Dealing with the DTs

Irritability. Tremors. Sweating and a rapid heart rate. Extreme confusion. Fever. Convulsions. These are all symptoms of acute alcohol withdrawal syndrome. A patient may develop acute alcohol withdrawal syndrome when chronic alcohol use is interrupted by hospital admission. Increasingly patients are being treated for alcohol withdrawal on general medical wards.

Acute withdrawal is most safely managed in an inpatient setting if the patient has been using high doses of sedatives, has a history of seizures or delirium tremens, or has co-morbid medical or psychiatric problems.1 The severity of the withdrawal syndrome is affected by concurrent medical illness. Up to 20% of patients develop delirium tremens if left untreated.2 Recognition and effective treatment of alcohol withdrawal are needed to prevent excess mortality or prolonged hospitalization due to complications. It is essential for hospitalists to recognize and effectively treat acute alcohol withdrawal to prevent adverse outcomes in hospitalized patients.

Acute withdrawal is most safely managed in an inpatient setting if the patient has been using high doses of sedatives, has a history of seizures or delirium tremens, or has comorbid medical or psychiatric problems.

Development of Withdrawal

Hospitalized patients may not be forthcoming about their alcohol consumption for numerous reasons. They may not consider it a problem; they may not recognize that acute withdrawal is a serious and even fatal complication; or they may wish to conceal their alcoholism from family and physicians due to concerns about stigmatization.

Even when patients acknowledge their drinking, they often underestimate the amount, which may be because a patient is minimizing or because alcohol is an amnestic agent, causing drinkers to lose count of how much they have had to drink. It is simplest to ask—in a nonjudgmental manner—all patients admitted to the hospital about drinking and to be alert for signs of acute alcohol withdrawal in all patients.

Not all patients who drink alcohol will develop an acute withdrawal syndrome. Those who drink less frequently—only on weekends with no drinking at all on weekdays, for example—are at lower risk of acute withdrawal. Those who drink on most days of the week are more likely—due to tolerance—to develop withdrawal. Even a habit of two or three drinks each day is enough to set up a person for withdrawal. Not all daily drinkers are guaranteed to develop withdrawal, and it is difficult to predict who will and who will not. The best predictor of whether a patient will develop acute withdrawal while hospitalized is a past history of acute alcohol withdrawal.

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