quick reference
Toxidromes Overview are generally a diagnosis of exclusion, rule out life-threatening diagnoses
- Acute head trauma (chronic ETOH use = 2-10x risk of head bleed)
- Infection (aspiration, poor self care)
- GI Bleed (varices)
- Advanced liver disease (hepatic encephalopathy)
- Focal neuro deficits
- Electrolyte disarray (beer potomania)
CIWA-Ar for Alcohol Withdrawal
CIWA <8 = outpatient management
- observe in ED for at least 6 hours
Admission Criteria: - Consider if CIWA-Ar >8
- Inability to control withdrawal despite appropriate therapy
- Focal Seizures
- Status Epilepticus
- DTs
- Poor home situation
- Unable to walk/eat
patho
clinical features
Signs/Symptoms:
- Nausea/Vomiting
- Tremors
- Diaphoresis
- Headache
- Anxiety/Agitation
- Hallucinations (visual, auditory, tactile)
- *auditory alone suggest other pathology (schizophrenia, etc.)
- “clouded sensorium”
CIWA-Ar for Alcohol Withdrawal
8-15 = Mild Withdrawal
15-20 = Moderate Withdrawal
over 20 = Severe Withdrawal
workup
Physical Exam
- Neuro: CN2-12, tremor, stocking/glove paresthesias
- Heart/lungs: tachyarrhythmias, transudative effusion, comorbid lung patho
- Abd: Varicosities, distension, pain on palpation, fluid wave
- Skin: jaundice, bruising
- Eyes: Scleral icterus, PERRL, conjunctival pallor
Labs
- STAT fingerstick glucose.
- CBC with differential
- BMP
- Ca/Mg/Phos
- LFTs
- PT-INR, PTT
Imaging
- Chest X-ray.
- Consider CT head to exclude subdural hematoma.
diagnosis
Clinical
treatment
Supportive
- IV volume resuscitation
- Thiamine, 100mg IV
- MgSO4, 2-4g IV
- Folate, 1mg IV
- Multivitamin PO/IV
Banana bags are waste of money (must be compounded)
Phenobarbital
- First Line Drug
- Delayed onset compared to Benzos (~30min IV)
10mg/kg IBW IV over 30 min
!! Wait 30 min to assess efficacy !!
Benzodiazepines
PICK ONE AND STICK WITH IT!!
- Don’t switch between benzos - makes titration/dosing a headache when dealing with different half lives, onset time, etc.
Goal: Rapid Upfront Titration
- Give in escalating IV doses
- Give until RASS 0 to -1 (relaxed, very mildly sedated)
Ideal:
5-10mg IV Diazepam q5-10min