1. UCI internal medicine mini-lecture series By Julia Kao
Alcohol withdrawal
UCI internal medicine
mini-lecture series
By Julia Kao

2. Objectives Discuss the symptoms and signs of alcohol withdrawal.
Discuss the management of alcohol withdrawal.

3. Case 1
70-yo M with unknown PMHx was brought into ED after being found down. Pt was found to have displaced hip fracture and was taken to OR for ORIF. Pt initially did well post-op, but 48 hrs after admission pt started having tachycardia, hypertension, fever, and agitation.
What are some differential diagnosis?
Sepsis, drug intoxication/ withdrawal, alcohol withdrawal (esp. DT)

4. Withdrawal symptoms timeline
Minor withdrawal (“the shakes”): tremulousness, anxiety, GI upset, headache, diaphoresis hours after last drink.
Seizures: 6-48 hours after last drink
Alcoholic hallucinosis: visual/ auditory/ tactile hallucinations, with intact orientations and stable vital signs hours after last drink.
Delirium tremens: delirium, agitation, tachycardia, hypertension, fever, diaphoresis hours after last drink.

5. What’s in Quest CIWA order set?
Vital signs q4h, cardiac monitoring, pulse oximetry, fall/seizure/ aspiration precautions.
CIWA scores (components of CIWA: N/V, sweats, anxiety, agitation, tremor, HA, auditory/ visual/ tactile disturbances, orientation and clouding of sensorium).
“banana bag”: NS with 100mg thiamine, 1g folate, and multivitamin.
PRN IV Ativan 2mg for CIWA 10-15, 4mg for CIWA> 15.

6. What is not in the order set?
Electrolyte replacement: especially watch out for low K, low Mg, and low phos!

7. When do you call the ICU? Status epilepticus
Possible DTs, esp. persistent hyperthermia, hemodynamic instability
Severe electrolyte or acid/base disturbances
Severe withdrawal symptoms, requiring large amount of benzodiapezines.

8. Case 2
40-yo M with h/o alcohol abuse presented with palpitations, nausea/ vomiting, and tremors.
Pt drinks half a gallon of vodka daily and reports that his last drink was approximately 12 hours prior to admission. On further questioning, pt reports history of alcohol withdrawal seizures and has been admitted to OSH ICUs in the past for alcohol withdrawal.
In the ED, pt is tremulous, afebrile, has regular tachycardia, slightly hypertensive.
H/o ICU admissions for alcohol suggests pt may have had DTs in the past. Pt also at increased risk if + h/o seizures and prolonged heavy alcohol use.

9. Which electrolytes do you check?
Which protocol do you initiate to monitor and manage withdrawal symptoms?
Which electrolytes do you check?
What IVF and medications do you order?
When is the pt at greatest risk for alcohol withdrawal seizures? For DTs?
Under what circumstances would you call the ICU?
Labs: electrolytes, Mg, Phos. CIWA order set. “banana bag”, prn Ativan. Seizures can occur 6-48 hrs after last drink, DTs hrs after last drink.

10. Summary
Depending on the time of last drink, there are symptoms/ signs and possible complications to watch out for and manage.
Initiate CIWA protocol when patient was admitted with possibility of alcohol withdrawal, include IV fluid, vitamins, and prn lorazepam.
Don’t forget to check and replace electrolytes.

11. References
UpToDate.com
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