Discontinuing alcohol intake may result in a range of withdrawal effects.

When discussing alcohol withdrawal, it's important to note that it doesn't look the same for everyone. For those who have been heavy drinkers for a long time, there are actually four distinct withdrawal syndromes, which can be ranked by severity.

The first one, often called minor withdrawal, doesn't have a fancy name but includes symptoms like anxiety, headaches, sweating, shaking, rapid heartbeat, and palpitations. Even though it's labeled as "minor," patients often feel quite uncomfortable. This syndrome usually kicks in between six to twenty-four hours after the last drink and can last up to a week, though it rarely starts more than two to three days into sobriety.

The next syndrome, known as alcoholic hallucinosis, is a bit more serious but still not the worst. In this case, patients experience hallucinations, often visual or tactile, like feeling bugs crawling on their skin. However, they remain aware of their surroundings and recognize that what they're seeing isn't real. This can happen as soon as 12 hours after the last drink, but it's more common to see it develop between 24 to 36 hours later.

Withdrawal seizures can also occur, but they are usually brief and followed by a short recovery period. If seizures last longer, it might indicate another underlying issue. Finally, the most severe and dangerous syndrome is delirium tremens, often shortened to DT. It's interesting to note that some people mistakenly add an "S" at the end and refer to it as DTS.

DTS was mentioned last night, but it's important to note that it's not a plural term; the "S" doesn't belong there. DT stands for delirium tremens, which includes severe tachycardia, severe hypertension, and severe hypothermia. Patients experiencing DT have a seriously unstable autonomic nervous system, and this condition makes alcohol withdrawal potentially life-threatening. The onset of DT typically happens later than other withdrawal symptoms, usually between 48 to 96 hours after the last drink. It's worth mentioning that almost all patients who develop DT have shown some earlier signs of withdrawal. While classic descriptions suggest a clear shift from minor withdrawal to DT, this isn't always the case. Instead, you might notice a gradual worsening of minor withdrawal symptoms, where anxiety escalates into delirium and tachycardia leads to hemodynamic instability. Factors that increase the risk for DT include a history of DT or withdrawal seizures, being over 30 years old, having concurrent illnesses, and showing symptoms of alcohol withdrawal while blood alcohol levels are still high, indicating heavy and consistent alcohol use. Even with treatment, the mortality rate for DT is around 5%. Alcohol withdrawal can vary widely in severity, from barely noticeable symptoms to those that are life-threatening. It's crucial to assess patients' risk for severe withdrawal, and the most reliable method for this is the PAWS score, which stands for Prediction of Alcohol Withdrawal Severity Scale. To determine if a patient needs a PAWS score calculated, you should first ask if they have...

DTS was brought up last night, but remember, it's not a plural term; the "S" is unnecessary. DT refers to delirium tremens, which includes severe tachycardia, severe hypertension, and severe hypothermia. Patients with DT have a critically unstable autonomic nervous system, making alcohol withdrawal potentially life-threatening. DT usually appears later than other withdrawal symptoms, typically 48 to 96 hours after the last drink. It's important to note that nearly all patients who develop DT have experienced some earlier withdrawal symptoms. While traditional descriptions suggest a clear divide between minor withdrawal and DT, this isn't always true. Instead, you might see a pattern where minor withdrawal symptoms gradually worsen, with anxiety escalating into delirium and tachycardia leading to hemodynamic instability. Risk factors for developing DT include a history of DT or withdrawal seizures, being over 30 years old, having other illnesses, and showing withdrawal symptoms while blood alcohol levels are still elevated, indicating heavy and consistent alcohol use. Even with treatment.

It is essential to determine whether the individual has consumed any alcohol in the past 30 days or if there is evidence of a positive blood alcohol level upon admission. If the response to either inquiry is affirmative, the individual receives their first point in the scoring system, and the remainder of the assessment should proceed. Points are awarded for each instance of prior withdrawal episodes, withdrawal seizures, or delirium tremens (DT). Additionally, points are given if the individual has undergone any form of alcohol rehabilitation, experienced alcohol-related blackouts, or combined alcohol with benzodiazepines or opioids within the last 90 days, as well as for combining alcohol with any other substances of abuse during the same timeframe. A point is also assigned if the blood alcohol level upon admission exceeds 200 milligrams per deciliter, and another point is awarded if the patient exhibits minor withdrawal symptoms. The scoring system allows for a maximum of 10 points, with a score of four or higher indicating a high risk of severe withdrawal. In managing withdrawal, the initial consideration is whether the patient requires admission. It is advisable to admit patients when they explicitly express a desire to abstain from alcohol. If a patient is unwilling to make such a statement, admission may be futile and potentially hazardous, as they may resume drinking shortly after discharge. However, if the patient does express a desire to quit, it is important to assess whether at least one of the following conditions is met: a PAS score of four or higher, or any history of withdrawal seizures or DT.

