ED APPROACH TO ALCOHOL DETOX

48year old male came to EMD last week with c/o giddiness for 3 days and sound in the ear for 3 days. I was thinking of vertigo and tinnitus and asked him to go to yellow zone. After some more history taking I found that patient is all jittery and he started saying how his body starts to shiver every now and then. My next question like all clinician was ” do you consume alcohol?”. He then says he used to take alcohol but now he has stopped drinking, and his wife agrees with him. I started thinking about neurological diseases with acute onset giddiness, tinnitus and tremors. I then asked him “How long have you been sober?”. He said 4days!!!!

His wife then started speaking and she gave me a clear picture, this patient started drinking alcohol at the age of 20 years. His frequency and quantity of alcohol consumption had increased significantly over these years and in the last 2 months he drinks every day 1 quarter to half brandy or rum and after her threatening him he has stopped drinking 4 days back.

Alcohol is one of the most commonly used intoxicants in the world. The image below shows the amount of alcohol consumed in each country in the year 2025 according to WHO

Due to increased use of alcohol, it becomes important that Emergency physicians get well versed with effects of alcohol and other disorders associated with it. In this blog we are going to discuss on Alcohol withdrawal syndrome (AWS).

“AWS is a constellation of physiologic disorders related to central nervous system excitability in the setting of cessation of or decreasing alcohol consumption.’

Symptoms range from mild tremors, anxiety to seizures and delirium.

Symptoms can start as early as 6 hours of cessation of alcohol consumption.

• Volume of distribution is 0.6L/Kg.
• Metabolised and eliminated in liver. Ethanol gets converted to Acetaldehyde (hepatic ADH). Build-up of Acetaldehyde causes adverse effects (hang over)

Effects of alcohol on Central nervous system and cause of AWS

In chronic alcoholics there will be down regulation of GABA -A receptors and upregulation of NMDA receptors. When there is sudden cessation of alcohol consumption, there will be an unopposed glutamate activity on NMBA receptors resulting in AWS.

CIWA-Ar should be reassessed every 4-6 hours of initiation of treatment

• Patients with alcohol withdrawal hallucinosis, seizures or altered mental status
• 0.2 – 12% with AWS has hallucinosis
• Delirium tremens – severe form of AWS presented as delirium and alteration in mentation such as inattention or disorientation. It manifests about 24-72 hours of last alcohol drink.

• AWS is always diagnosis of exclusion

• Blood sugars should be tested for all altered patients
• Complete blood count: Leukocytosis – underlying infection
• Anemia, thrombocytopenia and leukopenia indicated alcohol induced bone marrow suppression, decreased thrombopoietin synthesis and splenic sequestration in cirrhosis
• Anion gap acidosis – alcohol ketoacidosis. In severe metabolic acidosis consider toxic alcohol consumption
• Electrolyte abnormalities: hyponatremia, hypokalemia, hypomagnesemia, hypocalcemia
• Serum alcohol levels
• CT brain if patient is in altered mental status or has had seizures
• ECG

Benzodiazepines – main stay of treatment.

Symptom triggered protocol vs fixed dosing protocol – the total dose of benzodiazepines and decreased median length of stay in hospital with symptom triggered protocol.

Phenobarbital (10mg/Kg) – along with GABA -A activity phenobarbital also suppresses glutamate

Adjunctive therapy

• IV fluids
• Inj Thiamine 100mg IV (if simple AWS)
• Intravenous Thiamine 500mg in case of Wernicke’s encephalopathy
• Thiamine should be administered before dextrose containing fluid to prevent Wernicke’s encephalopathy
• Antiseizure medications: there is no role for antiepileptics other than benzodiazepines in AWS