Alcohol Withdrawal Syndrome: Improving Outcomes in the Emergency Department With Aggressive Management Strategies - Pharmacology EXTRA Supplement - (Pharmacology CME) -

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Publication Date: March 2021 (Volume 23, Supplement 3)

CME Credits: 4 AMA PRA Category 1 Credits™. CME expires 03/15/2024. This course is included with an Emergency Medicine Practice subscription

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology credits, subject to your state and institutional approval.

Authors

Peer Reviewer

Editor-in-Chief

Abstract

Alcohol use disorder is a prevalent medical and psychiatric disease, and consequently, alcohol withdrawal is encountered frequently in the emergency department. Patients commonly manifest hyperadrenergic signs and symptoms, necessitating admission to the intensive care unit, administration of intravenous sedatives, and frequently, adjunctive pharmacotherapy. This issue reviews the pathophysiology of alcohol withdrawal syndrome, describes the manifestations of alcohol withdrawal, and examines the available evidence for optimal treatment of alcohol withdrawal. An aggressive frontloading approach with benzodiazepines is presented, and the management of benzodiazepine- resistant disease is addressed.

Case Presentations

A 56-year-old woman presents to the ED seeking detoxification from alcohol...

• Her reported consumption is 750 mL of vodka daily. Her last drink was 15 hours prior. The patient denies any history of illicit drug use and states that she has no history of alcohol withdrawal seizures or delirium tremens.
• Upon presentation to the ED, her vital signs are as follows: heart rate, 139 beats/min, and blood pressure, 172/84 mm Hg. She is diaphoretic and has a severe tremor. She is unable to hold a glass of water without spilling it.
• She is given 1 L IV normal saline and 5 mg of IV diazepam. Fifteen minutes later, her tremor is worsening and her vital signs have failed to improve. What treatment modalities should you employ for her worsening symptoms?

As you consider treatment options, a nurse asks for your assistance in an adjacent room where EMS has brought in a 62-year-old man with agitated delirium...

• The paramedics tell you he’s a local man with known severe alcohol use disorder. He has a history of pancreatitis, and his wife told the paramedics that he has complained of abdominal pain and has been vomiting for the past 2 or 3 days. The paramedics were initially called for seizure-like activity.
• You find a disheveled man who appears to be malnourished being restrained by 2 security guards. His vital signs are as follows: heart rate, 162 beats/min, and blood pressure, 165/92 mm Hg. He is attempting to sit up in the stretcher and appears to be miming turning a key in a car ignition, repeating over and over, “I have to go.” He is diaphoretic and tremulous.
• What are your priorities in the initial diagnosis and management of this patient?