Even though more than half a million patients are seen in U.S. emergency departments for alcohol withdrawal each year, this seemingly straightforward diagnosis is missed more often than we may believe.1 Even when it is picked up, it is often mismanaged. Why?
We sometimes don’t suspect it in the first place. For example, we may not think about alcohol withdrawal in the older patient who presents with delirium.2 Second, the differential diagnosis is enormous, and the presentation overlaps with other common ED diagnoses such as sympathomimetic drug intoxication and sepsis. There is no lab test to rule in the diagnosis, and we sometimes get sidetracked by other concurrent medical, psychiatric, and traumatic issues.
Mismanagement of these patients may stem from a lack of ED training on this topic and be due to little standardization in management. There is, unfortunately, still a stigma associated with alcoholism, which may contribute to indifference to these patients by ED staff, and the medications used to treat alcohol withdrawal are often dosed incorrectly.3 Mismanaged alcohol withdrawal can be fatal, and untreated severe withdrawal often ends up with your patient seizing and sometimes progressing to delirium tremens.4
Management of Alcohol Withdrawal Involves Four Steps
First, accurate diagnosis based on clinical features is paramount. Next, the use of a standardized, symptom-guided tool to assess symptom severity and guide treatment is important. Third, ensure that patients are fully treated prior to ED discharge, and fourth, provide a pathway to support for patients who are trying to quit.
1. Tremor is central to the diagnosis of alcohol withdrawal.
The diagnosis of alcohol withdrawal should be thought of as a clinical diagnosis of exclusion after infection, other toxidromes (ie, sympathomimetics, anticholinergics, toxic alcohols), serotonin syndrome, neuroleptic malignant syndrome, hypertensive crisis, acute pain, and thyrotoxicosis have been considered. There must be clear evidence of recent cessation or reduction of alcohol after high-dose regular use. Symptoms from alcohol withdrawal usually start within six to eight hours after the blood alcohol level decreases, peak at 72 hours, and diminish by days five to seven of abstinence. Delirium tremens can occur anytime from three to 12 days after abstinence.
The tremor of alcohol withdrawal is central to the diagnosis. It is important to understand the three key features of alcohol withdrawal tremor. It is an intention tremor (there is no tremor at rest, but when you ask the patient to extend their hands or arms, you will see a fine motor tremor) 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. If malingering is suspected, ask the patient to protrude their tongue. A tongue tremor is impossible to feign and is thought to be a more sensitive sign of alcohol withdrawal than hand tremor.