Question

    Alcohol Withdrawal

    An alcoholic man with delirium[1]

    Alcohol withdrawal syndrome is characterized by onset of symptoms that occurs in individuals who suddenly stop drinking alcohol. It essentially occurs in the alcohol drinking population who all of a sudden either decreases their alcohol intake or stops its consumption.

    The disease originates from the following process: Poison.

    Presentation

    Symptoms of alcohol withdrawal usually develop within 8 hours after the last drink. However, in many instances, symptoms may occur after many days. Symptoms include depression, anxiety, nervousness, mood swings, nightmares, irritability, fatigue, headache, enlarged pupils, pallor, sweating and rapid heart rate. In more severe forms of alcohol withdrawal, delirium tremens may set in. Individuals experience fever, hallucinations, seizures, confusion and agitation [7]. Symptoms continue for several weeks and peak within 24 to 72 hours after the onset of preliminary signs [8].

    Entire body system
    Agitation
    • Ibrahim contends that it’s both safe and effective in treating agitation.[todayshospitalist.com]
    • The CIWA-AD is copyrighted, whereas the CIWA-Ar is not. [ 7 ] The RASS (Richmond Agitation Sedation Scale) and Riker SAS (Sedation Agitation Scale) are agitation/sedation scales used in the ICU and appear to have similar efficacy in delirium assessment[emedicine.medscape.com]
    • Time Required to Control Agitation Only 2 studies were identified that considered the time required to control agitation.[archinte.jamanetwork.com]
    • Individuals experience fever, hallucinations, seizures, confusion and agitation.[symptoma.com]
    • After very heavy alcohol consumption over a period of time, sudden cessation of drinking can bring on agitation, fever and seizures.[narconon.org]
    Fatigue
    • Individuals however, tend to suffer from insomnia, fatigue and irritability for several months.[symptoma.com]
    • Symptoms such as sleep changes, rapid changes in mood, and fatigue may last for months.[nlm.nih.gov]
    • Symptoms of withdrawal include fatigue and nausea.[addictioncenter.com]
    • Symptoms include anxiety, depression, fatigue, unclear thinking, headache and nausea.[huffingtonpost.com]
    • If you are concerned that someone you love is suffering from alcohol withdrawal, here are some of the common alcohol withdrawal symptoms to be aware of: Behavior/psychological symptoms: Mood swings Anxiety/nervousness Irritability Fatigue Confusion/unclear[myvictorycenter.com]
    Fever
    • DT has extreme autonomic hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever.[en.wikipedia.org]
    • Individuals experience fever, hallucinations, seizures, confusion and agitation.[symptoma.com]
    • Go to the emergency room or call the local emergency number (such as 911) if seizures, fever, severe confusion, hallucinations, or irregular heartbeats occur.[nlm.nih.gov]
    • A high fever, hallucinations, and heart disturbances are all reasons to seek immediate help.[healthline.com]
    • This is when you may experience the most uncomfortable withdrawal symptoms such as insomnia, rapid heartbeat, changes in blood pressure, sweating, tremors and fever.[alcoholrehabguide.org]
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  • neurologic
    Agitated Delirium
    • Low-risk patients with no history of agitated delirium or risk factors receive lorazepam PRN triggered by CIWA scores.[todayshospitalist.com]
    • Benzodiazepines occasionally fail to control alcohol withdrawal, and may promote agitated delirium.[emcrit.org]
    Dizziness
    • Depending on what and how much you drank, you may notice: Fatigue and weakness Thirst Headaches and muscle aches Nausea, vomiting or stomach pain Poor or decreased sleep Increased sensitivity to light and sound Dizziness or a sense of the room spinning[mayoclinic.org]
    • Common symptoms of PAWS include: Irritability and emotional outbursts Anxiety Low energy Trouble sleeping Memory problems Dizziness Increased accident proneness Delayed reflexes[alcoholrehabguide.org]
    • Dizziness : A very common symptom to experience during withdrawal is that of dizziness.[mentalhealthdaily.com]
    Hand Tremor
    • While alcohol withdrawal symptoms are often mild—pronounced sweating, hand tremors, and nausea, for example—more severe cases can critically damage the nervous system.[slate.com]
    • Alcohol withdrawal symptoms can include the following: hand tremors nausea anxiety vomiting insomnia hallucinations seizures autonomic instability These symptoms tend to grow in severity with how long a person has abused alcohol, but it is important to[libertybayrecovery.com]
    • tremors - Involuntary eyelid movements Severe symptoms Hallucinations, confusion and instability of the auto-immune system known as delirium tremens (commonly known as DT’s) Agitation Fever Convulsions Alcohol withdrawal symptoms from prolonged drinking[goodbyedrinking.com]
    • tremors) Withdrawal symptoms can be more severe in the elderly and those who have repeated withdrawals that lead to repeated intoxications.[caron.org]
    • The timeline for common withdrawal symptoms is: Six to 12 hours post-ingestion: Agitation Anxiety Headaches Shaking Nausea and vomiting 12 to 24 hours post-ingestion: Disorientation Hand tremors Seizures 48 hours post-ingestion: Seizures Insomnia High[alcoholrehabguide.org]
    Hyperactivity
    • This hyperactivity can result in tremors, seizures and even death.[healthyplace.com]
    • DT has extreme autonomic hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever.[en.wikipedia.org]
