Intensivist Interview: Acute alcohol intoxication and withdrawal syndrome

Intoxicated patients in ED and alcohol withdrawal syndrome — Dr. Natalie Htet and I bust some myths about caring for drunk patients in emergency as well as dive into the complexities of alcohol withdrawal.

Intoxicated patients in the emergency department

  • Myth busted: IVF does not speed-up alcohol metabolism (does not lower serum alcohol lovels)
  • Serum alcohol metabolizes at roughly 30 mg/dL/hour. If your patient does not “wake-up” after this calculated time, consider a CT or co-ingestion.

Alcohol Withdrawal Syndrome (AWS)

Pathophysiology

Chronic alcoholics have an increase in their excitatory receptor, glutamate (or NMDA) and a decrease of their inhibitory receptor, GABA.

When alcohol is removed for their system, alcoholics have too much NMDA and not enough GABA. Their CNS is in overdrive and needs to be calmed down.

Courtesy of IBCC

Assessment Findings

From the journal Acta Neurologica Scandinavica
  • Physical assessment: sweating, tremors, nausea/vomiting
  • Neurologic assessment: anxiety, disorientation, agitation, headache, tactile/auditory/visual disturbances
  • Vital signs: hypertension, tachycardia

Pharmacologic Treatment

  • Benzodiazepines. Watch out of paroxysmal agitation, which is rare but more common in alcoholics. Causes respiratory depression. Great info can be found at Core EM
    • Fast on, medium off: Diazepam (Valium)
    • Medium on, medium-long off: Lorazepam (Ativan)
    • Long on, long off: Chlordiazepoxide (Librium)
  • Phenobarbital This barbiturate is well-loved by Josh Farkas from EMCrit. Used only when 100% sure of the diagnosis. A great medication for severe withdrawal as it doesn’t produce the respiratory complications seen with benzos.
  • Anticonvulsants
    • Gabapentin to supplement the patients’ low GABA levels, promoted by Dr. Maldonado
    • Valproic Acid
  • Alpha-2 binders: Clonidine, Guanfacine (Tenex), Dexmedetomidine (Precedex). Can be used in conjunction with other medications for a poly drug approach. Causes CNS depression but doesn’t address the underlying neurotransmitter imbalance.
  • Vitamin supplementation: Thiamine, folic acid, B-complex and multivitamin address underlying encephalopathies.

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