A 48-year-old man is admitted to a hospital because of pneumonia. Two days after the hospitalization, the patient becomes agitated and restless with tachycardia and hypertension. On physical examination, the patient is noted to be alert, but anxious, tremulous, and disoriented to place and time. And these findings differ from those on examination at admission. His alcohol history is significant (eg, drinking 3 or more vodkas a day for years; most recent alcohol intake occurred 2 days before coming to the hospital), but no history of liver diseases or alcohol withdrawal is evident. Subsequent physical examinations reveal no specific changes from the admission assessment except disorientation and anxiety. His respiratory status appears stable, and repeated CXR does not show any progression compared with the admission assessment. Routine laboratory workups including CBC, CMP, EKG, and blood glucose are stable. Since he has a history of alcohol dependence, alcohol withdrawal is considered.
1. What is the next step to determine the treatment? Once you start medications, how do you adjust the dose of them? And before deciding how to give them, what should you consider first?
1. Patients may develop autonomic instability within 48 hours of admission, given significant alcohol use. Therefore, under the suspicion of alcohol withdrawal, it is necessary to calculate Clinical Institute Withdrawal Assessment for Alcohol scale (revised) (CIWA-Ar; see below) score to determine the use of benzodiazepine. If the score is more than 20, pharmacologic treatment is indicated. Since dose of benzodiazepine needs to be adjusted according to patient's symptom report, you should make sure that the patient is able to communicate his symptoms before implementing the protocol.
Given his history of alcohol abuse and symptoms, he is at high risk for alcohol withdrawal and possibly delirium tremens (DTs).
Approach to Alcohol Withdrawal Problems
Screen a patient at risk of alcohol abuse, and assess the necessity of initiating withdrawal protocol.
Alcohol-related problems are estimated in up to 20% of patients in community teaching hospitals. We are frequently asked to manage these problems in a patient who was admitted to the hospital for other medical or surgical illnesses. Although DTs had a mortality rate as high as 20% in the untreated, early recognition of a patient at risk and initiation of appropriate treatment can lower the mortality significantly.
The easiest method to screen a patient at risk of alcohol withdrawal is the CAGE mnemonic (cut–annoyed–guilty–eye opener). More than 2 positive responses correlate highly with severe alcohol abuse and should raise concerns as to whether the patient will experience alcohol withdrawal.
Currently, CIWA-Ar is recommended for determining the need to treat alcohol withdrawal. In general, a score of less than 10 requires no pharmacologic treatment; a score of 10 to 20 requires at least later assessment, ...