Alcohol Withdrawal Admission

Patient might have been drinking a lot of alcohol recently and suddenly stopped drinking for whatever reason. Some may present to ER voluntarily or some may be brought by EMS after police find them somewhere confused. The symptoms can be mild for some. More severe symptoms seen are seizures, hallucinations, delirium, agitation, diaphoresis, hypertension, tachycardia etc. Some fall and have injuries.

EMS:

IV fluids

ER:

Continue IV fluids or my give boluses

Banana bag-A banana bag (or rally pack) is a bag of IV fluids containing vitamins and minerals. The bags typically contain thiaminefolic acid, and magnesium sulfate.

Routine labs, ammonia level if confused, Blood alcohol level.

If patient has injuries, trauma team will evaluate the patient initially.

Hospitalist:

Admit to Telemetry if patient has signs of alcohol withdrawal like high blood pressure or if confused or if shaking. Monitor for development of Delirium Tremens.

Continue IV fluids-Include Dextrose if they are confused and not expected to eat well. They have high tendency to have hypoglycemia.

IV Ativan as needed per CIWA scale. Give IV ativan until CIWA-Ar score is less than 10.

Revised Clinical Institute Withdrawal Assessment for Alcohol scale [CIWA-Ar scoring], max score is 67.

0-9 absent of minimal withdrawal.

10-19 Mild to moderate withdrawal.

>20 is severe withdrawal.

PO Librium can be given TID. Taper it down as patient improves. Usually, hospitalists prefer not to discharge patients on this medication or any benzos for alcoholics.

Some do Phenobarbital load when in the hospital and stop it. Since it has long half life, it acts as auto tapering after stopping to give Phenobarbital.

Gabapentin [if they don’t have renal insufficiency] can be used for BZD sparing. Start with high dose Gabapentin and taper it down. Gabapentin can be given in liver disease patients.

Valproic acid tapering doses can be used too for some patients who have prior brain injury, existing SZD, or h/o withdrawal seizure.

Clonidine PO can help with heart rate and blood pressure control.

Check Phosphorus and Magnesium if not done by ER already. They usually have low Potassium, Phosphorus or Magnesium and replace if that is the case.

Give Multivitamin, Folic Acid and Thiamine IV if unable to take PO.

Thiamine is the most important and needs to be given promptly. Some prefer to give high dose IV initially.

Some my withdraw severely and might need intubation and ICU monitoring. They may need drips like Ativan drip, Propofol (if LFTs are OK) or Precedex drip etc. Precedex drip to sedate and BZDs for managing alcohol withdrawal. Phenobarbital protocol when BZDs are maxed out or are not effective.

Some may need to be discharged to inpatient alcohol rehab.

Counsel them to quit alcohol abuse. Explain to them about Cirrhosis, Encephalopathy, cardiomyopathy and other complications with alcohol.

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