Withdrawal Syndromes Follow-up

  • Author: Nathanael J McKeown, DO; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Nov 16, 2010
 

Further Inpatient Care

  • Symptoms of alcohol withdrawal are often mild or absent in the ED and may manifest only after the patient is admitted to the hospital for other reasons (eg, multiple trauma).
  • Patients already manifesting advanced stages of withdrawal in the ED (eg, seizure, DT) require admission.
  • Patients with DT require admission to the ICU because their hemodynamic picture can change rapidly and because appreciable mortality is associated with DT.
  • Patients may require admission for associated conditions (eg, GI bleed, pancreatitis). In these cases, use of sedatives may be more complex if the patient is hypotensive from blood or third-space fluid losses.
  • In uncomplicated cases of withdrawal, the sedative regimen can be continued until the patient is calm and vital signs are normalized. At that point, decreasing the dose or increasing the dosing interval over 3-4 days can taper the administration of sedatives.
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Further Outpatient Care

  • Referral of patients with chronic alcoholism or intravenous drug use to ongoing treatment programs is worthwhile, even if a minority of these patients maintain sobriety for long periods. Numerous agencies offer inpatient and outpatient treatment programs; the most successful groups appear to be Alcoholics Anonymous and Narcotics Anonymous.
  • The following options are available for people addicted to heroin:
    • Methadone is a long-acting opiate that prevents occurrence of somatic withdrawal symptoms but does not produce sedation or euphoria equivalent to heroin.
    • Buprenorphine is a μ-opioid agonist/antagonist and is prescribed in a manner that is similar to methadone.
    • Both treatment programs require patient compliance and motivation. This appears to be the limiting factor in their success rates.
  • Patients withdrawing from chronic stimulant abuse are best cared for under medical supervision; refer these patients to appropriate institutions or agencies.
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Transfer

  • Because of the risk of seizures, patients in active withdrawal from alcohol are unstable for transfer until they have received adequate sedation.
  • Decisions about when to transfer largely depend on underlying associated conditions that may have stabilization requirements of their own (eg, pancreatitis, acute MI).
  • Patients in opiate withdrawal are generally stable for transfer unless underlying conditions render them unstable.
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Complications

  • Numerous complications are associated with long-term alcohol and intravenous drug abuse. Complications are more common and more serious in alcohol withdrawal than in opiate or stimulant withdrawal.
  • Alcohol withdrawal
    • Metabolic complications
    • GI complications
      • Pancreatitis
      • Gastrointestinal bleeding (eg, peptic ulcer, esophageal varices, gastritis)
      • Hepatic cirrhosis
    • Infectious complications
      • Pneumonia
      • Meningitis
      • Cellulitis
    • Neurologic complications
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Patient Education

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Contributor Information and Disclosures
Author

Nathanael J McKeown, DO  Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University

Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick L West, MD  Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Theodore J Gaeta, DO, MPH, FACEP  Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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Clinical Institute of Alcohol Withdrawal Scale-Revised (CIWA-Ar)
 
 
 
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