Alcohol Withdrawal Syndromes and Timecourse

a) Minor Withdrawal - shakes/tremors, diaphoresis, anxiety, GI upset including nausea/vomiting, headaches.  EARLY ONSET - as early as 6 hours (even when patient is still intoxicated!).  Usually lasts for several days.

b) Seizures – generalized tonic-clonic.  EARLY ONSET - usually 24-48 hrs.  Untreated, leads to DTs in 30%.  Must rule out other causes of seizures (i.e. intracranial pathology such as a bleed).  Status epilepticus is rare – if this occurs, search hard for other etiologies.

c) Alcoholic Hallucinosis – EARLY ONSET, usually 12-48 hrs.  Typically get visual hallucinations, although can be auditory or tactile.  Main difference vs DTs is that patients have normal mental status and lack of severe autonomic activation, as well as earlier onset.

d) Delirium Tremens - peaks at 3-5 days which is later than the other syndromes, and can last for > 1 week when severe.  Manifestations are hallucinations, disorientation, and severe autonomic activation (tachycardia, fever, hypertension, diaphoresis) as well as exaggerated symptoms of minor withdrawal (shakes/tremors,  GI upset, etc).

• Risk factors for DTs include prior history of DTs and advanced age, as well as concurrent medical illness.
• Main complications and concerns with DTs are severe hypovolemia and electrolyte disturbances (hypokalemia, hypomagnesemia, hypophosphatemia) --> arrhythmias and cardiovascular collapse are a common cause of death!

Note that the life-threatening, "severe" withdrawal syndromes we are really concerned about are Seizures and DT's, whereas the minor shakes and even hallucinosis are considered benign syndromes.

(Chanu Rhee MD, 11/11/10)