EtOH: screening for abuse & considering the possible complications of intoxication & withdrawal!

This week, we discussed some of the complications of alcoholism and EtOH Withdrawal. Here are a few reminders:

Complications of Alcoholism

Acute intoxication: injuries, aspiration pneumonia, etc

Acute withdrawal: minor withdrawal, seizures, hallucinations, delirium tremens (DTs)

Chronic alcoholism is associated with multiple complications, including:

·         Neurological: Wernicke-Korsakoff syndrome, cognitive dysfunction, cerebellar degeneration, peripheral neuropathy, myopathy

·         Psychiatric: dependence, depression, anxiety, homicide, suicide

·         Cardiovascular: HTN, CAD, dilated cardiomyopathy, atrial fib

·         Hepatic: fatty liver, alcoholic hepatitis, cirrhosis

·         Pancreas: acute on chronic pancreatitis

·         Nutritional issues: electrolyte abnormalities (i.e. hypokalemia, hypomagnesemia, hypophosphatemia), malnutrition

·        Hematological: alcohol can be a toxin to the bone marrow (i.e. pancytopenia); macrocytic anemia, thrombocytopenia, splenomegaly

·        Cancer: oral cavity, esophageal, pharynx, larynx, breast, liver

·        Endocrine: alcoholic hypoglycemia and ketosis, hypogonadism

·        Social: accidents, domestic violence, job loss, fetal alcohol syndrome in offspring

Rational Clinical Exam (JAMA): does this patients have an alcohol problem?

CAGE- “Do you feel that you should Cut down?, Are you annoyed by criticisms regarding your drinking?, Do you feel guilty about drinking?, Do you ever have an eye-opener*(drink first thing in the morning)?;

Positive Likelihood Ratio (+LR) for heavy drinking (defined as >8 drinks/day): 0 points=0.14, 1 point=1.5, 2 points=4.5, 3 points=13.2, 4 points=101. NOTE:  Scores of 3-4 strongly support the diagnosis of EtOH abuse

Withdrawal

Minor withdrawal: within 6h of EtOH cessation, resolves in 24-48h; due to SNS hyperactivity. Symptoms may develop while there is still a notable concentration of EtOH in the serum! Symptoms may include insomnia, tremor, mild anxiety, GI upset, headache, diaphoresis, palpitations, anorexia

Alcoholic Hallucinations: develop within 12-24h of abstinence and resolve within 24-48h. Predominantly visual, however, other forms (i.e. auditory, tactile, etc) may occur. Unlike DT, hallucinations are NOT associated with global confusion/decreased LOC.

Withdrawal Seizures: usually occur within 48h after the last drink, however, may occur after only 2h of abstinence! These occur predominantly in patients with a long history of chronic alcoholism and dependence. Seizures are typically generalized tonic-clonic convulsions. If the patient develops focal seizures or evidence of status epilepticus, consider other etiologies (i.e. intra-cranial hemorrhage). Left untreated, 1/3 of these patients with seizures will progress to DT. The mainstay of treatment is Benzodiazepines.

Delirium Tremens (DTs): typically between 48h-96h after the last drink, and lasts 1-5 days. Symptoms include hallucinations, disorientation, tachycardia, HTN, low-grade fever, agitation, and diaphoresis. Risk Factors include history of sustained drinking, history of previous DTs, concurrent illness, greater number of days since last drink, age >30 years.

Clinical Institute Withdrawal Assessment for Alcohol- CIWA-A R (revised)

Example at the following site: http://www.regionstrauma.org/blogs/ciwa.pdf