Alcoholism

 

 

Considerations

 

  • Multisystem disease:

    • CNS: peripheral neuropathy, Wernicke-Korsakoff syndrome (ocular, ataxia, confusion), cerebral atrophy/dementia 

    • Cardiovascular: cardiomyopathy, palpitations, arrhythmias 

    • GI: liver dysfunction/cirrhosis, esophagitis, gastritis, pancreatitis, malnutrition

    • Heme: pancytopenia 

    • Endocrine/metabolic: hypoglycemia, hypoalbuminemia, electrolyte abnormalities (hypokalemia, hypomagnesemia) 

    • MSK: myopathies, osteoporosis

    • Other addictions 

  • Altered pharmacology:

    • Induction of liver enzymes

    • ↑ MAC

  • Alcohol withdrawal syndromes & need for CIWA protocol (tremors, autonomic hyperactivity, DTs) 

 

 

Alcohol Withdrawal & Syndromes

 

  • Earliest & most common: 

    • Generalized tremors that may be accompanied by perceptual disturbances (nightmares, hallucinations), autonomic nervous system hyperactivity (tachycardia, hypertension, cardiac dysrhythmias), nausea, vomiting, insomnia, & mild confusional states with agitation 

    • Symptoms usually begin within 6 to 8 hours after a substantial ↓ in blood alcohol concentration & are typically most pronounced at 24 to 36 hours

    • These withdrawal symptoms can be suppressed by the resumption of alcohol ingestion or by administration of benzodiazepines

  • Delirium tremens: 

    • Occurs in ~5% of those experiencing withdrawal 

    • Symptoms begin 2-4 days after alcohol cessation 

    • Manifests as hallucinations, combativeness, hyperthermia, tachycardia, hypertension or hypotension, & grand mal seizures

    • Treatment: 

      • First line = benzodiazepines (titrated to effect without loss of respiration) 

      • Beta blockers to reduce tachycardia & hypertension 

      • Fix metabolic abnormalities (potassium, magnesium, & thiamine) 

      • Severe cases will need ICU admission & propofol infusion/dexmedetomidine & possible intubation

      • Mortality = 10% (usually due to hypotension, dysrhythmias, or seizures)

  • Wernicke-Korsakoff syndrome:

    • Wernicke's encephalopathy:

      • Loss of neurons in the cerebellum

      • Acute syndrome requiring emergent treatment to prevent death & neurologic morbidity 

    • Korsakoff's psychosis:

      • Chronic neurologic condition  

      • Loss of memory resulting from the lack of thiamine (vitamin B1), which is required for the intermediary metabolism of carbohydrates

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