When someone is experiencing withdrawal symptoms while their baseline cognitive function is still impaired, it can make it unsafe for them to use benzodiazepines on an outpatient basis. If they have unstable psychiatric conditions or can't keep daily appointments during withdrawal, I believe they should be admitted for monitored alcohol withdrawal treatment. So, what do we use to treat them? Benzodiazepines are the primary treatment for all types of alcohol withdrawal in the U.S. The three most commonly used ones are:

First up is diazepam, which is also known as Valium. It works quickly, lasts a long time, and can be given either through an IV or taken orally. I usually choose diazepam for most patients going through withdrawal. The typical starting dose is between 5 to 10 milligrams, either IV or orally, and the IV can be repeated every five to ten minutes until the symptoms start to get better. The ideal state for the patient is to be calm and maybe a bit sleepy, but still able to wake up and talk.

Next is lorazepam, or Ativan. This one acts more quickly, which can lead to a bumpier experience for patients, but it’s considered safer for those with liver issues due to how it’s processed in the body. This makes it the preferred choice for patients with cirrhosis or alcoholic hepatitis. It can also be given IV or orally, with a typical starting dose of 2 to 4 milligrams, and the IV can be repeated every 15 to 20 minutes if needed.

Lastly, there’s another common benzodiazepine used for withdrawal, but it wasn’t mentioned in the text.

Chlordiazepoxide, commonly referred to as Librium, is a long-acting benzodiazepine that is available exclusively in oral form. This makes it a frequently utilized medication for the outpatient management of alcohol withdrawal, typically administered in a short tapering regimen over several days. Initial dosages generally range from 25 to 100 milligrams orally, which may be repeated every two to three hours as necessary. While it would be advantageous to have a reliable method for converting typical alcohol consumption into anticipated benzodiazepine requirements, such a method does not currently exist. However, patients who have previously needed unusually high doses of benzodiazepines during withdrawal episodes are more likely to require similar high doses in subsequent episodes. Historically, there have been two predominant approaches to benzodiazepine dosing: one advocating for a fixed schedule with a planned taper, and the other supporting an as-needed, symptom-triggered administration. Recent studies and clinical experience have favored the symptom-triggered approach, as it has demonstrated comparable or superior outcomes while necessitating a significantly shorter treatment duration. To effectively implement a symptom-triggered strategy, it is essential to have a standardized method for assessing the severity of withdrawal symptoms, which is accomplished through the Clinical Withdrawal Scale (CWS). This scoring system allocates between 0 to 7 points for each of ten clinical criteria, including anxiety, tremors, headaches, orientation, diaphoresis, and hallucinations. A higher total score indicates more severe withdrawal, with a score below eight considered minimal.

Withdrawal symptoms occurring when a patient is over 20 are classified as severe. Many hospitals have established protocols whereby nursing staff assess a patient's IVA score at regular intervals, typically every hour upon admission. Based on the patient's score, a specific dosage of benzodiazepine is administered if the score falls within a designated range. If the score remains below a certain threshold for a specified duration, the frequency of assessments is gradually reduced. This method of managing withdrawal minimizes the need for frequent physician notifications, empowers nursing staff, and, most importantly, facilitates more timely treatment. In rare instances, a patient experiencing delirium tremens (DT) may show resistance to standard benzodiazepine treatments. In such cases, alternatives may include continuous infusion of benzodiazepines, propofol, phenobarbital, or dexmedetomidine. Most patients requiring these treatments will also need intubation and mechanical ventilation. A minority of specialists have proposed treatment protocols that limit the routine use of benzodiazepines, known as benzodiazepine-sparing protocols. These may involve the use of clonidine, dexmedetomidine, valproic acid, and gabapentin. However, there is insufficient trial data to support these protocols, and their implementation cannot currently be endorsed. Additionally, several historically utilized treatments are deemed hazardous and should be avoided. For instance, phenytoin has proven ineffective for withdrawal seizures, while Haldol may alleviate psychotic symptoms associated with hallucinosis and essential tremor but poses a risk by lowering the seizure threshold and is not particularly effective in this context.

Benzodiazepines and beta blockers can help manage tachycardia and alleviate some mild withdrawal symptoms, but they mainly just hide the symptoms instead of addressing the real issue. This can make it harder to spot and treat early signs of delirium tremens (DT). It's also important to remember that patients in this situation need supportive care, which includes giving them IV fluids and thiamine before glucose to avoid causing Wernicke's encephalopathy. Additionally, correcting any electrolyte imbalances, like low phosphate levels, and providing nutritional support is crucial. Don't forget to identify and treat any other health issues they might have, such as alcohol-related liver disease, alcoholic gastritis, aspiration pneumonia, pancreatitis, mental health disorders, and various neurological problems that can arise from long-term heavy drinking, like dementia, cerebellar degeneration, and peripheral neuropathy.

Benzos and beta blockers can help control rapid heart rates and ease some mild withdrawal symptoms, but they mainly just cover up the issues instead of really fixing them. This can slow down the detection and treatment of early delirium tremens (DT). It's also essential to provide supportive care for these patients, which should include IV fluids and thiamine before giving glucose to prevent Wernicke's encephalopathy. Plus, correcting any electrolyte imbalances, like low phosphate levels, and ensuring they get proper nutrition is vital. It's also important to find and address any other health problems they might have, such as liver disease from alcohol, alcoholic gastritis, aspiration pneumonia, pancreatitis, mental health issues, and various neurological complications from chronic heavy drinking, like dementia, cerebellar degeneration, and peripheral neuropathy.