Alcohol Withdrawal.

Abstract

Audience: Emergency medicine residents and medical students on emergency medicine rotations.

Introduction: Alcohol use disorder (AUD) is common in the United States, with an estimated lifetime prevalence of 30%.1 The rate of use is higher among white males, Native Americans, and individuals of low socioeconomic status.1 Alcohol withdrawal symptoms manifest in 50% of individuals who misuse alcohol.1 While life-threatening sequelae of alcohol withdrawal are rare, the syndrome is a common reason for emergency department (ED) presentations. Alcohol withdrawal symptoms range from benign, cravings, nausea, anxiety and tremulousness, to life-threatening autonomic dysfunction, seizures, coma, and death.2 The pathophysiology of this clinical syndrome involves dysregulation of central nervous system (CNS) receptor function. Alcohol acts as a CNS depressant through activation of the CNS Gamma-aminobutyric acid (GABA) receptors. Chronic or heavy alcohol use results in downregulation of CNS inhibitory GABA receptors and upregulation of CNS excitatory N-methyl-D-aspartate (NMDA) receptors.2 Upon discontinuation of alcohol use, this imbalance results in CNS hyperexcitability, creating the clinical symptoms of alcohol withdrawal.2 Symptoms typically manifest within eight hours after alcohol cessation, reach their peak in one to three days, and can extend for up to two weeks.3 Mild symptoms include anxiety, tremors, diaphoresis, nausea and/or vomiting. Severe symptoms include hallucinations (typically 12-24 hours after last alcohol intake) in 2-8% of patients, seizures (12-48 hours after last intake) in up to 15% of patients, and delirium tremens.3 Delirium tremens is a potentially fatal encephalopathy in patients experiencing alcohol withdrawal and occurs in 3-5% of patients approximately 72 hours after last alcohol intake.3 Without recognition or prompt treatment, mortality from delirium tremens can be as high as 50%.4 Management of alcohol withdrawal requires prompt recognition and control of symptoms. Most often this is accomplished by administering benzodiazepines, though alternative medications such as barbiturates, ketamine, or propofol are also used. Severe withdrawal may progress to intubation and mechanical ventilation.5 Given the high prevalence of AUD in the United States and the potential for life-threatening withdrawal symptoms, ED practitioners must recognize the spectrum of this disease and be comfortable with managing an array of presentations.

Educational objectives: At the end of this oral boards session, learners will: 1) demonstrate the ability to perform a detailed history and physical examination in a patient presenting with signs and symptoms of alcohol withdrawal, 2) investigate the broad differential diagnoses, including electrolyte abnormalities, trauma in the intoxicated patient, mild alcohol withdrawal, and delirium tremens, 3) list appropriate laboratory and imaging studies to include complete blood count (CBC), complete metabolic panel (CMP), magnesium level, computed tomography (CT) scan of the brain; 4) understand the management of hypoglycemia with concurrent administration of thiamine to prevent Wernicke's encephalopathy and subsequent Korsakoff syndrome, 5) appropriately treat acute alcohol withdrawal with intravenous (IV) hydration and benzodiazepines, phenobarbital, or alternative medications, and 6) understanding the need for the complex management of these patients, appropriately disposition the patient to the intensive care unit after consulting with critical care specialists.

Educational methods: The case was written as an oral boards case to test learners in a simulated oral board format. In this manner, learners could be evaluated on their critical thinking skills one-on-one with an instructor, outside of the distractions of the emergency department. Oral board simulation can test multiple modalities, including data collection, data synthesization and pharmacologic treatment in order to assess residents' overall clinical care and competence. Learners were assessed both by the instructor with immediate feedback, as well as by using Google forms to tie critical actions to Emergency Medicine Milestones. Results were compiled and used during clinical competency evaluations.

Research methods: Learners (n=40) and examiners were given the option to provide written feedback after the case was completed to assess for strengths and weaknesses of the oral boards case, and subsequent changes were made to improve the administration of the case.

Results: Residents and medical students rated this highly and found this to be an enjoyable, yet still challenging, way to stay current on their management skills of alcohol withdrawal. Learners rated the session 4.6 out of 5 using a five-point Likert scale (5 being excellent) after the session was completed (n=25).

Discussion: We found this oral board case to be an effective educational tool for reviewing alcohol use disorder among students and residents. Using an oral board case allows junior and senior residents to be tested quickly in a low-stakes environment. Learners and instructors both felt the content was appropriate, and using the completed forms in competency meetings improved the committee's ability to assess residents on specific milestones. Though we initially wrote this case requiring the examinee to have advance knowledge of the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar), this was not deemed essential to emergency medicine residents or faculty, and it was removed. The current case formatting represents a more realistic case presentation and critical actions.

Topics: Alcohol withdrawal, electrolyte abnormalities, seizures, altered mental status.