    • […] insomnia craving Stage II – 24 hrs hallucinations (visual, auditory, tactile) misperceptions irritability vivid dreams confused hypervigilant Stage III – 48 hrs generalised tonic-clonic seizures Stage IV – after 48 hrs global confusional state autonomic hyperactivity[lifeinthefastlane.com]
    • When the alcohol level is suddenly lowered, the brain remains in a hyperactive, or hyperexcited, state, causing withdrawal syndrome. 3 If people go through withdrawal a number of times without getting the right treatment, the symptoms may get worse each[alcoholanswers.org]
    • Hyperactivity Extreme cardiovascular disturbances: racing heart, temperature control, dramatic increase in blood pressure, dehydration Once DT begins, there is no known medical treatment to stop them.[caron.org]
    Hyperreflexia
    • Their general practice was to suspect benzodiazepine-induced delirium and trial flumazenil among patients with persistent confusion whose withdrawal seemed to have resolved (e.g. normal vital signs, no hyperreflexia).[emcrit.org]
    • Uncomplicated withdrawal: • Mild 24 hours after last drink Findings The “shakes,” insomnia, anxiety, hyperreflexia, diaphoresis, mild autonomic hyperactivity, GI upset. • Moderate 24-36 hours after last drink Findings Intense anxiety, tremors, insomnia[medical-dictionary.thefreedictionary.com]
    Insomnia
    • Antidepressants : may help relieve depression and insomnia symptoms.[luxury.rehabs.com]
    • Individuals however, tend to suffer from insomnia, fatigue and irritability for several months.[symptoma.com]
    • They include: Mood swings Fatigue Depression Anxiety Irritability Shakiness Nightmares Difficulty thinking clearly Night sweats Insomnia Mild anxiety Headaches Dilated pupils Insomnia Clammy skin Nausea Vomiting Loss of appetite Rapid heart rate Paleness[caron.org]
    • Common medications include benzodiazepines to help treat symptoms like anxiety , insomnia , and seizures.[webmd.com]
    Irritability
    • Individuals however, tend to suffer from insomnia, fatigue and irritability for several months.[symptoma.com]
    • They may include mood swings, anxiety, irritability, changing levels of energy and trouble sleeping.[addictioncenter.com]
    • Heroin withdrawal symptoms include dilated pupils, fever, chills, stomach cramps and diarrhea, vomiting, loss of appetite, irritability, panic, nausea, muscle cramps and runny nose.[withdrawal.net]
    • Excessive drinking excites and irritates the nervous system.[healthline.com]
    • […] and can be fatal manifests within 48 hours of stopping drinking CLINICAL FEATURES Stage I – 6-24 hrs anxiety restlessness decreased attention tremulousness insomnia craving Stage II – 24 hrs hallucinations (visual, auditory, tactile) misperceptions irritability[lifeinthefastlane.com]
    Nystagmus
    • We have added green lines indicating the plasma therapeutic range for phenobarbital (64-172 micromol/L 15-40 ug/ml), an orange line indicating the level at which mild signs of toxicity are usually noted such as ataxia and nystagmus (225 micromol/L 50[emcrit.org]
    Seizure
    • If a patient has seizures that are not typical of alcohol withdrawal seizures (such as partial or focal seizures, prolonged seizures, or seizures with a prolonged postictal state) or has signs of significant head trauma, then the underlying cause of the[emedicine.medscape.com]
    • 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[wikem.org]
    • Most seizures generally terminate spontaneously, or are easily controlled with benzodiazepines or other anti-seizure medications.[officer.com]
    • In severe cases, seizures and hallucinations follow.[addictioncenter.com]
    • 6-24 hrs anxiety restlessness decreased attention tremulousness insomnia craving Stage II – 24 hrs hallucinations (visual, auditory, tactile) misperceptions irritability vivid dreams confused hypervigilant Stage III – 48 hrs generalised tonic-clonic seizures[lifeinthefastlane.com]
    Tremor
    • The tremor may not be visible when the patient is at rest.[porticonetwork.ca]
    • The first stage of alcohol withdrawal is marked by tremors.[recoveryranch.com]
    • (especially hand tremors) Withdrawal symptoms can be more severe in the elderly and those who have repeated withdrawals that lead to repeated intoxications.[caron.org]
    • It causes confusion, tremors and hallucinations.[addictioncenter.com]
    • This hyperactivity can result in tremors, seizures and even death.[healthyplace.com]
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  • Skin
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  • cardiovascular
    Tachycardia
    • […] irritability vivid dreams confused hypervigilant Stage III – 48 hrs generalised tonic-clonic seizures Stage IV – after 48 hrs global confusional state autonomic hyperactivity tremors hallucinations seizures hyperadrenergic: diaphoresis, flushing, mydriasis, tachycardia[lifeinthefastlane.com]
    • […] fear, irritability, depression Catatonia Confusion Delirium tremens Derealization Euphoria Fever Gastrointestinal upset, nausea and vomiting, diarrhea Hallucinations Headache, migraine High blood pressure Insomnia, increased REM sleep Palpitations, tachycardia[healthyplace.com]
    • Presentation of DTs is characterized by tachycardia, hypertension, diaphoresis, delirium and low-grade fever. 2 Although DTs are present in only 5% of all patients who experience AWS, they carry a mortality rate up to 25%.[nurse-practitioners-and-physician-assistants.advanceweb.com]
    • Other signs include diaphoresis, tachycardia and hypertension.[porticonetwork.ca]
    • These signs include tachycardia [an abnormally rapid heart rate], hypertension, and fevers.”[withdrawal.org]
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  • urogenital
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  • psychiatrical
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  • Workup

