Drew Long1, Brit Long2, Alex Koyfman3. 1. Vanderbilt University School of Medicine, 1161 21st Ave S # T1217, Nashville, TN 37232, United States. Electronic address: drew.a.long@vanderbilt.edu. 2. San Antonio Military Medical Center, Department of Emergency Medicine, Fort Sam Houston, 3841 Roger Brooke Dr, TX 78234, United States. Electronic address: brit.long@yahoo.com. 3. The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States. Electronic address: akoyfman8@gmail.com.
Abstract
INTRODUCTION: Alcohol use is widespread, and withdrawal symptoms are common after decreased alcohol intake. Severe alcohol withdrawal may manifest with delirium tremens, and new therapies may assist in management of this life-threatening condition. OBJECTIVE: To provide an evidence-based review of the emergency medicine management of alcohol withdrawal and delirium tremens. DISCUSSION: The underlying pathophysiology of alcohol withdrawal syndrome (AWS) is central nervous system hyperexcitation. Stages of withdrawal include initial withdrawal symptoms, hallucinations, seizures, and delirium tremens. Management focuses on early diagnosis, resuscitation, and providing medications with gamma-aminobutyric acid (GABA) receptor activity. Benzodiazepines with symptom-triggered therapy have been the predominant medication class utilized and should remain the first treatment option with rapid escalation of dosing. Treatment resistant withdrawal warrants the use of phenobarbital or propofol, both demonstrating efficacy in management. Propofol can be used as an induction agent to decrease the effects of withdrawal. Dexmedetomidine does not address the underlying pathophysiology but may reduce the need for intubation. Ketamine requires further study. Overall, benzodiazepines remain the cornerstone of treatment. Outpatient management of patients with minimal symptoms is possible. CONCLUSIONS: Alcohol withdrawal syndrome can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Benzodiazepines are the predominant medication class utilized, with adjunctive treatments including propofol or phenobarbital in patients with withdrawal resistant to benzodiazepines. Dexmedetomidine and ketamine require further study. Published by Elsevier Inc.
INTRODUCTION:Alcohol use is widespread, and withdrawal symptoms are common after decreased alcohol intake. Severe alcohol withdrawal may manifest with delirium tremens, and new therapies may assist in management of this life-threatening condition. OBJECTIVE: To provide an evidence-based review of the emergency medicine management of alcohol withdrawal and delirium tremens. DISCUSSION: The underlying pathophysiology of alcohol withdrawal syndrome (AWS) is central nervous system hyperexcitation. Stages of withdrawal include initial withdrawal symptoms, hallucinations, seizures, and delirium tremens. Management focuses on early diagnosis, resuscitation, and providing medications with gamma-aminobutyric acid (GABA) receptor activity. Benzodiazepines with symptom-triggered therapy have been the predominant medication class utilized and should remain the first treatment option with rapid escalation of dosing. Treatment resistant withdrawal warrants the use of phenobarbital or propofol, both demonstrating efficacy in management. Propofol can be used as an induction agent to decrease the effects of withdrawal. Dexmedetomidine does not address the underlying pathophysiology but may reduce the need for intubation. Ketamine requires further study. Overall, benzodiazepines remain the cornerstone of treatment. Outpatient management of patients with minimal symptoms is possible. CONCLUSIONS:Alcohol withdrawal syndrome can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Benzodiazepines are the predominant medication class utilized, with adjunctive treatments including propofol or phenobarbital in patients with withdrawal resistant to benzodiazepines. Dexmedetomidine and ketamine require further study. Published by Elsevier Inc.
Authors: Ofir Livne; Richard Feinn; Justin Knox; Emily E Hartwell; Joel Gelernter; Deborah S Hasin; Henry R Kranzler Journal: Alcohol Clin Exp Res Date: 2022-03 Impact factor: 3.455
Authors: Elena García-Martín; María I Ramos; José A Cornejo-García; Segismundo Galván; James R Perkins; Laura Rodríguez-Santos; Hortensia Alonso-Navarro; Félix J Jiménez-Jiménez; José A G Agúndez Journal: Front Cell Neurosci Date: 2018-01-31 Impact factor: 5.505
Authors: Corinde E Wiers; Leandro F Vendruscolo; Jan-Willem van der Veen; Peter Manza; Ehsan Shokri-Kojori; Danielle S Kroll; Dana E Feldman; Katherine L McPherson; Catherine L Biesecker; Rui Zhang; Kimberly Herman; Sophie K Elvig; Janaina C M Vendruscolo; Sara A Turner; Shanna Yang; Melanie Schwandt; Dardo Tomasi; Mackenzie C Cervenka; Anders Fink-Jensen; Helene Benveniste; Nancy Diazgranados; Gene-Jack Wang; George F Koob; Nora D Volkow Journal: Sci Adv Date: 2021-04-09 Impact factor: 14.136