Critical Cases - Alcohol Withdrawal Syndrome!
Tue, 06/22/2021 - 5:11am
Editor:
History
- 54 year old male with history of alcohol use disorder presents complaining of restlessness and tremor
- He drinks a case (24 beers) per day
- His last drink was 12 hours prior
- He feels "bus crawling" on his skin, tremor, and nausea
Physical Exam
T 97.7 BP 185/90 HR 124 Pox 94%
- General: Restless, diaphoretic, +actively vomiting (non-bilious, non-bloody)
- Heart: tachycardic
- Pulm: Lungs clear
- Abdomen: Soft, nontender
- Neuro: alert and oriented, gross tremor of upper extremities
- Psych: anxious
DDx
- History and exam strongly suggestive of alcohol withdrawal syndrome
- Sympathomimetic use also a possibility
Treatment
- Treatment with a symptom-triggered protocol is preferred
- A widely used scoring system for severity of withdrawal symptoms is the CIWA-Ar score found here
- A CIWA score >10 should be treated initially with IV/PO diazepam 20 mg
- If CIWA still >10 after one hour, can double dose to IV/PO diazepam 40 mg, then to 60-80 mg after another hour if symptoms not improving
Disposition
- Discharge home on a benzo taper with close outpatient followup if CIWA<10
- Consider admission for: poor ability to followup, problems with access to medications/filling prescriptions, refractory symptoms, or evidence of respiratory depression
Alternative therapy
- Although benzodiazepenes are considered first line, there is mounting evidence for use of phenobarbital or gabapentin as first line agents