuscitation as needed; thiamine then glc to prevent Wernicke’s encephalopathy(ataxia, ophthalmoplegia, short-term memory loss); replete K, Mg, PO 4• Prophylaxis: if min sx or asx (ie, CIWA score 8) but prolonged heavy EtOH consumptionor h/o withdrawal seizures or DTs S chlordiazepoxide 25–100 mg(based on severity of EtOH use) q6h 24h, then 25–50 mg q6h 2dETOH 9-5