Alcohol and trauma go hand-in-hand as alcohol is involved in 30-40% of traffic-related and violent crimes. As we care for trauma patients in the days and weeks following their trauma, it's important to recognize the various syndromes of alcohol withdrawal and manage them appropriately. Patients with alcohol withdrawal have longer length of stay, higher complications, need for mechanical ventilation and higher mortality.
Within 3-6 hours of the last drink, patients may have mild symptoms of headache, anxiety, diaphoresis and tremulousness. These may start to occur even with a blood alcohol level above zero in chronic drinkers.
From 2 hours to 24 hours, patients are at risk of withdrawal seizures and hallucinations.
From 24 hours to 7 days out, patients may develop delirium tremens, characterized by severe autonomic dysfunction, with tachycardia, hypertension, fevers, agitation and hallucinations. There is a 5-15% mortality associated with unrecognized delirium treatments, which is reduced to about 1% with adequate treatment. Mortality is due to malignant arrhythmias and respiratory arrest caused by automatic dysregulation.
The treatment of delirium tremens utilizes benzodiazepines to balance the chronic down regulation of GABA receptors and up regulation of NMDA receptors which develops in chronic drinkers. This disbalance causes CNS excitability and lowered seizure threshold. Interestingly, there is a "kindling phenomenon" where the number of previous withdrawals increase the risk and severity of future episodes.
Predicting who is at risk for alcohol withdrawal is difficult. We know that patients with alcohol withdrawal are more likely to be male, and older (avg age ~ 45-50). Interestingly, initial blood alcohol is negative is a significant portion (~14%) of patients who later develop alcohol withdrawal. Liver function can be predictive, especially ALT > 1.5 upper limit of normal. The best screening test for withdrawal is history, which is why our institution has adopted routine CAGE screening of all new trauma patients. This helps to identify the long-term and heavy drinkers who are at highest risk. Prior episodes of withdrawal syndromes or seizures are also highly predictive of future episodes.
The best treatment for alcohol withdrawal is a symptom-based assessment of the patient at regular intervals, with defined benzodiazepine doses to be given based on the score. The most widely used assessment tool is the system is the Clinical Institute Withdrawal Assessment for Alcohol (CIWA). The elements of CIWA include: nausea/ vomiting, tremor, sweating, anxiety, agitation, tactile/auditory or visual disturbances, headache and orientation. Based on the CIWA score, the patient is given lorazepam (Ativan) on a standing or as needed basis. Clonidine is also a useful adjuvant as it addresses the adrenergic symptoms of tachycardia and hypertension. Additional sedation may be accomplished using dexmedetomidine (Precedex) but this is still in the trial phase and not an approved FDA indication.
In summary, alcohol withdrawal is a common and deadly complication which may arise in trauma patients. Proper diagnosis and treatment are crucial to patient survival.
References
Awissi DK, Lebru G, Coursin DB, et al. Alcohol withdrawal and delirium tremens in the critically ill: a systat5mic review and commentary. Intensive Care Medicine 2013 39: 16-30/
Jawa RS, Stothert JC, Shostrom V, at al. Alcohol withdrawal syndrome in admitted trauma patients. The American Journal of Surgery 2014 208; 781-787.
Mainerova B, Prasko J, Latalova K, et al. Alcohol withdrawal delirium- diagnosis, course and treatment . Biomed Pap med Fac 2015; 157: 1-9
by: Laura Grimmer MD PGY4
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