Position Statement: The Role of a Medical Toxicologist for Assistance in the Treatment of Alcohol Withdrawal Syndrome
American College of Medical Toxicology
Int J Med Toxicol 2001; 4(3): 22
While individual practitioners may differ, this is the position of the College at the time written, after a review of the issue and pertinent literature.
Alcohol withdrawal syndrome is a complex problem which may present in a variety of clinical scenarios, including simple physical and mental discomfort, auditory and visual hallucinations, discrete withdrawal seizures, status epilepticus and delirium tremens. The clinical presentation and management may vary according to the age of the patient, underlying illness, and associated conditions such as trauma. The clinician treating the patient with alcohol withdrawal syndrome should have a comprehensive understanding of the pathophysiology of alcohol withdrawal and be prepared to administer treatment carefully adapted to the clinical scenario(s) present and its (their) severity.
Morbidity and Mortality
While the mortality of alcohol withdrawal syndrome has decreased with improvements in intensive care, a significant minority of these patients will die either from the effects of withdrawal itself or from its complications, including infection and cerebral hypoxia among others. Failure to recognize and rapidly treat thiamine deficiency or intercurrent hypoglycemia may result in irreversible brain damage.
The differential diagnosis of alcohol withdrawal syndrome includes withdrawal from other sedative agents such as barbiturates and benzodiazepines, encephalopathy of toxic or nontoxic origin, serotonin syndrome and acute intoxication with stimulant and proconvulsant agents such as cocaine, phencyclidine, and ethylene glycol. The presence of complicating infection, such as meningitis, encephalitis, or pneumonia may make the diagnosis more difficult and significantly complicate management. Concomitant illness such as meningitis, encephalitis, pneumonia, and sepsis are not only part of the differential diagnosis but often may precipitate alcohol withdrawal, as the ethanol-dependent person becomes ill and consumes smaller than usual quantities of alcohol.
Benefits of Medical Toxicology Consultation
Given the potential for mortality or significant morbidity, a differential diagnosis which involves primarily drug intoxications or other forms of withdrawal, the frequent need for "heroic" quantities of sedatives in treatment, the need for intensive monitoring, and the risk of such complications as rhabdomyolysis and adverse medication effects, early involvement of a medical toxicologist may be of significant benefit in the care of patients with alcohol withdrawal. The American College of Medical Toxicology strongly recommends consultation with or care by a medical toxicologist in cases of suspected or confirmed alcohol withdrawal syndrome.
- Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997 278:144-51.
- Stewart DG, Brown SA. Withdrawal and dependency symptoms among adolescent alcohol and drug abusers. Addiction 1995;90:627-635.
- Marik P, Mohedin B. Alcohol-related admissions to an inner city hospital intensive care unit. Alcohol Alcoholism 1996;31:393-396.
- Erwin WE, Williams DB, Spier WA. Delirium tremens. S Med J 1998;91:425-432.
- Adinoff B, Bone GHA, Linnoila M. Acute ethanol poisoning and the ethanol withdrawal syndrome. Med Toxicol 1988;3:172-196.
- Moss M, Bucher B, Moore FA, Moore EE, Parsons PE. The role of chronic alcohol abuse in the development of acute respiratory distress syndrome in adults.
Copyright 1999-2003, American College of Medical Toxicology.