Episode 87 – Alcohol Withdrawal and Delirium Tremens: Diagnosis and Management

This is 'Alcohol Withdrawal and Delirium Tremens: Diagnosis and Management' on EM Cases. Alcohol withdrawal is everywhere. We see over half a million patients in U.S. EDs for alcohol withdrawal every year. Despite these huge volumes of patients and the diagnosis of alcohol withdrawal seeming relatively straightforward, it’s actually missed more often than we’d like to admit, being confused with things like drug intoxication or sepsis. Or it’s not even on our radar when an older patient presents with delirium. The differential diagno­sis is enormous - and no blood test on the planet will help us diagnose alcohol withdrawal. In fact, the diagnosis is entirely a clinical one. What’s even more surprising is that even if we do nail the diagnosis, observational studies show that, in general, alcohol withdrawal is poorly treated. There’s several reasons for our all too often mismanagement of these patients: few EDs have a standardized approach (or training of an approach) to the management of alcohol withdrawal, there’s unfortunately still a bit of a stigma associated with alcoholism in many EDs which may contribute a kind of indifference to these patients by ED staff, and the medications used to treat alcohol withdrawal are often dosed incorrectly. So what if alcohol withdrawal is missed or poorly treated? Well, mismanaged alcohol withdrawal can be fatal - and untreated severe withdrawal often ends up with your patient seizing, or maybe progressing to delirium tremens. To help you become masters of alcohol withdrawal management, our guest experts on this podcast are Dr. Bjug Borgundvaag, an ED doc and researcher with a special interest in emergency alcohol related illness and the director of Schwartz-Reismann Emergency Medicine Institute, Dr. Mel Kahan, an addictions specialist for more than 20 years who’s written hundreds of papers and books on alcohol related illness, and the medical director of the substance use service at Women’s College Hospital in Toronto, and Dr. Sara Gray, an ED-intensivist at St. Michael's Hospital, an inner city hospital that sees high volumes of alcohol related illness. Written Summary and blog post written by Keerat Grewal, edited by Anton Helman October, 2016 Cite this podcast as: Helman, A, Borgundvaag, B, Gray, S. Alcohol Withdrawal and Delirium Tremens: Diagnosis and Management. Emergency Medicine Cases. October, 2016. https://emergencymedicinecases.com/alcohol-withdrawal-delirium-tremens/. Accessed [date]. General Approach to the Management of Patients with Alcohol Withdrawal The ideal management of alcohol withdrawal involves 4 steps: * Identify which patients actually have alcohol withdrawal and require treatment * Use a standardized, symptom guided approach to assess symptom severity and guide treatment * Ensure that patients are fully treated prior to ED discharge * Provide a pathway to support patients who are trying to quit Step 1: Identify which patients actually have alcohol withdrawal and require treatment Alcohol withdrawal is a clinical diagnosis and a diagnosis of exclusion. The tremor of alcohol withdrawal is central to the diagnosis. It is important to understand the key features of alcohol withdrawal tremor. The characteristic tremor is an intention tremor: at rest there is no tremor, but when you ask the patient to extend their hands or arms you will see a fine motor tremor (typically 7-12Hz) that is constant and does not fatigue with time. Other symptoms associated with alcohol withdrawal include: gastrointestinal upset, anxiety, nausea/vomiting, diaphoresis, tachycardia, hypertension and headache. PEARL: A tongue tremor (as in this video) is difficult to feign ...