Alcohol withdrawal seizures

Background

• Onset after last drink: 6-48h
• Multiple seizures: 60% of patients
• Progression to Delerium tremens: 33% of patients
• May occur in spectrum or independent of Alcohol withdrawal syndrome

Clinical Features

• Single or multiple brief tonic-clonic seizures in the appropriate time setting for alcohol withdrawal

Differential Diagnosis

Ethanol related disease processes

• Ethanol toxicity
• Alcohol withdrawal
  • Alcohol withdrawal seizures
  • Delerium tremens
• Electrolyte/acid-base disorder
  • Wernicke-Korsakoff syndrome
  • Beer potomania syndrome
  • Alcoholic ketoacidosis

Seizure

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
• Non-epileptic seizure
  • Meningitis
  • Encephalitis
  • Intracranial hemorrhage
  • Alcohol withdrawal
  • Eclampsia
  • Neurocysticercosis
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
  • Seizure with VP shunt
  • Toxic ingestion
• Intracranial mass
• Syncope
• Hyperventilation syndrome
• Migraine headache
• Movement disorders
• Narcolepsy/cataplexy

Evaluation

• Clinical features
• Elevated CIWA

CIWA score

Clinical Institute Withdrawal Assessment – Alcohol – revised (CIWA-Ar)

• Headache 0-7
• Orientation 0-3
• Tremor 0-7
• Sweating 0-7
• Anxiety 0-7
• Nausea (and Vomiting) 0-7
• Tactile Hallucinations 0-7
• Auditory Hallucinations 0-7
• Visual Hallucinations 0-7
• Agitation 0-7

Maximum Score = 67

• <8: Typically do not require medication
• 8-19: Medication
• ≥20: Medication and admission

Management

• Treat with benzos (not phenytoin)
• See Alcohol withdrawal#Inpatient Management

Disposition

• Admission

See Also

• Alcohol withdrawal
• Delerium tremens
• EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal

External Links

• MDCalc - CIWA-AR Calculator

References

Authors

Amr Badawy, Ross Donaldson, Neil Young, Daniel Ostermayer