 |
| Image Credit |
Loyola University Chicago Stritch School of Medicine
AAEM/RSA Social Media Committee
 |
| This post was peer reviewed. Click to learn more. |
There are roughly eight million Americans who are alcohol-dependent, with 500,000 cases of alcohol withdrawal requiring treatment each year.[1] Being able to recognize and manage alcohol withdrawal is an essential skill for every emergency room physician. Long-term ethanol use causes downregulation of gamma-aminobutyric acid (GABA) receptors causing an increased inhibitory tone, as well as upregulation of glutamate receptors to maintain excitatory pathways. With sudden cessation of ethanol, there is decreased inhibition via GABA receptors and increased excitatory effects from glutamate receptors, causing central nervous system (CNS) excitation and the symptoms of alcohol withdrawal.[2]
As with all emergency department (ED) patients, the first step is to manage ABC’s (airway, breathing, and circulation). Aspiration can occur with withdrawal seizures. Initial symptoms of withdrawal can begin as soon as six hours after the patient’s last drink, so asking for a timeline of the patient’s last alcoholic drink is essential for determining when symptoms can be anticipated. A serum ethanol should also be obtained. Hypoglycemia is commonly associated with alcoholic abuse, so checking serum glucose remains essential. Given alcohol’s association with liver and pancreatic damage, a complete blood count (CBC), basic metabolic panel (BMP), Liver enzymes, and Lipase should be checked if there is suspicion for hepatitis or pancreatitis.[3] For the first 6 to 36 hours after the last drink, symptoms can include tremulousness, anxiety, headache, diaphoresis, palpitations, and gastrointestinal upset.[2] Benzodiazepines (often lorazepam or diazepam) are used for management, as they stimulate GABA receptors to inhibit the increased excitatory CNS effects. Withdrawal seizures can occur within 12 to 48 hours, usually occurring as singular seizures or brief flurries. Benzodiazepines are also the treatment of choice here. Examples of doses are Lorazepam IV 2-4mg every 15-20 minutes, or diazepam IV 5-10mg IV every 5-10 minutes, until symptoms resolve.[3]
