From my first discussion with Alcohol Withdrawal, I talked about my personal experience that's now become a driving motivation to improve the care we render for patients suffering from Alcohol Withdrawal Syndrome in my state, but how exactly can we do that? How do we reduce a number as high as a 37% mortality rate to an incredible 5%? Let's briefly discuss a case.
We're dispatched for a reported altered mental status patient with no further information, arriving on scene we find a 40-year-old male, he's lying in bed drenched in sweat, shaking heavily, confused, and seeing people in the room who aren't actually there. His wife tells us he's a long-term alcoholic who drinks several pints of vodka every day, and 3 days ago tried to start weaning himself off by drinking less than 1 pint.
Where do we go from here? Assessment? Vitals? We do a quick evaluation and find a heart rate of 140BPM, BGL of 47mg/dl, 92 O2 on room air, BP of 160/112, a temperature of 102.5 Fahrenheit, and a 12 lead that looks like this:
(Buttner et al., 2021)
We're dealing with a patient now who's febrile, hypoglycemic, hypertensive, and has a concerningly prolonged QT interval at 510ms, and that's just what we can find! Is anyone else feeling like we will have to have a shotgun approach? Well, you're not too far off.
Management of severe Alcohol Withdrawal Syndrome (AWS), especially in the pre-hospital setting, becomes profoundly complex, but there are things we can do to get to that magic number of 5%.
Manage Symptoms: Severe AWS often presents with the above symptoms, and each needs to be managed appropriately. Address fevers, address low blood sugar, and administer fluids as indicated as part of initial care (Mirijello et al., 2015).
The tank is full: Fluid resuscitation should only be when indicated for signs of hypotension after addressing other findings, and used judiciously and cautiously. Liberal fluid resuscitation can result in worsening of hyponatremia secondary to issues such as beer potomania (Wolf et al., 2020)
Electrolyte Abnormalities: Patients in severe withdrawal can present with a host of life-threatening imbalances, including low magnesium, low sodium, low calcium, and low phosphate levels, all of which can induce life-threatening arrhythmias and require prompt management. Be aware that patients are pre-disposed to developing arrhythmias such as Torsades De Pointes, and administer Magnesium Sulfate and Calcium as indicated! (Baj et al., 2020)
Benzos Benzos Benzos: Benzodiazepines are the front-line and mainstay of AWS management, and no choice is proven superior, although Diazepam tends to be favored due to its longer duration. Aggressive and frequent dosing reduces anxiety and the likelihood of withdrawal seizures and prevents Delirium Tremens. Equivalence in AWS is 1mg Lorazepam to 2mg Midazolam, and 10mg Diazepam is roughly equivalent to 3mg Midazolam (Gortney et al., 2016) (Sachdeva, 2015)
QT Prolongation: Be cautious when administering QT-prolonging agents such as neuroleptics (Haloperidol, Droperidol) or common anti-emetics (Ondansetron) as severe AWS is prone to severe QT interval prolongation. While the above agents prolong QT relatively minimally, it's crucial to be aware of the risks when QT is already excessively prolonged (Sachdeva, 2015)
Consider Advocacy: Multiple systems in the U.S. lack specific guidance for these patients, and as a result, we lose sight of the fact that they are truly patients. If we create protocols to address this problem, we also make a paradigm shift in how healthcare personnel view them and empower EMS personnel. My home state (Maryland) will enact a specific Alcohol Withdrawal Protocol statewide in 2025 after joint advocacy efforts to address this gap in care.
Scales: There are numerous different scales with varied levels of accuracy out there to judge the severity of withdrawal symptoms and be familiar with what the local facilities use to speak a 'common language'; some more common ones are BAWS (Brief Alcohol Withdrawal Scale), CIWA-Ar ( Clinical Institute Withdrawal Alcohol Assessment Revised)
Successfully raising the bar and dropping the number requires a multi-pronged approach. As healthcare clinicians the primary objective is compassionate care, the patients need to be treated as human beings rather than us falling into the trap of them being a 'waste' and the care 'pointless'. Compassionate care improves outcomes and compliance with care, if we start there then the rest of patient care becomes far more likely to be successful (Watts et al., 2023).
Building on compassionate care, we need to take an aggressive approach to managing symptoms. Clinicians should be wary of dysrhythmias, electrolyte imbalances, and other severe problems that can appear in the AWS patient and become more likely and life-threatening the more severe the presentation of the patient (if they look sick, they are sick). Finally, we need to administer benzodiazepines early and aggressively to control withdrawal symptoms, which will rapidly reduce their mortality.
Management of the Alcohol Withdrawal patient in the field is often highly complex and requires a careful and measured approach to their care. If you're cognizant of the wide-ranging risks to these patients and aggressively treat symptoms, as well as administer benzodiazepines in a timely fashion, you can have a significant impact on reducing their mortality rate to the magic 5 (Gortney et al., 2016).
References: The Asam Clinical Practice guideline on Alcohol Withdrawal Management: Erratum. (2020). Journal of Addiction Medicine, 14(5). https://doi.org/10.1097/adm.0000000000000731
Baj, J., Flieger, W., Teresiński, G., Buszewicz, G., Sitarz, R., Forma, A., Karakuła, K., & Maciejewski, R. (2020). Magnesium, calcium, potassium, sodium, phosphorus, selenium, zinc, and chromium levels in Alcohol Use Disorder: A Review. Journal of Clinical Medicine, 9(6), 1901. https://doi.org/10.3390/jcm9061901
Buttner, R., Larkin, J., & Larkin, R. B. and J. (2021, March 11). Hypomagnesaemia. Life in the Fast Lane • LITFL. https://litfl.com/hypomagnesaemia-ecg-library/
Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., Leggio, L., Gasbarrini, A., & Addolorato, G. (2015). Identification and management of alcohol withdrawal syndrome. Drugs, 75(4), 353–365. https://doi.org/10.1007/s40265-015-0358-1
Reuben. (2023, October 1). Symptom-triggered brief alcohol withdrawal scale inpatient AWS protocol. emupdates. https://emupdates.com/baws/
Sachdeva, A. (2015a). Alcohol withdrawal syndrome: Benzodiazepines and beyond. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2015/13407.6538
Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353–1357, 1989
Jesse, S., Bråthen, G., Ferrara, M., Keindl, M., Ben-Menachem, E., Tanasescu, R., Brodtkorb, E., Hillbom, M., Leone, M. A., & Ludolph, A. C. (2016). Alcohol withdrawal syndrome: Mechanisms, manifestations, and management. Acta Neurologica Scandinavica, 135(1), 4–16. https://doi.org/10.1111/ane.12671
Wolf, C., Curry, A., Nacht, J., & Simpson, S. A. (2020). Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives. Open access emergency medicine : OAEM, 12, 53–65.