There are bugs on that ECG (and other thoughts on severe alcohol withdrawal)

Your next patient is a man in his 50′s with a presenting complaint of ‘I don’t feel right’. He’s irritable and has psychomotor agitation. He’s tremulous, diaphoretic and looks unwell. His heart rate is 125, blood pressure 210/110, temp 38.4C. He seems anxious; ‘I’m gonna die doc, you’ve got to help me!’  He tells you he quit drinking 3 days ago after a 3 month bender.

Most community hospitals have some version of an alcohol withdrawal protocol. At my hospital it’s a CIWA score tied to a benzodiazipine dose. For mild to moderate alcohol withdrawal the use of such a protocol provides good care and good results. Whenever possible mild to moderate alcohol withdrawal should be referred out of the hospital to a community detox centre so the patient can receive concurrent early addiction treatment along with a safe medical detox.

Severe alcohol withdrawal is a different story. These patients are sick, have a propensity to die, and can be difficult to manage. Not only should they not be managed in a community detox, they should not even be managed on a regular hospital ward, rather they should be in a high dependancy unit or an ICU setting.

There are 2 schools of thought in the management of severe alcohol withdrawal; the sugar and spice approach (a dab of benzodiazipines, a dash of barbiturates, a sprinkle of antipsychotic) and the salty food approach (sprinkle benzodiazipines on the patient until the patient is just right). Neither approach is right, but personally I prefer and have had excellent success with a benzos only approach. The doses used in alcohol withdrawal protocols will usually be insufficient for these patients and in fact the entire approach is somewhat different.

The patient we started with will probably have been placed in an unmonitored area as far away from the nursing station as possible. My first job with severe alcohol withdrawal is to identify the patient as critically ill and move them to a monitored care area and put them on a monitor (remember, geography is destiny in the ED). My drug of choice is diazepam (Valium) and for the severely withdrawing patient the route should always be IV. I start with 10mg IV and quickly escalate my dose to 20, 30 and even 40mg at a time. The nursing staff will definitely be uncomfortable with this, fearing respiratory depression but you can reassure them that if needed the patient can be intubated and because of the high acuity area of the emerg the patient will be closely monitored. You can also remind them that if benzos fail to work you will be intubating the patient anyways.  The doses of benzodiazipines you will need to control severe alcohol withdrawal can be phenomenal! I have given patients 350mg of Valium over a couple of hours and seen them finally start to settle down. Some experts advise that benzodiazipines have only failed when doses exceed 400mg of Valium or equivalent.

Some patients will experience somnolence or respiratory depression without resolution of their autonomic  instability as the dose of benzodiazipine escalates. These are good candidates for intubation and maintenance on a propofol infussion. Some patients may have resolution of their autonomic instability but persistent hallucinosis and these patients are good candidates for a dose of haloperidol.

Many patients with severe alcohol withdrawal will also have hypokalemia, hypomagnesemia, and depleted glycogen stores. They will benefit from thiamine, electrolyte correction and a maintenance IV solution containing dextrose.

Severe alcohol withdrawal is fun to manage. The doses of benzodiazipine needed are often outrageous but if you’re willing to go there you can manage these patients well. These patients can be loud and obnoxious, and are often repeat visitors; don’t let that dissuade you, they are critically ill and unless you identify that they will end up under treated and unmonitored on a regular ward, at high risk for poor outcomes.