special subjects
Alcohol Toxicity and Withdrawal
Treatment of Alcohol Toxicity and Withdrawal
Supportive measures For withdrawal, benzodiazepines and sometimes alsophenobarbitalorpropofol Treatment of alcohol toxicity may include the following: Airway protection Sometimes IV fluids with thiamin, magnesium, and vitamins The first priority is Airway Establishment and Control ; endotracheal intubation and mechanical ventilation are required for apnea or inadequate respirations. IV hydration is needed for hypotension or evidence of volume depletion but does not significantly enhance IV hydration does not significantly enhanceethanolclearance. Disposition of the acutely intoxicated patient depends on clinical response, not a specific BAC. Patients with severe alcohol withdrawal or delirium tremens should be managed in an intensive care unit until these symptoms abate. Treatment may include IV thiamin to prevent Wernicke encephalopathy Benzodiazepines orphenobarbitalto manage agitation and/or seizures Thiamin 100 mg IV is given to prevent Wernicke encephalopathy. Alcohol-tolerant people are cross-tolerant to some drugs commonly used to treat withdrawal (eg, benzodiazepines). Benzodiazepinesare the mainstay of therapy. Dosage and route depend on degree of agitation, vital signs, and mental status.Diazepam, given 5 to 10 mg IV or orally hourly until sedation occurs, is a common initial intervention;lorazepam1 to 2 mg IV or orally is an alternative.Chlordiazepoxide50 to 100 mg orally every 4 to 6 hours, then tapered, is an older acceptable alternative for less severe cases of withdrawal. (when there is no liver disease or pregnancy) may also be used as an adjunct to benzodiazepines or when benzodiazepines are contraindicated ( Treatment reference ). Phenothiazines andhaloperidolare not recommended initially because they may lower the seizure threshold. For patients with a significant liver disorder, a short-acting benzodiazepine (lorazepam) or one metabolized by glucuronidation (oxazepam) is preferred. (NOTE: Benzodiazepines may cause intoxication, physical dependence, and withdrawal in patients with alcohol use disorder and therefore should not be continued after the detoxification period.Carbamazepine200 mg orally 4 times a day may be used as an alternative and then tapered.) For severe hyperadrenergic activity or to reduce benzodiazepine requirements, short-term therapy (12 to 48 hours) with titrated beta-blockers (eg,metoprolol25 to 50 mg orally or 5 mg IV every 4 to 6 hours) andclonidine0.1 to 0.2 mg IV every 2 to 4 hours can be used, but only as an adjunct and only if absolutely necessary. Aseizure,if brief and isolated, needs no specific therapy; however, some clinicians routinely give a single dose oflorazepam1 to 2 mg IV as prophylaxis against another seizure. Repeated or longer-lasting (ie,>2 to 3 minutes) seizures should be treated and often respond tolorazepam1 to 3 mg IV. Routine use ofphenytoinis unnecessary and unlikely to be effective. Outpatient therapy withphenytoinis rarely indicated for patients with simple alcohol withdrawal seizures when no other source of seizure activity has been identified because seizures occur only under the stress of alcohol withdrawal, and patients who are withdrawing or heavily drinking may not take antiseizure drugs. Delirium tremensmay be fatal and thus must be treated promptly with high-dose IV benzodiazepines, preferably in an intensive care unit. Dosing is higher and more frequent than in mild withdrawal. Very high doses of benzodiazepines may be required, and there is no maximum dose or specific treatment regimen.Diazepam5 to 10 mg IV orlorazepam1 to 2 mg IV every 10 minutes is given as needed to control delirium; some patients require several hundred milligrams over the first few hours. In patients with severe symptoms, evidence suggests dosing regimens ofdiazepamstarting at 10 mg IV with doubling of the dose every 10 to 15 minutes until the patient is sedated is efficacious. Patients refractory to high-dose benzodiazepines may respond tophenobarbital120 to 240 mg IV every 20 minutes as needed; however, ifphenobarbitalis used after benzodiazepines, respiratory depression can be significant. As an alternative,phenobarbitalmay be used as the first agent. Severe drug-resistant DT can be treated with a continuous infusion oflorazepam,diazepam,midazolam,propofol, ordexmedetomidine, usually with concomitant mechanical ventilation. Physical restraints should be avoided if possible to minimize additional agitation, but patients must not be allowed to escape, remove IVs, or otherwise endanger themselves. Intravascular volume must be maintained with IV fluids, and thiamin must be given promptly. Appreciably elevated temperature with DT is a poor prognostic sign. 1.American Society of Addiction Medicine: Alcohol Withdrawal Management Guideline. Accessed October 3, 2022. 