LAS VEGAS – Diane M. Birnbaumer, MD, FACEP, and presenter at the 39th American Academy of Physician Assistants Annual Meeting, knows drunks. Her education began in medical school when her frequent visits to the Rathskellar in Washington, D.C., earned Birnbaumer a spot on the establishment’s “Wall of Fame.”
Now as a clinician in the department of emergency medicine at the Harbor-University of California Los Angeles Medical Center, she specializes in the managing alcohol emergencies brought on by withdrawal symptoms in chronic drinkers.
Alcohol withdrawal, commonly known as “the shakes” or “rum fits,” is the result of an abrupt cessation or relative decrease in alcohol consumption. However, a patient can still be drinking and have alcohol withdrawal, according to Birnbaumer. “You can have an alcohol level of 140 or 200 and still be in withdrawal if your normal alcohol level is 300 or 400.”
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Withdrawal stages
There are four stages of alcohol withdrawal. Stages 1, 2 and 3 are early alcohol withdrawal and symptoms will be present within 24 to 72 hours of decrease or cessation of alcohol consumption.
Stage 4, which is delirium tremens, is a late syndrome that does not manifest until three-to-five days after cessation. “That timing differentiation is very important for clinicians to determine what’s wrong with a patient,” Birnbaumer said.
Stage 1, also known as “the shakes,” begins six to eight hours after cessation or reduction of alcohol intake. Symptoms include tremulousness, anxiety, GI upset (nausea, vomiting, diarrhea) and agitation.
The tremors associated with this stage are rapid and increase with intention. Clinicians may see mildly increased BP, heart rate and temperature. Highly abnormal vital signs may suggest another diagnosis. Stage 1 peaks at 24 to 36 hours and resolves after two to three days. The majority of patients do not progress beyond Stage 1.
Stage 2 is marked by alcohol withdrawal hallucinations and is accompanied by autonomic hyperactivity. About 25% of withdrawing patients experience withdrawal hallucinations. The hallucinations are almost always visual, but can be tactile (formication) as well. The patient is fully oriented during the hallucinations. Onset is four to six hours after he or she stops consuming alcohol, peaks at one-to-three days and then tends to disappear.
Alcohol-related hallucinosis may be found in Stage 2. There is no accompanying autonomic hyperactivity in this stage. The hallucinations may occur at any point during an alcoholic’s lifetime and are almost exclusively auditory and often threatening and frightening to the patient. “This is a chemical change, a permanent change in the brain,” Birnbaumer said.
Stage 3 of early alcohol withdrawal is marked by seizures. Alcohol withdrawal seizures (AWDS) are found in 3% to 10% of untreated withdrawal patients. “The key is to understand what an alcohol withdrawal seizure is so that you can distinguish it from all of the other things that can cause seizures,” according to Birnbaumer.
If left untreated, one-third of patients with AWDS will go on to delirium tremens. Seizures are usually seen in chronic alcoholics, but there are no reliable predictors of which patients will seize.
Stage 3 occurs one to 48 hours after cessation or decrease in alcohol consumption. Most seizures occur within six hours, and virtually all of them will occur within 12 hours.
Seizure onset is abrupt, generalized and tonic-clonic, not focal. Forty percent of patients have a single AWDS. If multiple seizures occur, there are usually two to three in number and never more than six. In cases of multiple seizures, the total duration of seizure activity is usually less than six hours. There is usually a lucid phase between seizures and a short post-ictal phase.
“One of the things you absolutely want to check if anybody ever seizes is sugar levels, I do not care who they are or what age they are,” Birnbaumer stressed. “Alcohol is a great calorie source. It stores no glycogen in your liver at all.”
Stage 4, delirium tremens, is a symptom complex. “It’s basically autonomic anarchy,” Birnbaumer said.
This stage is marked by profound confusion, tremor, agitation, delusions, hallucinations, fever, tachycardia, diaphoresis, seizures and hyper-reflexia.
Four to six percent of untreated withdrawal patients go on to delirium tremens. This stage is usually but not always preceded by AWDS.
Usual onset is three-to-five days after cessation or decrease in alcohol intake and may be as late as 14 days. Mean duration is four to five days, but reported cases have lasted weeks. Mortality is estimated at 1% to 15% and is dependent on the degree of underlying disease.
“If somebody comes in with delirium tremens, it is an ICU admission, and they are there for four to five days at minimum. These people are really sick,” Birnbaumer said.
Evaluation and treatment
All patients with suspected withdrawal have to be examined completely. Be particular alert for acute head trauma, infection, GI bleeding and ascites.
Laboratory, radiographic and other studies should be performed as indicated. “One of the things I do not want you to do is routinely order a head CT scan when the patient clearly has a case of alcohol withdrawal,” Birnbaumer stressed.
She recommended using the CAGE Questionnaire on a regular basis to assess for alcohol dependence. Ask the patient:
• Has anyone ever asked you to Cut down on your alcohol use?
• Do you get annoyed when asked questions about your alcohol use?
• Do you ever feel guilty about your drinking?
• Do you ever need an “eye-opener” drink in the morning?
The patient’s response to these questions will help you gauge whether he or she is drinking too much.
A more precise assessment tool is the Clinical Institute for Withdrawal Assessment – Alcohol – Revised (CIWA-Ar). This takes 10 to 15 minutes to complete, so it may not be helpful in emergency situations. The checklist includes questions about nausea, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache and orientation.
The goals of treatment are to calm the patient, manage associated illnesses, prevent progression to more severe withdrawal, avoid iatrogenesis and provide social service support.
Pharmaceutical therapy
Benzodiazepines are the treatment of choice for cases of acute withdrawal, and it makes no difference which are used, according to Birnbaumer. Give this medication in small, frequent and as needed (symptom-triggered) doses. Large total doses may be required in some patients.
“The patient dictates what they need,” Birnbaumer said. “Don’t worry about iatrogenesis if they need the meds.” If benzodiazepines are given for outpatient therapy, only dispense up to a three-day supply.
Phenobarbital can be used as a first-line drug and may be a useful adjunct with benzodiazepines. Beta blockers may be helpful in controlling tremor and autonomic end-organ hyperactivity. They may decrease the need for benzodiazepines but do not appear to prevent progression.
