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Home , Alcoholic ketoacidosis, Alcohol tolerance

CME *aa-0 Emergency management of acute . problems

Part 1: Uncomplicated withdrawal

JEREMY M. ETHERINGTON, MD, CCFP(EM)

NE OF THE MOST COMPLEX to leave. It is often difficult to decide SUMMARY Alcohol-related problems are tasks physicians face when how much illness actually represents a common dmong patients in working in emergency patient's normal dysfunctional state of emergency departments. departments (EDs) is sort- equilibrium. As a result, expeditious Primary care physicions must ing out the nature and severity of patient care is sometimes sidetracked recognize and treat a variety problems related to alcohol misuse. by a host of chronic conditions that of alcohol-related and The spectrum ranges from could alcohol-induced problems: simple reasonably occupy a full-time alcohol withdrawal, acute intoxication to serious life- physician for many patient visits. alcohol-related seizures, threatening illness masquerading as Emergency physicians must learn to , malnutrition, intoxication and spans a variety of dis- work around many ofthese conditions concomitant illness, poisoning, orders that demand superb diagnostic in order to deal with the acute presen- trauma, and lack of social and management skills. Physicians can tation in a timely fashion. support. This paper focuses on recognizing and managing be called upon to diagnose and treat It is easy to become complacent acute alcohol withdrawal. acute withdrawal, alcohol-related when treating alcoholics because most seizures, delirium tremens, Wernicke's of them wake up, sober up, and even- RESUME encephalopathy, alcoholic ketoacido- tually depart without any interven- Les problemes relies a la sis, methanol or ethylene glycol poi- tion. However, these patients could consommation d'alcool sont soning, occult cervical spine fractures, well harbour life-threatening illnesses. courants dans les services and intracranial hemorrhages.' It is imperative to maintain a high d'urgence. Les medecins de premiere ligne doivent To complicate matters, patients are index of suspicion and be alert for identifier et traiter toute la often garrulous, if not outright abu- unexpected turns of events: tachycar- gamme des problemes lies ou sive, and try to walk, stumble, or dia that does not resolve, unexplained induits par l'alcool : sevrage, crawl out of the department before fever, a level of consciousness that convulsions, delirium tremens, their examination is complete. Some does not ameliorate as expected, malnutrition, maladies sober up but are unable to walk no unusual concomitantes, intoxications, weakness, or deterioration traumatismes et soutien matter how badly the staff want them from a previous level of functioning. social deficient. Cet article These might be the only clues to seri- porte principalement sur Dr Etherington is Chair ofthe Department ous underlying disease. l'identification et le traitement ofEmergency Medicine at St Paul's Hospital and Although some alcoholics frequent du stade aigu du sevrage a Head ofthe Division ofEmergeny Medicine in EDs in search offood, shelter, and com- l'alcool. the Department ofFamily Practice at the panionship, most arrive involuntarily Can Fam Physidan 1996;42:2186-2190. Universi_ ofBritish Columbia in Vancouver, BC. when some event has interrupted their

