EM Reflections Sept 2021 – Managing alcohol withdrawal

Authored and Copyedited by Dr. Mandy Peach

Big thanks to Dr. Paul Page for leading this month’s discussions.

All cases are imaginary but highlight important learning points.

 

Case

A 72 yo male presents to the emergency department with left sided CP after sustaining a fall 3 days ago. He states he hasn’t slept and is having a hard time breathing due to the pain – “ I think I cracked a rib”. On further history surrounding the fall he divulges that he was quite intoxicated at the time of injury and that he does fall quite often when drinking. He drinks 8-10 beers per day, sometimes more, and has done so for many years. He denies any complications of his drinking other than frequent injuries and has never been admitted or attended a rehabilitation facility.

Financially there have been increasing constraints and currently he is unable to obtain alcohol. His last drink was 2 days ago. He states he feels uneasy and slightly nauseous with a mild headache, but he feels it is related to the chest pain.

His PMH is non-contributory – he has no family doctor and has no regular care. He has smoked 1-2ppd for “as long as I can remember”.

His vital signs: 142/76, HR 112, RR 20, O2 93% on RA, T 36.7. He appears diaphoretic, mildly uncomfortable and taking shallow breaths.

Physical exam for signs of trauma reveals no significant injury except for a small area of bruising and tenderness at the L 10^th rib with air entry heard bilaterally. As the trauma was 2 days ago, and he is satting 93% on RA on a background of suspected COPD, you feel it is unlikely he has any complication of his fall. Imaging is unlikely to change your management – he needs analgesia.

You instead focus on his alcohol use as you suspect that is what is contributing most to his symptoms.

What are symptoms/signs of alcohol withdrawal? How soon do you anticipate symptoms?^1,2

A spectrum – early withdrawal -> seizures -> alcoholic hallucinosis -> delirium tremens (DT).

Symptoms	Signs
Abdominal pain	Tachycardia
Nausea/vomiting	Elevated BP
Headache	Tremor – The tremor is key to diagnosis. It is an intention tremor – when resting it is not visible. Ask the patient to extend their arms/hands and it becomes apparent. This is a persistent tremor and it does not fatigue
Anxiety	Tongue Tremor – more sensitive finding. See video
Hallucinations – clear cognition with hallucinations *High risk deterioration to DT	Seizures – occur at 12-48 hours and are typically preceded by tremor

 

 

Tongue tremor¹

Symptoms from alcohol withdrawal can start as early as 6-8 hours after the last drink, as the alcohol levels decline.

Symptoms typically peak at 72 hours and are gone by day 5-7.

Delirium Tremens can be anytime from day 3-12 after abstinence.

You examine your patient for signs of withdrawal. From the vitals he is tachycardiac. On exam he appears diaphoretic and he complains of a few symptoms. You ask him to extend his arms and he does have an intention tremor that doesn’t fatigue.

You confirm he is in alcohol withdrawal – this is a clinical diagnosis.

Are there any investigations that should be done for acute alcoholic withdrawal?

It depends on the patient presentation and the level of severity.

Mild cases – lab work/imaging rarely contributory. But there are situations where it is warranted.

• Severe symptoms with potential DTs – really this could be a patient with acute delirium of any etiology. So screen for :
  • electrolyte abnormalities
  • alcoholic ketoacidosis
  • infection
  • toxidromes
  • thyrotoxicosis
  • neuroleptic malignant syndrome
  • serotonin syndrome
  • hypertensive crisis
  • acute pain
  • ECG – chronic alcohol use leads to hypomagnesemia and electrolyte abnormalities, increasing risk of long QT.
  • CT head – These patients are high risk for falls during both intoxication and withdrawal. Combine this with fragile intracranial bridging veins and potential coagulopathy if underlying liver disease and their risk of ICH goes up substantially.

 

• Unclear history? Maybe the patient is not in DTs but actually is acutely intoxicated. An alcohol level can be ordered, but keep in mind that patients experiencing withdrawal will have symptoms at varying levels. Chronic users may have withdrawal symptoms at a level that is intoxicating to someone who rarely drinks. Add a urine tox screen if concern for co-ingestants as above.

 

So, if alcohol levels aren’t helpful how do I differentiate between an acute alcoholic intoxication vs severe withdrawal with DTs?¹

Giving benzodiazepines to a patient who is acutely intoxicated can lead to decreased LOC.

Before considering treatment look for the withdrawal tremor – if it isn’t present they are likely intoxicated.

 

The CIWA-Ar protocol is one method to monitor withdrawal symptoms and quantify the severity to ensure the patient receives appropriate treatment.

https://insight.qld.edu.au/shop/clinical-institute-withdrawal-assessment-of-alcohol-scale-revised-ciwa-ar-insight-2019

This is a 10 item scale and is done hourly. If a patient scores > 10 they are treated, if  back to back scores are < 10 they can be discharged.

