Day #10 - Alcohol Withdrawl

Today's case involved the diagnosis and management of the various alcohol withdrawal syndromes. The take home points include:

Alcohol withdrawal can have several phases which begin after cessation of regular alcohol consumption. These do not necessarily all occur, or occur in order but generally speaking:

• Seizures -- generalized, tonic-clonic, generally no focality, lasting short duration and with short period of post-ictal confusion. Can have up to five in rapid succession. Tend to occur 6-48h post ETOH and can occur with ETOH still on board. Treatment is supportive. Benzodiazepines like lorazepam or diazepam can prophylax against further seizures and other symptoms of alcohol withdrawal
• Autonomic symptoms -- tremor, flushing/diaphoreis, agitation/anxiety, tachycardia, mild hypertension. Treatment is supportive with benzodiazepines given either as an up-front load until drowsy or on a prn basis with the CIWA protocol.
• Hallucinosis -- Development of visual (often frightening images/faces/animals) hallucinations and tactile hallucinations
• Delirium Tremens -- Autonomic instability, agitation, fluctuating level of consciousness/delirium. Need to exclude other causes of delirium.

We also talked about some of the hematological consequences of ETOH abuse including:

• macrocytosis with or without overt anemia
• thrombocytopenia -- can become thrombocytosis if ETOH stopped as platelets will "rebound"
  
• pan cytopenia with con-commitment folate or B12 deficiency

Other important nutritional deficiencies include:

• thiamine -- Wernike's encephalopathy think WACO (W=Wernike A=ataxia C=confusion O=opthalmopalegia) where the opthalmopalegia is most commonly 6th nerve (bilateral or unilateral). Korsikoff's encephalopathy -- anterograde amnesia, confabulation
• B6 -- pernicious beri-beri, alcoholic neuropathy
• folate/B12
• magnesium