2186 Canadian Family Physician * Le Midecin defamille canadien * VOL 42: NOVEMBER * NOVEMBRE 1996 CME Emergency management of acute alcohol problems quest for short-chain hydrocarbons. This event These considerations have led to the develop- could be as trivial as a need for sleep that overcame ment of a fairly standard therapeutic regimen them on a downtown street much to the dismay of (Table 1). Early treatment should be three-tiered: concerned bystanders. More commonly, however, management of fluid, electrolyte, and other nutri- patients have temporarily poisoned themselves with tional deficiencies; management of acute withdraw- too much alcohol, have had a seizure, have hemor- al symptoms; and management ofalcoholic rhaged, have been assaulted, or have simply become symptoms, which are invariably present. These too sick to reach their favourite watering holes. problems are usually treated concurrently. Following successful initial intervention, appropriate care dur- Acute alcohol withdrawal ing resolution of withdrawal must be arranged. Patients frequently arrive in the ED complaining of acute alcohol withdrawal. Some of these Table 1. Management ofuncomplicated acute patients are habituated to - drugs alcohol withldrawal and come in to get replenished when other Fluids Initial bolus: 1 L ofintravenous sources fail. Unless they are suffering from acute normal saline (NS). Continued or have a systemic illness, these replacement of 5% dextrose (D5) patients usually appear well and have normal in NS or D5 in halfNS IV ...... vital signs, good hydration, and warm, dry skin. 25g IV Patients in withdrawal, on the other hand, pre- ...... 100mg IV sent with sympathomimetic overdrive and gener- ...... ally have of anxiety, Multivitamins B complex and C, orally or IV epigastric discomfort, diaphoresis, tremulousness, ...... Folate 1-5 mg, orally or IV , and hypertension.2 Due to the ...... diuretic effects of alcohol, they are almost always Magnesium 5 g IV ...... dehydrated.2 In contrast to the drug seekers, these Potassium 40 mEq/L IV, if required patients look distinctly unwell...... , orally or IV True withdrawal generally occurs within 6 ...... hours of cessation of drinking, but its speed of Treat gastritis onset and symptoms vary widely.2 In heavy ...... and follow drinkers, the symptoms of withdrawal sometimes Arrange appropriate disposition up appear while the serum level is still high Fluid, electrolyte, and nutritional deficien- enough to render some people comatose. It is not cies. Alcoholics in withdrawal are almost always uncommon to see patients begin to withdraw dehydrated, usually from a combination of the with an ethanol level of 35 to 60 mmol/L diuretic effects of alcohol, poor fluid intake, and (17 mmol/L is the legal limit for driving) because losses from vomiting. Many are deficient by sever- increases markedly with - al litres. If there are no contraindications to rapid induction.3 If patients have a history of volume replacement (congestive heart failure, car- seizures during withdrawal, they might quickly go diomyopathy, renal failure), it is generally safe to on to have them.4 They frequently become hypo- give a litre bolus of normal saline (NS) followed glycemic from a combination of poor nutrition by several litres of IV fluid over the remainder of and deficient hepatic glycogen stores, which in the patient's stay in the ED. If the patient cannot turn can provoke seizures.5 Treating them with tolerate oral vitamin supplements, an ampule of intravenous (IV) glucose can induce Wernicke's multivitamins can be added to the IV solution, encephalopathy (classically, confusion, , and giving it a distinctive "banana bag" appearance. oculomotor problems, such as palsies and hori- The vitamin supplement should include folate. If zontal nystagmus) if thiamine is not administered not, 1 to 5 mg of folate administered concurrently concurrently.2 is usually sufficient.

VOL 42: NOVEMBER NOVEMBRE 1996 * Canadian Family Physician . Le Midecin defamille canadien 2187 CME Emergency management of acute alcohol problems

Patients should have their blood sugar checked by Both thiamine and magnesium are cofactors in rapid glucose determination on arrival.6 If low, they glucose ,2 and low serum magnesium should be given a standard 25-g dose of glucose and is associated with neuromuscular irritability, cen- have their monitored closely. Iforal tral nervous system symptoms (vertigo, ataxia, sugar-containing fluids cannot be tolerated during seizures), and an increased incidence of delirium treatment, IV solutions for volume replacement tremens.8 Because the leading cause of hypomag- should contain glucose (5% dextrose [D5] in normal nesemia in Canadian patients is chronic, severe saline or D5 in halfNS. See also Table 1), especially if , it has become common practice to the patient has been hypoglycemic. give these patients 5g of MgSO4 IV, especially if they have symptoms of withdrawal.9 This can be Table 2. regimen: A prescription administered slowly, but patients with previous tapering doses over 4 days could be based on thefollowing sample. seizure history who look like they might be about to have another seizure should be given 5 g IV PORTION OF DOSE ADMINISTERED over 30 minutes. This could be as effective as any DAY OF TRETMENT IN THE EMERGENCY DEPARTMENT other treatment in preventing seizures. 1 Total ED dose, Administering magnesium intramuscularly divided four times daily ...... (IM) is very painful and should be avoided unless 2 3/4 total ED dose, IV access is impossible. It is best to treat patients divided four times daily ...... empirically and avoid obtaining serum magne- 3 1/2 total ED dose, sium levels, which correlate poorly with divided four times daily total-body magnesium...... Once replacement is 4 1/4 total ED dose, undertaken, hypermagnesemia is an exceedingly divided four times daily rare problem as long as the kidneys are function- ...... 5 "Cold turkey"* ing. In fact, due to deficiency, most alcoholic patients can be given 10 to 20 g of magnesium *4 days is rarely enough treatment, but by day 4 patients should before it even starts to be excreted in the urine. have established contact with a primary carephysician or be in a detoxjfication centre. Serum potassium should be measured because alcoholic patients are often deficient. Potassium Thiamine should be given with IV glucose. can be replaced, if indicated, by adding 40mEq Although it only takes 2mg of thiamine to reverse of KCI to each litre of IV solution and monitoring Wernicke's encephalopathy, patients with the potassium level to document a return to nor- Wernicke's encephalopathy often have serious mal.9 Most physicians are familiar with the effects total-body thiamine deficits and require inpatient of and further discussion is beyond care with 100 mg of thiamine daily for at least the scope ofthis article. 5 days.7 Since most patients with acute withdrawal do not demonstrate Wernicke's encephalopathy, it Acute withdrawal symptoms. Alcoholics devel- is standard practice to give 100 mg ofthiamine and op cross-tolerance to benzodiazepines and barbitu- leave it at that until the next visit. Ifphysicians wait rates so these drugs can be used to treat alcohol to see the classic triad of Wernicke's encephalopa- withdrawal.'0 appear to have fallen thy, however, most cases would be missed. Many from grace due to their high abuse potential and patients present with only one or two classic find- narrow therapeutic window; benzodiazepines have ings, with hypothermia and bradycardia, or with become the drugs of choice. Many benzodiazepines no recognizable symptoms.2 This is part of the have been studied, but none is clinically superior." rationale for treating all alcoholic patients with vit- Chlordiazepoxide, once the oral benzodiazepine of amin supplementation. If patients can tolerate oral choice, has now largely been replaced by diazepam intake, multivitamins and thiamine can be given by or lorazepam, but is still a reasonable choice.'2 mouth at considerable cost savings. However, it is absorbed extremely erratically when