    A preliminary physical exam to evaluate the signs and symptoms of the condition would be carried out. Physical examination would show signs of tremors, fever, dehydration, abnormal movements of eye and arrhythmia.

    In addition to physical examination, blood and urine tests would also be carried out to assess the amount of alcohol in body. A toxicology screen is also required to confirm the diagnosis.

    Laboratory

    Serum
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  • Treatment

    The type of treatment involved depends on the severity of the symptoms experienced. Some patients with mild to moderate symptoms can be treated at home; while others may require hospitalization to avoid onset of unnecessary complications such as delirium. Treatment of alcohol withdrawal is aimed at relieving symptoms, preventing onset of complications and achieving permanent abstinence from alcohol [9].

    Outpatient treatment: In this, the individual gets treated for alcohol withdrawal symptoms, through medications and regular visits to the doctor. It is required that the patient is constantly monitored by a caregiver to look for adverse symptoms of the condition. The individuals are put on sedatives to ease the symptoms and are regularly screened through blood tests. In addition, they are also screened for other medical problems which can worsen the existing condition.

    Inpatient treatment: Individuals experiencing severe symptoms may require a hospital stay to be monitored closely for onset of complications. All the vital parameters of the individual such as blood pressure, heart rate, body temperature, and blood levels of chemicals will be tested. In case of dehydration, the individual will be given IV fluids to correct the condition. Administration of sedatives such as benzodiazepines will be employed, until the withdrawal process is completed. Patients are also given nutritional supplements to correct nutritional deficiencies that have occurred due to long term alcohol abuse [10].

