Approach Considerations
Serum, imaging, and cerebrospinal fluid (CSF) studies are important in the assessment of patients with alcohol withdrawal. Moreover, routine screening for unhealthy alcohol use in patients admitted to the hospital can be used to detect patients who are at risk for developing alcohol withdrawal. The American College of Surgeons Committee on Trauma mandates routine screening for unhealthy alcohol use for level 1 and 2 trauma centers. Screening tools include the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and the CAGE screening test.
Serum Chemistry Studies
Serum chemistry studies should include:
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Sodium
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Potassium
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Chloride
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Bicarbonate
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Blood urea nitrogen (BUN)
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Creatinine
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Magnesium
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Phosphorous
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Liver function tests
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Creatine phosphokinase - Some patients develop rhabdomyolysis
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Lipase
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Ketones
Other Laboratory Studies
Serum ethanol concentration is important to assess, because patients who exhibit withdrawal while ethanol is still present in the serum are likely to have a more severe course. Additional laboratory tests include the following:
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Serum glucose
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Complete blood count with differential
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Drug screen, if suspicion of drug use is present
Measure serum anticonvulsant levels if the patient is known or suspected to be taking anticonvulsant medication. Other studies that may be useful in certain patients include measurement of serum lactate, as well as serum osmolality, with calculation of the osmolal gap.
Imaging Studies
About 50% of patients with delirium tremens (DTs) who present with fever will have an infection, pneumonia being most common. A chest radiograph should be obtained in all patients suspected of having DTs. If there is any suspicion of trauma or head injury, imaging of the cervical spine (plain radiography or CT scanning) and head CT scanning should be performed.
Computed tomography (CT) scanning of the head is performed selectively. Indications for a head CT scan include the following:
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New-onset seizure
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Seizures occurring over longer than a 6-hour period
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More than 6 seizures
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Focal seizures
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Evidence of head trauma
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Focal neurologic deficits
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A prolonged postictal state
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Deteriorating level of consciousness
Lumbar Puncture
Patients with alcohol withdrawal syndrome who have had a seizure and continue to be obtunded should have a lumbar puncture if no signs of increased intracranial pressure are present. Some patients may not have the classic signs of meningitis, such as nuchal rigidity, and the cerebrospinal fluid (CSF) of these patients should be examined to rule out meningitis. CSF pleocytosis is often present after withdrawal seizures, even in the absence of infection or intracranial bleeding. However, CSF pleocytosis after seizures should not be attributed solely to the seizures without a search for a treatable infectious cause.
Even in the absence of seizures, perform lumbar puncture if any suspicion of meningitis exists (fever, lethargy, confusion, or headache). The absence of nuchal rigidity does not reliably rule out meningitis in these patients.
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Average annual deaths from alcohol.
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Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal. From Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 1989;84:1353-1357.
