·
Approach
to Alcohol Withdrawal
Hx: Recent
substantial ETOH intake in a patient with a h/o tolerance.
A. Minor symptoms: (0-6 hrs
after last drink, and up to 36 hrs) insomnia, tremors, anxiety, GI upset,
diaphoresis, headache, etc.
B. Withdrawal seizures: (2-48
hrs) incidence ~3% of withdrawal cases,
3% of which progress to status epilepticus.
C. Alcoholic hallucinosis:
(12-24 hrs) usually visual hallucinations. Not associated with global clouding
of mentation, but rather with specific hallucinations.
D. Delirium Tremens: (48-96
hrs) ~5% of EtOH withdrawal cases progress to this syndrome, characterized by
hallucinations, disorientation, tachycardia, HTN, low-grade fevers, agitation,
diaphoresis. Mortality ~5%.
Tx: IVF,
Thiamine (prior to glucose-containing solution to reduce risk of
Wernicke/Korsakoff syndrome), MVI, watch for hypo K, Mg, Phos (refeeding
hypophos syndrome), Can use Atenolol 50 mg po qd if patient is hypertensive and
tachycardic (faster resolution of symptoms and reduced length of stay—[NEJM
1985; 313, 905-909]), Haldol (for alcoholic hallucinosis, but NOT for DTs b/c
it reduces seizure threshold), Serax taper (start with 45 mg po q6hrs—check for
improvement after 3hrs; if no improvement, increase Serax dose—be aggressive in
order to prevent progression to DTs!!).
Treatment should ideally be started in the ED, or at least upon arrival
to the floor.
A
commonly prescribed Serax taper: 45 mg PO q6h x 24h --> 30 mg PO q6h x 24
h --> 30 mg PO q8h x 24h --> 15 mg PO q8h x 24 h --> 15 mg PO q12h x
24h -->15 mg PO q24h x 24h then D/C.
Write to hold Serax for excessive somnolence. Serax and Ativan are long acting and metabolized mainly by
kidneys. May need to convert to ativan
drip if symptoms not controlled adequately with po Serax. Serax is often used
because of its relative safety in patients with hepatic insufficiency. Ativan drips as high as 100 mg/hr have been
needed in some patients. Start low and
titrate as needed. Adjuvant Haldol is
sometimes helpful.
·
Approach
to Heroin Withdrawal
Hx: watery
eyes, runny nose, congestion, sweats, anxiety, insomnia, yawning, abdominal
cramps, diarrhea, nausea, joint/muscle pains, fever, mydriasis, dehydration.
Symptoms peak 36-72 hours after last use and last for 7-10 days.
If on Methadone, call to verify the dose and to let the program know that the
patient is hospitalized so spot in the program is not lost.
Dx: Urine
Toxicology
Tx: Can either wait for symptoms to
begin, or begin low dose treatment (0.3 mg IM of Buprenorphine)
empirically. For symptomatic patients,
use a Buprenorphine taper: 0.9 mg IM
Q4-6hrs x 24hrs then 0.6 mg IM Q6 x 24hrs then 0.6 mg IM Q12hrs x 24hrs. Can
also use a clonidine patch on the last day for further symptom alleviation.
Also, Bentyl 10mg po Q6hrs for abd cramps can be useful. Keep in mind that Bup
is an agonist and antagonist and in higher doses (> 4mg/day) will interfere
in narcotic pain control, and if given after meds for pain can precipitate
withdrawal. Never give Bup as an IV
dose…it’s like giving a temporary “high” to your patient.
Management of Drug and Alcohol withdrawal [NEJM 2003;
348:1786-1795]
Hx:
hypoglycemia, metabolic derangement, uremia, hypoxia, infection (CNS &
sepsis), brain tumor, vasculitis, CNS bleed, EtOH withdrawal, and drug toxicity
Dx:
Direct observation of seizure activity by staff. CMP, HEME 8, ABG, capillary blood glucose, urine tox, serum
volatiles, lactic acid, prolactin, Head CT, EEG may reveal etiology.
Tx:
Acute management: give lorazepam 2mg IV q5min &
check capillary blood glucose (dexi).
Tx
of Status epilepticus (continuous or rapidly repeating
seizures without recovery between attacks for > 20 – 30 minutes)
-Management of status:
1.
assess & control airway, 100% O2 via
facemask use nasopharangeal trumpet
2.
check vitals, pulse oximetry, & capillary
blood glucose (dexi)
3.
thiamine 100mg & D50 1 amp IV
4.
lorazepam 0.1mg/kg IV @ 2mg/min (or 2mg IM x 4)
5.
if sz continues => phenytoin 20mg/kg IV @
50mg/min (in glucose-free IVF)
6.
if sz continues => phenobarbital 20mg/kg IV @
50mg/min can give additional 5-10mg/kg
7.
if sz continues => anesthesia with midazolam
or propofol
8.
Page Neurology (3-7777) for help.
-
Loading
of phenytoin after sz (consider if sz resolved but no
reversible cause is identified/corrected) => 20mg/kg @ 50mg/min (watch for
hypotension / arrhythmia, hold or reduce rate if symptoms occur) Then start on standing Phenytoin.
Causes: drugs (opiates, benzos, TCA, salicylates,
EtOH, anti-cholinergics, cocaine, anti-epileptics), encephalitis/meningitis
(bacterial, viral, cryptococcal, fungal), low flow (MI, CVA, hypotension),
trauma (CNS bleed, subdural hematoma), acute psychosis (steroids,
anti-cholinergics), metabolic (hypoglycemia, uremia, hypercalcemia,
hyponatremia, hypoxia, hypercarbia, ammonia, lactic acidosis, hypothyroidism),
seizure
Studies: capillary blood glucose (dexi), pulse oximetry,
ABG, CMP, Heme8, urine tox, serum volatile screen, NH3, EKG, head CT, LP,
consider EEG.
Causes:
Alzheimer’s, Multi-infarct dementia, AIDS dementia, Parkinson’s with dementia,
Picks disease, Lewy Body Dementia, EtOH, B12 deficiency, thyroid disease,
depression, cerebral vasculitis, thyroid disease, medication side effects
(analgesics, anti-cholinergic, anti-hypertensive, psychotropic,
sedative-hypnotic agents), NPH, tumor, subdural hematomas, and delirium
Tests: MMSE, B12, RPR, TSH, head CT (consider MRI),
consider HIV test.
[NEJM (1996) 335: 330 – 36.]
Eye Opening (spontaneous 4; to speech
3, to pain 2, none 1)
Best Verbal Response (oriented 5, confused 4,
inappropriate 3, incomprehensible 2, none 1)
Best Motor Response (obeying 6, localizing 5,
withdrawing 4, flexing 3, extending 2, none 1)