    Prognosis

    The prognosis of the condition is usually favorable when individuals are given prompt treatment. Individuals however, tend to suffer from insomnia, fatigue and irritability for several months. It is necessary that alcohol withdrawal symptoms are treated with appropriate medications and therapies. This is so because, if the patients begin experiencing delirium, it can turn life threatening [6].

    Complications

    Alcohol Withdrawal
    • Alcohol withdrawal is a common phenomenon.[symptoma.com]
    • Alcohol Withdrawal - Symptoms of Alcohol Withdrawal Alcohol withdrawal often begins after sleep but sometimes almost immediately after the alcoholic stops drinking.[healthyplace.com]
    • […] state with delirium , Mental and behavioural disorders due to use of alcohol, withdrawal state with delirium , ALCOHOL WITHDRAWAL IND DELIRIUM TREMENS , DELIRIUM TREMENS ALCOHOL WITHDRAWAL IND , alcohol withdrawal delirium , alcohol withdrawal with delirium[fpnotebook.com]
    Alcohol Withdrawal Delirium
    • withdrawal delirium , alcohol withdrawal with delirium , DTs , alcohol withdrawal delirium (diagnosis) , alcohol withdrawal delirium ('D. tremens') , Delirium tremens, alcoh-ind , [X]Delirium tremens, alcoh-ind , Delirium tremens, alcohol-induced , [[fpnotebook.com]
    • According to a study in the journal American Family Physician , 226,000 people were discharged from a short-stay hospital with a diagnosis of alcohol withdrawal , alcohol withdrawal delirium or alcohol withdrawal hallucinosis.[huffingtonpost.com]
    • Background Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal.[archinte.jamanetwork.com]
    • The most severe form of alcohol withdrawal, delirium tremens, is most common in people who have experienced alcohol withdrawal in the past.[well.blogs.nytimes.com]
    • In more severe forms of alcohol withdrawal, delirium tremens may set in.[symptoma.com]
    Anxiety
    • You need an anxiety cure.[calmclinic.com]
    • Alcohol-related anxiety may also be improved by a combination of vitamin C, vitamin B6, niacin, and vitamin E, though the high amounts B vitamins studied need a doctor’s supervision.[uofmhealth.org]
    • Symptoms include depression, anxiety, nervousness, mood swings, nightmares, irritability, fatigue, headache, enlarged pupils, pallor, sweating and rapid heart rate.[symptoma.com]
    • They range from anxiety and insomnia to extreme achiness and nausea.[blackbearrehab.com]
    Cardiac Arrhythmia
    • Propranolol and chlordiazepoxide effects on cardiac arrhythmias during alcohol withdrawal.[sccm.org]
    • arrhythmias Severe tremors Low-grade fever Hallucinations – primarily visual, cannot be distinguished from reality Disorientation Tachycardia Hypertension Treatment for Alcohol Withdrawal Syndrome Any successful treatment for alcohol withdrawal syndrome[highlandridgehospital.com]
    • Mortality risk is increased with advanced age, cardiac arrhythmias, fever greater than 104 degrees Fahrenheit, comorbid liver disease, lung disease, and other states of critical illness.[nurse-practitioners-and-physician-assistants.advanceweb.com]
    • Zilm DHJacob MSMacLeod SMSellers EMTi TY Propranolol and chlordiazepoxide effects on cardiac arrhythmias during alcohol withdrawal.[archinte.jamanetwork.com]
    • Prolongation of the corrected QT and torsades de pointes cardiac arrhythmia associated with intravenous haloperidol in the medically ill.[journals.lww.com]
    Chronic Alcoholism
    • Patients with a CAGE score 2 are considered chronic alcoholics.[journals.lww.com]
    • Delirium tremens is a component of alcohol withdrawal hypothesized to be the result of compensatory changes in response to chronic alcohol abuse.[en.wikipedia.org]