Is there a faster tool that can be used in the ED to quantify alcohol withdrawal?¹

SHOT protocol is a 4-item scale. It is done every 1-2 hours. It is not validated, but has been shown to correlate well with CIWA score. It is shorter and easier to administer. Patient can be discharged if back to back scores are 0-1.

You decide to calculate your patient’s SHOT score³.

You calculate the patient’s SHOT score to be 6

• Sweating: He has beads of sweat on his forehead (2)
• Hallucinations: He has no hallucinations (0)
• Orientation: He knows where he is, but gets the month wrong (1)
• Tremor: he has a moderate intention tremor (3)

Any score over 2 requires medical intervention

Your patient requires intervention.

What medication do you choose to treat alcohol withdrawal?

Longer acting benzodiazepines are preferred as they have a more predictable course and are less likely to result in withdrawal or seizures ^1,2,4.

	Lorazepam	Diazepam
Onset of action	Slower	Faster
Half-life	8-12 hours	100 hours
Duration of action	12 hours	5 days
Risk withdrawal	Higher	Lower
Sedation risk	Less risk of oversedation Use if liver dysfunction as less systemic accumulation	Oversedation risk if liver dysfunction, elderly, low albumin, methadone or high dose opiods

Use oral doses if mild withdrawal and the patient can tolerate.

You order oral diazepam for the patient when a trauma team activation is heard overhead – it is a multiple vehicle MVC. Currently the department is critically understaffed, and all available staff are sent to trauma while one nurse manages the acute patients.

A couple of hours have passed and you finally get back to reassess your withdrawal patient. He has since had a CT head that showed the expected atrophy but no hemorrhage. You review his lab values and other than some mild electrolyte abnormalities there are no glaring values or signs of co-ingestants. You hear raised voices in the department and go to assess. Your patient now appears to the hallucinating and is severely agitated. He is not responding to verbal de escalation. A code white is called. The patient is restrained and a glucose is immediately checked to r/o hypoglycemia – it is 5.8. IV access is still intact.

Your patient is likely experiencing DTs and is in severe withdrawal.

What medication do you want to avoid in this agitated patient withdrawing from alcohol¹?

Haldol – antipsychotics can prolong QT interval in patients already at risk of long QT. It can also lower seizure threshold.

How do you manage severe alcohol withdrawal ⁵?

Lots of benzos via IV with the goal of having a calm, cooperative patient.

Start with diazepam 10 mg IV and reassess in 5 minutes, if not suffice then re-dose another 10mg. If still no success than increase the dose increase by 10mg and repeat that pattern, reassessing every 5 mins.

What if the patient doesn’t respond to these treatments?

Once approaching 200mg total – these patients are benzo resistant and will likely require intubation (*keeping in mind you’ve considered other etiologies)⁵.The same is true for refractory seizures that have not responded to escalating benzodiazepine doses.

Before proceeding to intubation you can consider phenobarbital as adjunct, but there is no evidence that phenobarbital alone is superior to benzos in treating withdrawal. The side effect profile is also higher if using an anticonvulsant instead of a benzodiazepine ².

If you intubate the patient, consider the following adjuncts⁶:

Of these – phenobarbital, propofol and dexmedetomidine have been shown to decrease benzodiazepine requirements in severe withdrawal, but none are proven to shorten duration of illness of length of stay in ICU.

If using demedetomidine you must have another adjunct as it does not protect against withdrawal seizures.

The following is a summary¹

 

You administer escalating benzodiazepine doses to your patient and eventually he settles. You are charting and preparing to admit the patient when the nurse lets you know the patient is now on 2L of oxygen despite having a normal respiratory rate and end tidal. His GCS is 13 – he opens his eyes to speech, is responding to questions but seems confused still and is moving spontaneously to command.

You go to reassess. You confirm the GCS and don’t feel that it is contributing. You remember the low oxygen saturation on initial vitals you thought was secondary to underlying COPD. You auscultate the lungs and now notice decreased air entry to the L side. In the setting of recent trauma you are concerned your patient had a pneumothorax that worsened.

Would PoCUS have been of benefit in initial assessment of the patient?

It depends on the thoroughness of the scan.

There is evidence that a single view of the anterior chest in the midclavicular line, 3^rd intercostal space, is comparable to a 4-zone lung scan for finding a clinically significant pneumothorax in the setting of blunt trauma. In this study clinically significant means those pneumothoraces that required thoracostomy⁷.

So, using this single view approach smaller pneumothoraces can be missed. But they are less likely to require a chest tube up front.

Could this patient have had a small traumatic pneumothorax that worsened in the setting of his agitation? Could he have had a secondary spontaneous pneumothorax in the setting of COPD?