2188 Canadian Family Physician Le Midecin defamille canadien VOL 42: NOVEMBER NOVEMBRE 1996 CME Emergency management of acute alcohol problems given by the IM route, which should be avoided for Another compared oral chlordiazepoxide and almost all benzodiazepines, except perhaps placebo transdermal patches with oral placebo and lorazepam, which is water soluble. More recently, clonidine transdermal patches.'4 Both studies clonidine, a centrally acting a-agonist, has been demonstrated a comparable response in their sub- used with some success. It blocks the peripheral groups. These studies were limited by small study sympathomimetic effects that make alcohol with- populations and the fact that only patients with drawal so unpleasant, but it lacks sedative action, a minor withdrawal symptoms were studied. potential disadvantage for agitated alcoholics. Nevertheless, in theory, clonidine is an attractive Both lorazepam and diazepam can be given IV drug for controlling withdrawal, and more studies or orally. Lorazepam, though shorter-acting, has the are needed to delineate its usefulness. It also has added advantage ofa sublingual format that is readi- very little abuse potential (except for heroin users, ly absorbed. Lorazepam is essentially unmetabolized who use it to potentiate the effects of heroin). For by the liver and is excreted largely unchanged by the clonidine, the dose is 100 to 200 ig orally four kidney, an important consideration in patients with times daily. At these doses, is not usu- serious liver disease. Diazepam has a longer half-life ally a serious problem because of the high degree and a proportionally longer duration of sedative of sympathetic drive normally seen in withdrawal. action, but it is largely metabolized by the liver, a big Once symptoms are controlled, discharge can be problem for alcoholics with severe liver disease.'0 In considered. Ifbeds in a detoxification centre can be patients with , diazepam can circulate virtu- arranged, the chances are good that patients will ally forever. This is inconvenient for discharge plan- not return to the ED for a week or two. If they are ning. Lorazepam has a longer antiseizure effect than sent back to the street or to their hotel rooms with- diazepam, even though its half-life is shorter. out follow-up treatment, they tend to "bounce How much medication should be given? There is back" very quickly. To avoid this, they can be given no magic number. Ifa patient is going through severe prescriptions for whichever benzodiazepine was withdrawal, 2 to 4 mg oflorazepam or 5 to 10 mg of used to control their symptoms. One regimen diazepam can be given IV every 10 to 15 minutes involves a tapering dose over 3 to 6 days based on until the patient settles down, and then continued as the total amount given in the ED9 (Table 2). needed. If symptoms are mnilder, the same doses can be given every 30 to 60 minutes until the desired Gastrointestinal symptoms. Almost univer- effect is achieved. If symptom control is subsequently sally, patients with alcohol withdrawal have some poor, quickly double the dose. Remembering that abdominal discomfort, much ofwhich is related to withdrawal patients sometimes have astounding alcoholic gastritis. A careful history and physical cross-tolerance to benzodiazepines helps physicians to examination are always indicated to rule out more base dosage on clinical improvement rather than on serious disease. If symptoms can be reasonably numbers. It is not unheard of to give 250mg of attributed to gastritis, many patients improve (and diazepam IV over 1 hour to control withdrawal, leave the ED sooner) if these symptoms are con- although this is much more than normally required. trolled. For most, antacids, clear fluids, and Titrating the amount given is essential, how- antiemetics suffice. Patients unresponsive to this ever, and requires careful monitoring of the conservative strategy need more detailed regimens, patient's progress. Patients who are resting com- such as a "pink lady" (30 to 60mL of antacid and fortably with normal vital signs have generally 10 mL of 4% viscous lidocaine), ranitidine (50 mg received sufficient benzodiazepines for the time IV), dimenhydrinate (50mg IV), or even metaclo- being. Putting them to sleep only prolongs dispo- pramide (10 mg IV) if persists. sition and discharge. Prochlorperazine (1Omg IV) can also be used if no Several recent studies have looked at the use of other measures control nausea. Because prochlor- clonidine to control withdrawal. One study com- perazine belongs to a class of drugs that can lower pared oral clonidine with oral chlordiazepoxide.'3 the seizure threshold, it should be administered