    • alcohol abuse Specific Treatment goal achieve light sedation to abate withdrawal symptoms, provide relief and protect patient. benzodiazepines (midazolam, diazepam) barbiturates propofol if intubated Underlying Cause stop intake An oslerphile emergency[lifeinthefastlane.com]
    • Chronic alcohol dependence is the most common cause of cardiomyopathy.[medical-dictionary.thefreedictionary.com]
    • Stress-response pathways are altered in the hippocampus of chronic alcoholics.[nature.com]
    Depression
    • Commonly, it is seen that cravings, depression, confusion, restlessness, tiredness, insomnia and lethargy can last up to 48 hours.[withdrawal.net]
    • Most of the symptoms of alcohol withdrawal are due to the fact that alcohol is a central nervous system depressant and when it's removed, the central nervous system become hyperactive.[healthyplace.com]
    • Drugs and alcohol are brain depressants that push down the spring.[addictionsandrecovery.org]
    • Although the effect of vitamin supplementation was no better than placebo in treating alcohol-associated depression, the vitamins did result in a significant drop in anxiety within three weeks of use.[uofmhealth.org]
    • […] to antidepressants in depressed individuals.[nature.com]
    Hyperpyrexia
    • […] consciousness, change in cognition or perceptual disturbance developing in a short period, and the emergence of symptoms during or shortly after withdrawal from heavy alcohol intake ( Table 1 ). 4 The classic clinical presentation of AWD also includes hyperpyrexia[archinte.jamanetwork.com]
    Hypertension
    • Clinical manifestations include agitation, global confusion, disorientation, hallucinations, fever, hypertension, diaphoresis, and autonomic hyperactivity (tachycardia and hypertension).[emedicine.medscape.com]
    • […] dreams confused hypervigilant Stage III – 48 hrs generalised tonic-clonic seizures Stage IV – after 48 hrs global confusional state autonomic hyperactivity tremors hallucinations seizures hyperadrenergic: diaphoresis, flushing, mydriasis, tachycardia, hypertension[lifeinthefastlane.com]
    • Presentation of DTs is characterized by tachycardia, hypertension, diaphoresis, delirium and low-grade fever. 2 Although DTs are present in only 5% of all patients who experience AWS, they carry a mortality rate up to 25%.[nurse-practitioners-and-physician-assistants.advanceweb.com]
    • Physical manifestations include hypertension, increased respirations and heart rate, fever, and severe dehydration (from excessive sweating).[officer.com]
    • Alpha adrenergic agonists such as clonidine are the most well known medicines used in the treatment of alcohol withdrawal, although beta blockers and calcium channel antagonist can also help treat extreme hypertension during withdrawal.[alcohol.addictionblog.org]
    Hypoglycemia
    • Hypoglycemia is common, and often a 5% dextrose solution in 0.90% or 0.45% saline will be used.[medical-dictionary.thefreedictionary.com]
    • NADH also opposes gluconeogenesis (thereby favoring hypoglycemia), increases alpha-glycerophosphate levels, and inhibits the Krebs cycle and fatty-acid oxidation [1] .[journals.lww.com]
    Hypophosphatemia
    • […] older age, lung disease, temperature 104 F, and significant hepatic dysfunction.(1) These patients can develop considerable dehydration, decreased cerebral blood flow (secondary to respiratory alkalosis), and profound hypokalemia, hypomagnesemia, and hypophosphatemia[sccm.org]
    • Hypophosphatemia may occur due to malnutrition, may be symptomatic, and if severe, may contribute to cardiac failure and rhabdomyolysis.[uptodate.com]
    Parkinson's Disease
    • As a depressant, alcohol can trigger episodes of depression, anxiety and lethargy, brain damage (Korsakoff's syndrome), and Parkinson's disease.[uncommonhelp.me]
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  • Etiology