Without imaging of some sort before hand it is difficult to know with certainty. Keep in mind that CXR has a sensitivity of 20-48% for pneumothorax ⁶. A thorough PoCUS exam has a higher sensitivity and equivocal specificity for pneumothorax in the setting of blunt trauma⁶. Gold standard? CT of course.

Regardless, have a low threshold to image elderly people in the setting of trauma.

You place a probe in the 3^rd IC space anteriorly and see the following

There is lack of lung slide or comet tails/B lines suspicious for pneumothorax.

What can complicate interpretation of a lung scan for pneumothorax? What is the most specific sign of pneumothorax?

In certain patient populations (ie. critically ill ICU patients, ARDS, pneumonia, fibrosis, pleurodesis, cardiopulmonary arrest) the typical findings of lack of lung sliding and B lines are not reliable.

Absence of lung sliding does not diagnosis pneumothorax (spec 78-91%) in these patients.

Definite sign? Lung point, or the area where the visceral pleural begins to separate from the parietal pleural – it is 100% specific.

You confirm a pneumothorax and place a chest tube without complication. You now CT the patient looking for further injury. The CT confirms multiple L sided rib fractures with a small hemothorax and reinflation of the pneumothorax. There is also stable, but acute, thoracic spine fractures.

The patient is admitted to the ICU for severe alcohol withdrawal in the setting of trauma.

What extra treatments do you consider before handing over to the ICU staff^1,2?

Fluids – often these patients are hypovolemic and hypoglycemic. Consider glucose containing fluids.

High dose Thiamine – thiamine deficit patients can develop Wernicke’s encephalopathy. Glucose and thiamine compete for the same co-factor so theoretically giving glucose in a thiamine deficient patient could precipitate Wernicke’s. However, there is no evidence that a single glucose dose will cause this. So, give glucose at the same time or after thiamine, but if critically low glucose don’t wait to administer.

Magnesium – required for thiamine related kinetics and is often low in this population. Check and replace when giving thiamine².

 

The patient did well and upon discharge he was provided resources and support for seeking treatment. He completed the detox while admitted.

What about patients being discharged from the emergency department with mild alcohol withdrawal? How are they managed ¹?

Key is avoiding prescription for benzodiazepine as an outpatient. This has a risk of oversedation, dependence and drug seeking behaviour. Giving diazepam in the ED can prevent seizures due to it’s long half life.

Take home points:

1. Alcohol withdrawal is a clinical diagnosis – recognize the symptoms and signs.
2. Persistent intention tremor is a sensitive sign of withdrawal.
3. Consider other causes in the acutely delirious patient.
4. These patients are high risk for injury – have a low threshold to image if suspicion of trauma
5. Quantify the severity for treatment – consider using the SHOT protocol. Diazepam > Lorazepam in the patient with no underlying liver dysfunction.
6. High, escalating IV benzos for refractory agitation/seizure
7. Avoid benzodiazepine prescriptions as an outpatient.

 

References and further reading

1. Helman, A, Borgundvaag, B, Gray, S. Alcohol Withdrawal and Delirium Tremens: Diagnosis and Management.Emergency Medicine Cases. October, 2016. https://emergencymedicinecases.com/alcohol-withdrawal-delirium-tremens/. Accessed [Oct 31, 2021].
2. Fabian, C. Alcohol: Beyond the “Breakfast Plan”. EM Ottawa. December 2015. https://emottawablog.com/2015/12/alcohol-beyond-the-breakfast-plan/. Accessed [Oct 31, 2021].
3. Gray S, Borgundvaag B, Sirvastava A, Randall I, Kahan M. Feasibility and reliability of the SHOT: A short scale for measuring pretreatment severity of alcohol withdrawal in the emergency department. Acad Emerg Med. 2010;17(10):1048-54
4. Hoffman R, Weinhouse G. Management of moderate and severe alcohol withdrawal syndromes. UpToDate. September 2021. https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawalsyndromes?search=alcohol%20withdrawal&sectionRank=1&usage_type=default&anchor=H17&source=machineLearning&selectedTitle=1~150&display_rank=1#H17. Accessed [Oct 31, 2021]
5. Justin Morgenstern. Management of Delirium Tremens, First10EM, 2016. Available at:

https://doi.org/10.51684/FIRS.1898

6. Darrel Hughes, “Benzodiazepine-Refractory Alcohol Withdrawal”, REBEL EM blog, April 28, 2016. Available at: https://rebelem.com/benzodiazepine-refractory-alcohol-withdrawal/.
7. Michael Prats, MD. Comparison of Four Views Versus Single View for Pneumothorax. Ultrasound G.E.L. Podcast Blog. Published on November 7, 2016. Accessed on November 1, 2021. Available at https://www.ultrasoundgel.org/6.