VOL 42: NOVEMBER * NOVEMBRE 1996 * Canadian Famiy Physician . Ie Midecin defamille canadien 2189 CME Emergency management of acute alcohol problems

only after other interventions have failed.10 If none Acknowledgment of these measures provides relief, more serious I thankDrJames Christenson and Dr Christopher Fernandesfor underlying disease, such as peptic ulcer disease, their invaluable assistance in reviewing the manuscript. , perforated viscus, or alcoholic ketoaci- dosis, must be urgently considered. Correspondence to: Dr J. Etherington, Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Discharge planning. Patients almost always Vancouver, BC V6Z If6 need medical follow up, which should be arranged before release from the ED. It is a mistake to References release patients with alcohol-related problems 1. Cook LS, Levitt MA, Simon B, Williams VL. without attempting to establish continuity of care. Identification ofethanol-intoxicated patients with minor If possible, speak to the physician who will be head trauma requiring computed tomography scans. assuming care and try to obtain a commitment to Acad Emerg Med 1994;1(3):227-34. contact the patient. Alcoholics can deteriorate dra- 2. Charness ME, Roger PS, Greenberg DA. Ethanol and the matically from any number of easily overlooked nervous system. NEnglj Med 1989;321:442-54. complications, such as poor nutrition, development 3. Vinson DC, Menezes M. Admission alcohol level: of alcoholic , renewed alcohol con- a predictor ofthe course ofalcohol withdrawal. J Fam Pract sumption, or concomitant disease processes. 199 1;33:161-7. Emergency physicians might have (or should con- 4. McMicken D. Seizures in the alcohol-dependent patient: a sider getting) access to social workers in the ED to diagnostic and therapeutic dilemma.JEnmzgMed 1984;1:311-6. assist with discharge planning. Social workers are a 5. Turnbull TL, Vanden Hoek TL, Howes DS, Eisner R. Utility tremendous resource, since they generally know the oflaboratory studies in the emergency department patient social-services system inside out and can arrange with a new-onset seizure. Ann EmergMed 1990;19:373-7. detoxification-centre placement, alternate housing, or 6. Romach MK, Sellers EM. Management ofthe alcohol alcohol-treatment program referral. They can also withdrawal . Ann Rev Med 1978;42:323-40. facilitate filling prescriptions and expedite home-care 7. Hoffman RS, Goldfrank LR. Ethanol-associated metabol- services ifnecessary. More importantly, they can often ic disorders. Emerg Med Clin North Am 1989;7:943-61. arrange for simple home visits to ensure that patients 8. Wolfe S, Victor M. The relationship ofhypomagnesemia are not languishing or deteriorating unattended. and to alcohol withdrawal symptoms. Ann N Y Acad Sci 1973;215:235-48. Conclusion 9. Seamens CM, Slovis CM. Seizures: current clinical Uncomplicated acute alcohol withdrawal can be guidelines for evaluation and emergency management. managed relatively easily in the emergency Emerg Med Rep 1995; 16:3,23-30. department. Careful attention should be directed 10. Goodman AG, Goodman AS, Gilman A. Thepharmaco- to the treatment offluid and electrolyte disorders, logic basis oftherapeutics. 6th ed. New York, NY: MacMillan symptoms of withdrawal, and alcoholic gastritis. Publishing Co, 1980. Discharge planning, including physician 11. Browne M, Anton RF, Malcolm R, BallengerJC. Alcohol follow-up appointments whenever possible, detoxification and withdrawal seizures: clinical support for a decreases the likelihood of rapid return to the kindling hypothesis. Biol Pychiatry 1988;23:507-14. ED. Although uncomplicated withdrawal is ubiq- 12. Bird R, Makela EH. Alcohol withdrawal: what is the uitous among alcoholics, patients often harbour benzodiazepine ofchoice? Ann Pharmacother 1994;28:971-2. more serious underlying disease. The indiscrimi- 13. Baumgartner GR, Rowen RC. Clonidine vs chlor- nate use of standard treatment regimens should diazepoxide in the management ofacute alcohol with- never substitute for careful assessment of each drawal syndrome. Arch Intern Med 1987; 147:1223-6. patient. Otherwise, more serious alcohol-related 14. Baumgartner GR, Rowen RC. Transdermal clonidine vs problems, such as seizures, delirium tremens, and chlordiazepoxide in the treatment ofacute alcohol with- toxic alcohol consumption, might be missed. * drawal syndrome. South Med] 1991;84:312-21.

2190 Canadian Family Physician . Le Medecin defamille canadien o VOL 42: NOVEMBER * NOVEMBRE 1996