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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, October 2, 2017

Alcohol Withdrawal in ED

Alcohol withdrawal is seen in those who stop or cut down their drinking abruptly. Symptoms  of withdrawal include tremors, nausea and vomiting, diaphoresis, hyperdynamic vitals, fever, agitation, craving, and anxiety, seizures, hallucinations, and delirium. Symptoms may begin within few hours after reduction in alcohol consumption. 

ED management
Ruling out the co-existing diagnosis and mimics (hyponatremia, hypoglycemia, hypomagnesemia, DKA, Wernicke’s encephalopathy, toxic ingestions, primary seizures, head injury, infection, sepsis)

Alcohol withdrawal seizures are tonic-clonic seizures that occur 6-48 hours after the decrease in intake or the last drink. Alcohol withdrawal seizures remains a diagnosis of exclusion. Focal seizures should prompt search for another diagnosis. Benzodiazepines are the drugs of choice for EtOH withdrawal fits. Phenytoin should not be used unless there is an underlying structural lesion. Lorazepam is typically started at 2mg IV and repeated as needed. 

Delirium tremens is characterised by fluctuating disturbances in consciousness, confusion, agitation, inattention and impairment in cognition and hallucinations. Patients are at risk of fluid and metabolic imbalances. High doses of sedatives are required to control agitation. Benzodiazepines are the initial treatment of choice and those who do not respond to BZDs need phenobarbital, propofol, or haloperidol. However, antipsychotics should be given only after adequate benzodiazepines are administered.

Treatment of concomitant illnesses and providing supportive care (hydration and electrolyte imbalance) is an important part of management. Patients may also need physical restraints until they are quiet and Pabrinex and Mg should be considered for all.

Goals of therapy

Our goal is to reduce autonomic hyperactivity and agitation. This is achieved mainly through BZDs.  

Lorazepam 1mg = Midazolam 2mg = Diazepam 5mg = Chlordiazepoxide 25mg

Lorazepam is well tolerated by patients with advanced liver disease. Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA) is a validated (not validated specifically for ED use), structured instrument for guiding continuing treatment once a diagnosis of alcohol withdrawal is established. A score <8 represents mild withdrawal; score of 9 to 15 moderate withdrawal, and score >15 severe withdrawal. 

Admission Criteria
  • Concomitant other diagnosis 
  • Suicidal or homicidal ideation 
  • Advanced age
  • Not responding well to ED treatment
  • Prior history of delirium tremens 
  • Alcohol withdrawal seizures

  1. Rathlev NK, Ulrich AS, Delanty N, D’Onofrio G: Alcohol-related seizures. J Emerg Med 31: 157, 2006.
  2. Greenberg DM, Lee JW: Psychotic manifestations of alcoholism. Curr Psychiatry Rep 3: 314, 2001.
  3. Kahan M, Borgundvaag B, Midmer D: Treatment variability and out come differences in emergency department management of alcohol withdrawal. Can J Emerg Med 7: 87, 2005.
  4. Clinical Institute Withdrawal Assessment for Alcohol scale. CIWA-Ar available at: http://www.stvincentshospital.ie/documents/CIWA-Ar.pdf. Accessed February 22, 2010.
  5. D’Onofrio G, Rathlev NK, Ulrich AS, et al: Lorazepam for the prevention of recurrent seizures related to alcohol. N Engl J Med 340: 915, 1999.
  6. McCowan C, Marik P: Refractory delirium tremens treated with propofol: a case series. Crit Care Med 28: 1781, 2000.
  7. Kang TM: Propofol infusion syndrome in critically ill patients. Ann Pharmacother 36(9): 1453, 2002.
  8. Mayo-Smith MF, Beecher LH, Fischer TL, et al; for the Working Group on the Man- agement of Alcohol Withdrawal Delirium, Practice Guidelines Committee, American Society of Addiction Medicine: Management of alcohol withdrawal delirium: an evi- dence-based practice guideline. Arch Intern Med 164: 1405, 2004.
  9. Kosten TR, O’Connor PG: Management of drug and alcohol withdrawal. N Engl J Med 348: 1786, 2003. 

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     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine


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