    Sudden cessation of alcohol consumption or significantly reducing the alcohol intake can cause development of alcohol withdrawal symptoms. It is more common in individuals who drink regularly and are unable to gradually decrease the consumption. Individuals who are suffering from certain underlying disease conditions are also at risk of developing alcohol withdrawal symptoms when they suddenly stop its consumption. In addition to adults, even teenagers and children who drink excessive alcohol are also susceptible to develop alcohol withdrawal symptoms [2].

    Epidemiology

    Alcohol withdrawal is a common phenomenon. It has been estimated that about 500,000 episodes of alcohol withdrawal symptoms occur each year in the US. About 5% of these individuals are known to fall prey to delirium tremens. The symptoms are so severe that they require pharmacologic intervention [3]. It has also been reported that about 50% patients who drink alcohol develop clinically relevant symptoms. In addition, less than 1 in 20 individuals who drink alcohol are also at risk of developing grand mal seizures or delirium tremens. Another statistical report revealed that mortality rate was as high as 20% in drinker’s population who suffered from delirium tremens [4].

    Sex distribution
    Age distribution

    Pathophysiology

    Drinking excessive alcohol on regular basis is known to gradually excite the nervous system. Over time when such a phenomenon continues, the body is unable to tolerate sudden cessation of alcohol. This means, the nervous system cannot easily adapt to sudden change in the alcohol consumption pattern causing various symptoms such as delirium, insomnia and anxiety to name a few [5].

    Prevention

    Individuals are advised to gradually and slowly decrease their dependence of alcohol. This can be achieved by making conscious efforts by decreasing alcohol intake steadily. Such a practice will help prevent symptoms of alcohol withdrawal from setting in. It is also advised that individuals who wish to completely quit alcohol should seek medical advice to ensure a healthy withdrawal.

    Summary

    Alcoholism is a common occurrence with an estimated 140 million people throughout the world which suffer from alcohol dependence. The practice of drinking alcohol is certainly not good for the human system and has debilitating effects on the nervous system and other body organs. Alcohol withdrawal can produce various physical and emotional symptoms, which if not managed appropriately can get life threatening. Such a kind of phenomenon is common in adults; however teenagers and children can also often fall prey to it [1].

    Patient Information

    Definition

    Alcohol withdrawal is a condition wherein individuals experience a group of symptoms when they suddenly stop drinking alcohol. An estimated 15.2 million Americans are alcoholic. Of these 1.2 million of hospital admissions occur due to alcohol withdrawal. Symptoms of alcohol withdrawal should be promptly treated to avoid onset of complications.

    Cause

    Sudden cessation of alcohol or significant decrease in alcohol intake causes alcohol withdrawal symptoms to set in. Individuals with certain underlying disease conditions experience more severe forms of alcohol withdrawal symptoms as compared to the normal population.

    Symptoms

    Symptoms of alcohol withdrawal include headache, anxiety, nervousness, mood swings, depression, irritability, enlarged pupil, sweating, arrhythmia, loss of appetite and insomnia. In more severe cases, individuals experience fever, agitation, seizures and severe confusion which occur due to development of delirium tremens.

    Diagnosis

    Diagnosis of alcohol withdrawal symptoms is done through a preliminary physical examination to categorize the signs and symptoms. In addition, blood and urine tests are also carried out to assess the level of alcohol in the system.

    Treatment

    Mild form of the condition is treated through medications and patients are allowed to stay at home. In severe cases, hospitalization is also required to manage the symptoms of the conditions. Medications such as benzodiazepines are recommended for patients with alcohol withdrawal.

    Self-assessment

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    References

    1. VICTOR M, ADAMS RD. The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis 1953; 32:526.
    2. Hack JB, Hoffmann RS, Nelson LS. Resistant alcohol withdrawal: does an unexpectedly large sedative requirement identify these patients early?. J Med Toxicol. Jun 2006;2(2):55-60.
    3. Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003; 348:1786.
    4. Monte R, Rabunal R, Casariego E, Lopez-Agreda H, Mateos A, Pertega S. Analysis of the factors determining survival of alcoholic withdrawal syndrome patients in a general hospital. Alcohol Alcohol. Mar-Apr 2010;45(2):151-8.
    5. Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. Mar 15 2004;69(6):1443-50.
    6. ISBELL H, FRASER HF, WIKLER A, et al. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol 1955; 16:1.
    7. Abraham E, Shoemaker WC, McCartney SF. Cardiorespiratory patterns in severe delirium tremens. Arch Intern Med 1985; 145:1057
    8. Turner RC, Lichstein PR, Peden JG Jr, et al. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med 1989; 4:432.
    9. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. Jul 12 2004;164(13):1405-12.
    10. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2010; :CD005063.

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    Media References

    1. An alcoholic man with delirium, CC BY 4.0

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